结直肠癌肝转移合并同时性肺转移患者手术治疗疗效分析

Efficacy analysis of surgical treatment for patients with colorectal cancer and simultaneous liver and lung metastases

摘要:

背景与目的 对于结直肠癌肝转移合并可切除肺转移的患者，手术治疗的疗效已经得到广泛认可，但对于合并不可切除的肺转移患者的治疗策略仍需要进一步明确。因此，本研究通过对笔者单位收治的结直肠癌肝转移合并同时性肺转移患者临床资料的回顾性分析，以期为该类患者的治疗提供数据参考。方法 本研究采用回顾性队列研究方法，纳入2008年1月—2020年12月期间在北京大学肿瘤医院肝胆胰外一科行手术治疗的127例结直肠癌肝转移合并同时性肺转移患者的资料，所有患者原发灶及肝转移灶均按肿瘤根治原则行完整切除（R₀/R₁），其中31例行肺转移灶的根治性局部治疗（局部治疗组），96例肺转移灶未行局部治疗（非局部治疗组），比较两组患者的临床资料、总生存时间（OS）、无复发生存时间（RFS），并对非局部治疗组的患者进行预后相关因素分析。结果 除局部治疗组肺转移灶直径大于非局部治疗组外（P<0.05），两组其余一般临床资料均无明显差异（均P>0.05）。全组患者中位随访时间为30（5~134）个月，失访率3%。全组患者中位OS为41（4~118）个月，1、3年OS率分别为96.8%和59.7%，其中非局部治疗组中位OS为37（4~118）个月，1、3年OS率分别为95.8%和51.2%；局部治疗组中位OS为72（15~101）个月，1、3年OS率分别为100.0%和82.9%，局部治疗组的OS率明显优于非局部治疗组（P=0.001）。非局部治疗组中位RFS为8（1~37）个月，1、3年RFS率分别为30.8%和2.4%；局部治疗组中位RFS为10（3~67）个月，1、3年RFS率分别为38.7%和18.1%，局部治疗组的RFS优于非局部治疗组，但差异无统计学意义（P=0.055）。对非局部治疗组的96例患者进行预后相关因素分析显示，原发肿瘤T4分期和RAS基因突变是影响OS的独立危险因素（均P<0.05），合并2个危险因素的患者，尽管生存逊于合并0或1个危险因素的患者（均P<0.05），但中位OS也达到27（4~35）个月。结论 对于结直肠癌肝转移合并同时性肺转移的患者应该积极行原发灶和肝转移的手术治疗以及肺转移的局部治疗。对于肺转移不可局部治疗的患者，无论合并危险因素与否，切除原发灶及肝转移灶也能带来生存获益。

Abstract:

Background and Aims For colorectal cancer patients with and liver metastases and resectable lung metastases, surgical treatment has been widely accepted as an effective method. However, the treatment strategy for those with unresectable lung metastases still needs to be further specified. Therefore, this study was performed to retrospectively analyze the clinical data of colorectal cancer patients with simultaneous liver and lung metastases treated in the authors' hospital, so as to provide data reference for the treatment of these patients.Methods Using a retrospective cohort method, the data of 127 patients with colorectal cancer and simultaneous liver and lung metastases undergoing surgical treatment in the Department of Hepatopancreatobiliary Surgery Unit I of Peking University Cancer Hospital from January 2008 to December 2020 were collected. Of the patients, all cases underwent complete gross resection (R₀/R₁) of the primary lesions and liver metastases following the principle of tumor radical surgery, and 31 cases received radical local treatment of the lung metastases (local treatment group), while 96 cases did not receive local treatment of the lung metastases (non-local treatment group). The clinical variables, overall survival (OS) and recurrence-free survival (RFS) of the two groups of patients were compared, and the prognostic factors for patients in non-local treatment group were also determined.Results Except that the diameter of the lung metastases in local treatment group was larger than that in non-local treatment group (P<0.05), all other clinical variables showed no significant difference between the two groups (all P>0.05). The median follow-up time for the entire group of patients was 30 (5-134) months, and the rate of lost to follow-up was 3%. For the whole group, the median OS was 41 (4-118) months, and the 1- and 3-year OS rate were 96.8% and 59.7%, in which, the median OS and the 1- and 3-year OS rate were 37 (4-118) months and 95.8% and 51.2% for non-local treatment group, and were 72 (15-101) months, and 100.0% and 82.9% for local treatment group, respectively. The OS was significantly better in local treatment group than that in non-local treatment group (P=0.001). The median RFS was 8 (1-37) months, and the 1- and 3-year RFS rate were 30.8% and 2.4% for non-local treatment group, and the median RFS was 10 (3-67) months, and the 1- and 3-year RFS rate were 38.7% and 18.1% for local treatment group. The RFS was better in local treatment group than that in non-local treatment group, but the difference did not reach a statistical significance (P=0.055). The results of prognostic analysis in the 96 patients in non-local treatment group showed that T4 stage of primary tumor and RAS gene mutations were independent risk factors for OS (both P<0.05), and the median OS in patients with two risk factors were inferior to those with 0 or 1 risk factor (both P<0.05), but their median OS still approached 27 (4-35) months.Conclusion For patients with colorectal cancer and simultaneous liver and lung metastases, surgical resection of the primary lesions and liver metastases combined with local treatment of the lung metastases should be aggressively performed. For patients whose lung metastases cannot be treated locally, irrespective of whether or not they have risk factors, surgical treatment of the primary colorectal cancer and liver metastases may also provide a survival benefit.