Hase K, Ueno H, Kuranaga N, Utsunomiya K, Kanabe S, Mochizuki H
Department of Surgery, Self-Defense Forces Central Hospital, Tokyo, Japan.
Dis Colon Rectum. 1998 Sep;41(9):1134-40. doi: 10.1007/BF02239435.
The aims of this study were to evaluate potential predictors of exfoliated free cancer cells in the peritoneal cavity and to assess intraoperative peritoneal lavage cytology as a prognostic indicator in patients with colorectal cancer.
From 1985 to 1987, intraoperative peritoneal lavage cytology was performed in 140 patients with colorectal cancer. Among them, 88 patients underwent curative resection and 52 patients had noncurative surgery. Cytology was examined twice, i.e., immediately after opening the peritoneal cavity (precytology) and just before closing the abdomen (postcytology). One hundred milliliters of saline was poured into the peritoneal cavity and it was retrieved by suction after irrigation. Cytologic examination was performed after staining with Papanicolaou, Giemsa, periodic acid-Schiff, and Alcian blue stains.
Among the 140 patients examined, the incidence of positive cytology in the prelavage was 15 percent, and that in the postlavage was 9 percent, although it was 16 percent in either lavage. Among patients with curative resection, 10 percent had positive cytology. Seven characteristics were identified as features of tumors which are prone to exfoliate cells into the peritoneal cavity: 1) macroscopic peritoneal dissemination, 2) liver metastasis, 3) more than 20 ml of ascites, 4) ulcerated tumors without definite borders, 5) invasion of the serosal surface or beyond, 6) semiannular or annular shape, and 7) moderate or marked lymphatic invasion. In patients undergoing curative surgery, among these features, circumferential involvement was the only one correlated closely with positive cytology (P < 0.02). Positive cytology was associated with a worse outcome. In patients who were resected curatively, the postcytology had a stronger influence on local recurrence than the precytology; the local recurrence rate in patients with positive postcytology was higher than in those with negative postcytology, regardless of the precytology. All patients with cancer cells in the peritoneal cavity at the end of surgery had recurrence.
Seven characteristics were identified as risk factors for exfoliation of cancer cells into the peritoneal cavity in patients with colorectal cancer. These findings may be helpful for the choice of laparoscopic surgery in this era of increasing port-site metastases after laparoscopic procedure. The results of peritoneal lavage cytology at the end of surgery were correlated with the long-term postoperative outcome of colorectal cancer. Thus, meticulous follow-up and possibly adjuvant chemotherapy may be beneficial for patients with free cancer cells in lavage fluid, even after curative surgery.
本研究旨在评估腹腔内脱落游离癌细胞的潜在预测因素，并评估术中腹腔灌洗细胞学检查作为结直肠癌患者预后指标的价值。
1985年至1987年，对140例结直肠癌患者进行了术中腹腔灌洗细胞学检查。其中88例行根治性切除术，52例行非根治性手术。细胞学检查进行两次，即打开腹腔后立即进行（灌洗前细胞学检查）和关闭腹腔前进行（灌洗后细胞学检查）。向腹腔内注入100毫升生理盐水，灌洗后通过吸引回收。采用巴氏染色、吉姆萨染色、过碘酸-希夫染色和阿尔辛蓝染色后进行细胞学检查。
在接受检查的140例患者中，灌洗前细胞学检查阳性率为15%，灌洗后为9%，不过任何一次灌洗的阳性率均为16%。在根治性切除的患者中，10%的患者细胞学检查呈阳性。确定了七个肿瘤特征，这些特征易于使癌细胞脱落至腹腔：1）肉眼可见的腹膜播散；2）肝转移；3）腹水超过20毫升；4）边界不清的溃疡型肿瘤；5）浆膜面侵犯或超出浆膜面；6）半环形或环形；7）中度或显著的淋巴侵犯。在接受根治性手术的患者中，在这些特征中，环周受累是与阳性细胞学检查密切相关的唯一特征（P<0.02）。阳性细胞学检查与较差的预后相关。在根治性切除的患者中，灌洗后细胞学检查对局部复发的影响比灌洗前细胞学检查更强；灌洗后细胞学检查阳性的患者局部复发率高于灌洗后细胞学检查阴性的患者，无论灌洗前细胞学检查结果如何。手术结束时腹腔内有癌细胞的所有患者均出现复发。
确定了七个特征为结直肠癌患者癌细胞脱落至腹腔的危险因素。这些发现可能有助于在腹腔镜手术后端口部位转移增加的时代选择腹腔镜手术。手术结束时腹腔灌洗细胞学检查结果与结直肠癌的长期术后预后相关。因此，即使在根治性手术后，对灌洗液中有游离癌细胞的患者进行细致的随访以及可能的辅助化疗可能是有益的。
