Govindarajan Anand, Coburn Natalie G, Kiss Alex, Rabeneck Linda, Smith Andrew J, Law Calvin H L
Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
J Natl Cancer Inst. 2006 Oct 18;98(20):1474-81. doi: 10.1093/jnci/djj396.
Evidence-based guidelines recommend multivisceral resection for patients with locally advanced adherent colorectal cancer because it reduces local recurrence and improves survival. However, this procedure can increase morbidity compared with standard resection and may not be practiced uniformly. We performed a population-based study to examine surgical practice and outcomes among patients with locally advanced adherent colorectal cancer in the United States.
Patients who were 18 years or older and who had surgical resection for nonmetastatic, locally advanced adherent colorectal cancer from January 1, 1988, through December 31, 2002, were identified from the Surveillance, Epidemiology, and End Results (SEER) registry. Logistic regression was used to examine patient, tumor, and geographic factors associated with multivisceral resection. Cumulative early mortality (i.e., at 1 and 6 months after diagnosis) and 5-year survival were obtained from Kaplan-Meier estimates; adjusted risks of death were calculated using Cox proportional hazards models. All statistical tests were two-sided.
We identified 8380 patients who underwent surgical resection for locally advanced adherent colorectal cancer, of whom 33.3% were managed with multivisceral resection. Among colon cancer patients, younger age at diagnosis, female sex, SEER region, node negativity, and left-sided tumors were independently associated with having had a multivisceral resection. Among rectal cancer patients, younger age at diagnosis and female sex were positively and statistically significantly associated with multivisceral resection, whereas receipt of neoadjuvant radiation was inversely and statistically significantly associated with multivisceral resection. Compared with standard resection, multivisceral resection was associated with improved overall survival for patients with colon (hazard ratio [HR] = 0.89, 95% confidence interval [CI] = 0.83 to 0.96) and rectal (HR = 0.81, 95% CI = 0.70 to 0.94) cancer, with no associated increase in early mortality.
The majority of patients with locally advanced colorectal cancer did not receive a multivisceral resection. The geographic variation in the application of this procedure in patients with colon cancer suggests that local organizational structures and processes of care may play an important role in patient treatment and, therefore, prognosis.
循证指南推荐对局部晚期浸润性结直肠癌患者进行多脏器切除术，因为该手术可降低局部复发率并提高生存率。然而，与标准切除术相比，此手术可能会增加发病率，并且实施情况可能并不统一。我们开展了一项基于人群的研究，以调查美国局部晚期浸润性结直肠癌患者的手术治疗情况及预后。
从监测、流行病学和最终结果（SEER）登记处识别出1988年1月1日至2002年12月31日期间接受非转移性局部晚期浸润性结直肠癌手术切除的18岁及以上患者。采用逻辑回归分析与多脏器切除术相关的患者、肿瘤及地理因素。通过Kaplan-Meier估计法得出累积早期死亡率（即诊断后1个月和6个月时）及5年生存率；使用Cox比例风险模型计算校正后的死亡风险。所有统计检验均为双侧检验。
我们识别出8380例接受局部晚期浸润性结直肠癌手术切除的患者，其中33.3%接受了多脏器切除术。在结肠癌患者中，诊断时年龄较小、女性、SEER地区、无淋巴结转移及左侧肿瘤与接受多脏器切除术独立相关。在直肠癌患者中，诊断时年龄较小及女性与多脏器切除术呈正相关且具有统计学意义，而接受新辅助放疗与多脏器切除术呈负相关且具有统计学意义。与标准切除术相比，多脏器切除术可改善结肠癌（风险比[HR]=0.89，95%置信区间[CI]=0.83至0.96）和直肠癌（HR=0.81，95%CI=0.70至0.94）患者的总生存率，且未增加早期死亡率。
大多数局部晚期结直肠癌患者未接受多脏器切除术。该手术在结肠癌患者中的应用存在地理差异，这表明当地的组织结构和医疗流程可能在患者治疗及预后方面发挥重要作用。
