An S L, Ji Z H, Li X B, Liu G, Zhang Y B, Gao C, Zhang K, Zhang X J, Yan G J, Yan L J, Li Y
Department of Peritoneal Cancer Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China.
Department of Surgical Oncology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China.
Zhonghua Wei Chang Wai Ke Za Zhi. 2023 May 25;26(5):434-441. doi: 10.3760/cma.j.cn441530-20230309-00071.
To construct a nomogram incorporating important prognostic factors for predicting the overall survival of patients with colorectal cancer with peritoneal metastases treated with cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC), the aim being to accurately predict such patients' survival rates. This was a retrospective observational study. Relevant clinical and follow-up data of patients with colorectal cancer with peritoneal metastases treated by CRS + HIPEC in the Department of Peritoneal Cancer Surgery, Beijing Shijitan Hospital, Capital Medical University from 2007 January to 2020 December were collected and subjected to Cox proportional regression analysis. All included patients had been diagnosed with peritoneal metastases from colorectal cancer and had no detectable distant metastases to other sites. Patients who had undergone emergency surgery because of obstruction or bleeding, or had other malignant diseases, or could not tolerate treatment because of severe comorbidities of the heart, lungs, liver or kidneys, or had been lost to follow-up, were excluded. Factors studied included: (1) basic clinicopathological characteristics; (2) details of CRS+HIPEC procedures; (3) overall survival rates; and (4) independent factors that influenced overall survival; the aim being to identify independent prognostic factors and use them to construct and validate a nomogram. The evaluation criteria used in this study were as follows. (1) Karnofsky Performance Scale (KPS) scores were used to quantitatively assess the quality of life of the study patients. The lower the score, the worse the patient's condition. (2) A peritoneal cancer index (PCI) was calculated by dividing the abdominal cavity into 13 regions, the highest score for each region being three points. The lower the score, the greater is the value of treatment. (3) Completeness of cytoreduction score (CC), where CC-0 and CC-1 denote complete eradication of tumor cells and CC-2 and CC-3 incomplete reduction of tumor cells. (4) To validate and evaluate the nomogram model, the internal validation cohort was bootstrapped 1000 times from the original data. The accuracy of prediction of the nomogram was evaluated with the consistency coefficient (C-index), and a C-index of 0.70-0.90 suggest that prediction by the model was accurate. Calibration curves were constructed to assess the conformity of predictions: the closer the predicted risk to the standard curve, the better the conformity. The study cohort comprised 240 patients with peritoneal metastases from colorectal cancer who had undergone CRS+HIPEC. There were 104 women and 136 men of median age 52 years (10-79 years) and with a median preoperative KPS score of 90 points. There were 116 patients (48.3%) with PCI≤20 and 124 (51.7%) with PCI>20. Preoperative tumor markers were abnormal in 175 patients (72.9%) and normal in 38 (15.8%). HIPEC lasted 30 minutes in seven patients (2.9%), 60 minutes in 190 (79.2%), 90 minutes in 37 (15.4%), and 120 minutes in six (2.5%). There were 142 patients (59.2%) with CC scores 0-1 and 98 (40.8%) with CC scores 2-3. The incidence of Grade III to V adverse events was 21.7% (52/240). The median follow-up time is 15.3 (0.4-128.7) months. The median overall survival was 18.7 months, and the 1-, 3- and 5-year overall survival rates were 65.8%, 37.2% and 25.7%, respectively. Multivariate analysis showed that KPS score, preoperative tumor markers, CC score, and duration of HIPEC were independent prognostic factors. In the nomogram constructed with the above four variables, the predicted and actual values in the calibration curves for 1, 2 and 3-year survival rates were in good agreement, the C-index being 0.70 (95% CI: 0.65-0.75). Our nomogram, which was constructed with KPS score, preoperative tumor markers, CC score, and duration of HIPEC, accurately predicts the survival probability of patients with peritoneal metastases from colorectal cancer treated with cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy.
为构建一个纳入重要预后因素的列线图，用于预测接受细胞减灭术（CRS）联合腹腔热灌注化疗（HIPEC）治疗的结直肠癌腹膜转移患者的总生存期，目的是准确预测此类患者的生存率。这是一项回顾性观察研究。收集了首都医科大学附属北京世纪坛医院腹膜肿瘤外科2007年1月至2020年12月期间接受CRS + HIPEC治疗的结直肠癌腹膜转移患者的相关临床和随访数据，并进行Cox比例回归分析。所有纳入患者均被诊断为结直肠癌腹膜转移，且无其他部位可检测到的远处转移。因梗阻或出血接受急诊手术、患有其他恶性疾病、因心脏、肺、肝或肾的严重合并症无法耐受治疗或失访的患者被排除。研究因素包括：（1）基本临床病理特征；（2）CRS + HIPEC手术细节；（3）总生存率；（4）影响总生存的独立因素；目的是识别独立预后因素并用于构建和验证列线图。本研究使用的评估标准如下。（1）卡氏功能状态评分（KPS）用于定量评估研究患者的生活质量。分数越低，患者状况越差。（2）通过将腹腔分为13个区域计算腹膜癌指数（PCI），每个区域最高评分为3分。分数越低，治疗价值越大。（3）细胞减灭程度评分（CC），其中CC - 0和CC - 1表示肿瘤细胞完全清除，CC - 2和CC - 3表示肿瘤细胞未完全清除。（4）为验证和评估列线图模型，从原始数据中对内部验证队列进行1000次自抽样。用一致性系数（C指数）评估列线图的预测准确性，C指数为0.70 - 0.90表明模型预测准确。构建校准曲线以评估预测的一致性：预测风险与标准曲线越接近，一致性越好。研究队列包括240例接受CRS + HIPEC治疗的结直肠癌腹膜转移患者。有104名女性和136名男性，中位年龄52岁（10 - 79岁），术前KPS评分中位数为90分。PCI≤20的患者有116例（48.3%），PCI>20的患者有124例（51.7%）。175例患者（72.9%）术前肿瘤标志物异常，38例（15.8%）正常。7例患者（2.9%）的HIPEC持续30分钟，190例（79.2%）持续60分钟，37例（15.4%）持续90分钟，6例（2.5%）持续120分钟。CC评分为0 - 1的患者有142例（59.2%），CC评分为2 - 3的患者有98例（40.8%）。Ⅲ至Ⅴ级不良事件发生率为21.7%（52/240）。中位随访时间为15.3（0.4 - 128.7）个月。中位总生存期为18.7个月，1年、3年和5年总生存率分别为65.8%、37.2%和25.7%。多因素分析显示KPS评分、术前肿瘤标志物、CC评分和HIPEC持续时间是独立预后因素。在用上述四个变量构建的列线图中，1年、2年和3年生存率校准曲线中的预测值与实际值吻合良好，C指数为0.70（95%CI：0.65 - 0.75）。我们用KPS评分、术前肿瘤标志物、CC评分和HIPEC持续时间构建的列线图准确预测了接受细胞减灭术联合腹腔热灌注化疗的结直肠癌腹膜转移患者的生存概率。
