Stocchi L, Nelson H, Sargent D J, O'Connell M J, Tepper J E, Krook J E, Beart R
Division of Colon and Rectal Surgery, Cancer Center Statistics Unit, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
J Clin Oncol. 2001 Sep 15;19(18):3895-902. doi: 10.1200/JCO.2001.19.18.3895.
Substantial and successful effort has been focused on decreasing the risk of local failure after rectal cancer surgery through the use of adjuvant therapies. Our study examined data from studies conducted by United States cooperative groups to investigate the impact of surgical and pathologic variables in rectal cancer outcomes.
Surgical and pathologic reports from 673 patients with stage II/III rectal cancer enrolled onto three adjuvant clinical trials were reviewed for tumor and surgical variables. Additional information on individual institutions and operating surgeon was collected. Variables were tested for association with 5-year local recurrence and survival after adjustment for adjuvant treatments and other important prognostic factors.
Five-year local recurrence and survival rates were 16% and 59%, respectively. Surgeons treating more than 10 study cases had lower local recurrence rates than those treating < or = 10 (11% v 17%, P =.02). Free radial margins also correlated with local recurrence (P =.01). Type of surgery, distal margins, and tumor radial spread were not significant. Tumor adherence to adjacent structures predicted local recurrence (35% v 14%, P <.001) and survival (30% v 63%, P <.001), regardless of en bloc resection. Although T and N classification predicted survival (P <.001), only N classification correlated with local recurrence. The number and percentage of positive nodes correlated with survival, but only the percentage independently predicted local recurrence. Several pathologic and surgical variables were reported suboptimally.
Moderate variability in outcomes among surgeons was detected in this high-risk population. Efforts to improve surgical results will require changes in reporting practices to allow for more accurate assessment of the quality of surgery.
通过辅助治疗，人们已在降低直肠癌手术后局部复发风险方面付出了巨大且成功的努力。我们的研究审查了美国合作组开展的研究数据，以调查手术和病理变量对直肠癌治疗结果的影响。
回顾了纳入三项辅助临床试验的673例II/III期直肠癌患者的手术和病理报告，以获取肿瘤和手术变量信息。收集了有关各个机构和手术医生的其他信息。在对辅助治疗和其他重要预后因素进行调整后，对变量与5年局部复发率和生存率的相关性进行了检测。
5年局部复发率和生存率分别为16%和59%。治疗超过10例研究病例的外科医生的局部复发率低于治疗≤10例的医生（11%对17%，P = 0.02）。环周切缘阴性也与局部复发相关（P = 0.01）。手术方式、远切缘和肿瘤径向扩散无显著意义。无论是否整块切除，肿瘤与相邻结构的粘连均可预测局部复发（35%对14%，P < 0.001）和生存率（30%对63%，P < 0.001）。虽然T和N分期可预测生存率（P < 0.001），但只有N分期与局部复发相关。阳性淋巴结的数量和百分比与生存率相关，但只有百分比可独立预测局部复发。一些病理和手术变量的报告不够理想。
在这个高危人群中，检测到外科医生之间的治疗结果存在适度差异。改善手术结果的努力将需要改变报告方式，以便更准确地评估手术质量。
