Elective bowel resection for incurable stage IV colorectal cancer: Prognostic variables for asymptomatic patients
Elective bowel resection for incurable stage IV colorectal cancer: Prognostic variables for asymptomatic patients
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DOI：
10.1016/s1072-7515(03)00136-4
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发表时间：
2003-05-01
影响因子：
5.2
通讯作者：
Wong, WD
中科院分区：
文献类型：
--
作者：
Ruo, L;Gougoutas, C;Wong, WD
背景：对于初次就诊的IV期大肠癌患者，手术切除原发性大肠癌仍存在争议。虽然主张通过肠切除术来治疗出血、穿孔或梗阻等症状，但对无症状患者的治疗尚未明确。患者依赖性因素（体力状态、共病）和远处转移的程度是影响无症状IV期CRC患者进行手术治疗的决定的考虑因素。我们假设，选择性切除无症状的原发性结直肠癌患者可能会受益。远处转移的程度进行了客观的测量，通过几种方法，以确定潜在的预后变量，可能有助于指导患者的选择，在这个population.Study设计：我们回顾了1996年至1999年的医院和结直肠服务数据库。确定了接受结直肠切除术并伴有大体残留转移性疾病的IV期患者（n = 209）。在这209例患者中，排除了82例因症状（梗阻、穿孔、出血或疼痛）而手术的患者，剩下127例患者接受了无症状原发性CRC的择期切除术。在同一时间段内，确定了103名未接受切除术的IV期患者。收集患者特征和临床管理数据。放射科医生对可用的CT扫描进行了独立审查，以评估肝脏疾病的程度。分类数据分析采用卡方检验，连续变量分析采用Student t检验。通过Kaplan-Meier方法确定生存率，并通过对数秩检验比较分布。多变量分析采用考克斯regression.RESULTS：切除组可以很容易地区分从非切除组的更高频率的右半结肠癌（p = 0.03）和转移性疾病仅限于肝脏（p = 0.02）或一个其他网站除了原发性肿瘤（p = 0.02）。与未切除的患者相比，切除患者的中位生存期（16个月vs 9个月，p < 0.001）和2年生存期（25% vs 6%，p < 0.001）延长。单变量分析确定了切除组中三个重要的预后变量（远处受累部位数量、仅肝转移和肿瘤替代肝脏体积）。在考克斯多变量回归分析中，肝脏替代体积也是生存率的重要预测因素（p = 0.01）。无症状原发性结直肠癌切除后，26例患者（20%）发生术后并发症。中位住院时间为6天。两名患者（1.6%）在30天内死亡surgical.CONCLUSIONS：第四阶段患者选择择期姑息性切除无症状原发性结直肠癌有实质性的术后生存率，这是显着优于那些从来没有切除。有限的转移性肿瘤负荷和较不广泛的肝脏受累与更好的生存率和更高的可能性，从择期肠切除术的无症状患者不可治愈的IV期CRC。(C)2003年由美国外科医生学会。
BACKGROUND: Surgical resection of primary colorectal cancer (CRC) in patients with stage IV disease at initial presentation remains controversial. Although bowel resection to manage symptoms such as bleeding, perforation, or obstruction has been advocated, management of asymptomatic patients has not been well defined. Patient-dependent factors (performance status, comorbid disease) and extent of distant metastases are among the considerations that impact on the decision to proceed with surgical management in asymptomatic stage IV CRC patients. We postulated that selected patients might benefit from elective resection of the asymptomatic primary CRC. The extent of distant metastases was objectively measured by several methods to identify potential prognostic variables that may help guide patient selection in this population.STUDY DESIGN: We reviewed hospital and colorectal service databases for the years 1996 to 1999. Stage IV patients who had colorectal resections with gross residual metastatic disease were identified (n = 209). Among these 209 patients, 82 patients operated on for symptoms (obstruction, perforation, bleeding, or pain) were excluded, leaving 127 patients who underwent elective resection of their asymptomatic primary CRC. Over the same time period, 103 stage IV patients who did not undergo resection were identified. Data on patient characteristics and clinical management were collected. A radiologist performed an independent review of available CT scans to assess extent of liver disease. The chi-square test was used for analysis of categoric data and Student's t-test for continuous variables. Survival was determined by the Kaplan-Meier method and distributions compared by the log rank test. Multivariate analysis was performed using Cox regression.RESULTS: The resected group could be easily distinguished from the nonresected group by a higher frequency of right colon cancers (p = 0.03) and metastatic disease restricted to the liver (p = 0.02) or one other site apart from the primary tumor (p = 0.02). Resected patients had prolonged median (16 versus 9 months, p < 0.001) and 2-year (25% versus 6%, p < 0.001) survival compared with patients never resected. Univariate analysis identified three significant prognostic variables (number of distant sites involved, metastases to liver only, and volume of hepatic replacement by tumor) in the resected group. Volume of hepatic replacement was also a significant predictor of survival in Cox multivariate regression analysis (p = 0.01). Subsequent to resection of asymptomatic primary CRC, 26 patients (20%) developed postoperative complications. Median hospital stay was 6 days. Two patients (1.6%) died within 30 days of surgery.CONCLUSIONS: Stage IV patients selected for elective palliative resection of asymptomatic primary colorectal cancers had substantial postoperative survival that was significantly better than those never having resection. Limited metastatic tumor burden and less extensive liver involvement were associated with better survival and a higher likelihood of benefit from elective bowel resection in asymptomatic patients with incurable stage IV CRC. (C) 2003 by the American College of Surgeons.