Troester Alexander, Weaver Lauren, Mott Sarah L, Welton Lindsay, Jahansouz Cyrus, Hassan Imran, Goffredo Paolo
Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA.
Ann Surg Oncol. 2025 Apr;32(4):2271-2281. doi: 10.1245/s10434-024-16608-8. Epub 2024 Dec 1.
Pelvic exenterations (PEs) are technically demanding procedures performed with curative intent for advanced malignancies to improve patient survival while balancing morbidity and functional outcomes. The majority of United States (US) data regarding PE for rectal cancers originate from single-center series.
We aimed to investigate patterns of care and oncologic outcomes for primary rectal cancer patients undergoing PE in a national registry.
The National Cancer Database (2004-2019) was queried for adults with a pT4 rectal adenocarcinoma. Logistic regression identified factors associated with positive margins. Multivariable Cox regression estimated treatment effects on overall survival (OS).
Of 673 patients (73% <65 years of age, 39% male, 82% White), median follow-up was 39 months. The majority received neoadjuvant chemotherapy (76%) and radiation (75%), while adjuvant chemotherapy (37%) and radiation (13%) were less common. Twenty-four percent had positive margins (R1 = 98, R2 = 11, R + NOS = 48). Univariable analysis demonstrated that only nodal involvement was associated with higher positive margin rates (odds ratio 1.75, 95% confidence interval [CI] 1.22-2.51). Five-year OS for R0 and R+ resections were 55% and 33%, respectively. On multivariable analysis, age <65 years (hazard ratio [HR] 0.73, 95% CI 0.53-0.99) and adjuvant chemotherapy (HR 0.62, 95% CI 0.47-0.82) were associated with improved OS, while N+ status (HR 2.13, 95% CI 1.67-2.70) and positive margins (HR 1.82, 95% CI 1.41-2.35) portended worse prognosis. No significant associations were observed between outcomes and institutional volume.
One in four US patients undergoing PE for locally advanced rectal cancer had an R+ resection regardless of center volume. Quality of surgical resection to achieve negative margins remains the most relevant prognostic factor.
盆腔脏器切除术（PEs）是技术要求较高的手术，用于对晚期恶性肿瘤进行根治性治疗，以提高患者生存率，同时平衡发病率和功能预后。美国关于直肠癌盆腔脏器切除术的大多数数据来自单中心系列研究。
我们旨在调查全国登记处中接受盆腔脏器切除术的原发性直肠癌患者的治疗模式和肿瘤学结局。
在国家癌症数据库（2004 - 2019年）中查询患有pT4直肠腺癌的成年人。逻辑回归确定与切缘阳性相关的因素。多变量Cox回归估计治疗对总生存期（OS）的影响。
673例患者（73%年龄<65岁，39%为男性，82%为白人），中位随访时间为39个月。大多数患者接受了新辅助化疗（76%）和放疗（75%），而辅助化疗（37%）和放疗（13%）则较少见。24%的患者切缘阳性（R1 = 98，R2 = 11，R + NOS = 48）。单变量分析表明，只有淋巴结受累与更高的切缘阳性率相关（比值比1.75，95%置信区间[CI] 1.22 - 2.51）。R0和R+切除的5年总生存率分别为55%和33%。多变量分析显示，年龄<65岁（风险比[HR] 0.73，95% CI 0.53 - 0.99）和辅助化疗（HR 0.62，95% CI 0.47 - 0.82）与总生存期改善相关，而N+状态（HR 2.13，95% CI 1.67 - 2.70）和切缘阳性（HR 1.82，95% CI 1.41 - 2.35）预示着更差的预后。未观察到结局与机构手术量之间的显著关联。
在美国，四分之一接受盆腔脏器切除术治疗局部晚期直肠癌的患者为R+切除，与中心手术量无关。实现切缘阴性的手术切除质量仍然是最相关的预后因素。
