Baird D L H, Kontovounisios C, Simillis C, Pellino G, Rasheed S, Tekkis P P
Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.
Department of Surgery and Cancer, Imperial College London, London, UK.
BJS Open. 2020 Aug 28;4(6):1172-9. doi: 10.1002/bjs5.50341.
Better understanding of the impact of metachronous metastases in locally advanced and recurrent rectal cancer may improve decision-making. The aim of this study was to investigate factors influencing metachronous metastasis and its impact on survival in patients who have a beyond total mesorectal excision (bTME) operation.
This was a retrospective study of consecutive patients who had bTME surgery for locally advanced and recurrent rectal cancer at a tertiary referral centre between January 2006 and December 2016. The primary outcome was overall survival. Cox proportional hazards regression analyses were performed. The influence of metachronous metastases on survival was investigated.
Of 220 included patients, 171 were treated for locally advanced primary tumours and 49 for recurrent rectal cancer. Some 90·0 per cent had a complete resection with negative margins. Median follow-up was 26·0 (range 1·5-119·6) months. The 5-year overall survival rate was 71·1 per cent. Local recurrence and metachronous metastasis rates were 11·8 and 22·2 per cent respectively. Patients with metachronous metastases had a worse overall survival than patients without metastases (median 52·9 months versus estimated mean 109·4 months respectively; hazard ratio (HR) 6·73, 95 per cent c.i. 3·23 to 14·00). Advancing pT category (HR 2·01, 1·35 to 2·98), pN category (HR 2·43, 1·65 to 3·59), vascular invasion (HR 2·20, 1·22 to 3·97) and increasing numbers of positive lymph nodes (HR 1·19, 1·07 to 1·16) increased the risk of metachronous metastasis. Nine of 17 patients (53 per cent) with curatively treated synchronous metastases at presentation developed metachronous metastases, compared with 40 of 203 (19·7 per cent) without synchronous metastases (P = 0·002). Corresponding median length of disease-free survival was 17·5 versus 90·8 months (P < 0·001).
As metachronous metastases impact negatively on survival after bTME surgery, factors associated with metachronous metastases may serve as selection tools when determining suitability for treatment with curative intent.
更好地了解异时性转移对局部晚期和复发性直肠癌的影响可能会改善决策。本研究的目的是调查影响异时性转移的因素及其对接受直肠系膜全切除（bTME）手术患者生存的影响。
这是一项对2006年1月至2016年12月在一家三级转诊中心接受bTME手术治疗局部晚期和复发性直肠癌的连续患者的回顾性研究。主要结局是总生存期。进行了Cox比例风险回归分析。研究了异时性转移对生存的影响。
纳入的220例患者中，171例接受局部晚期原发性肿瘤治疗，49例接受复发性直肠癌治疗。约90.0%的患者实现了切缘阴性的完整切除。中位随访时间为26.0（范围1.5 - 119.6）个月。5年总生存率为71.1%。局部复发率和异时性转移率分别为11.8%和22.2%。发生异时性转移的患者总生存期比未发生转移的患者更差（中位生存期分别为52.9个月和估计平均109.4个月；风险比（HR）6.73，95%置信区间3.23至14.00）。pT分期进展（HR 2.01，1.35至2.98）、pN分期（HR 2.43，1.65至3.59）、血管侵犯（HR 2.20，1.22至3.97）以及阳性淋巴结数量增加（HR 1.19，1.07至1.16）会增加异时性转移的风险。17例初诊时接受根治性同步转移治疗的患者中有9例（53%）发生了异时性转移，而203例无同步转移的患者中有40例（19.7%）发生了异时性转移（P = 0.002）。相应的无病生存期的中位长度分别为17.5个月和90.8个月（P < 0.）。
由于异时性转移对bTME手术后的生存有负面影响，与异时性转移相关的因素可作为确定是否适合进行根治性治疗时的选择依据。
