右侧结肠癌完整结肠系膜切除术的 5 年结果：基于人群的队列研究。
5-year outcome after complete mesocolic excision for right-sided colon cancer: a population-based cohort study.
机构信息
Department of Surgery, Nordsjællands Hospital Hillerød, University of Copenhagen, Hillerød, Denmark.
Department of Surgery, Nordsjællands Hospital Hillerød, University of Copenhagen, Hillerød, Denmark.
出版信息
Lancet Oncol. 2019 Nov;20(11):1556-1565. doi: 10.1016/S1470-2045(19)30485-1. Epub 2019 Sep 13.
BACKGROUND
The benefits of extensive lymph node dissection as performed in complete mesocolic excision are still debated, although recent studies have shown an association with improved long-term outcomes. However, none of these studies had an intention-to-treat design or aimed to show a causal effect; therefore in this study, we aimed to estimate the causal oncological treatment effects of complete mesocolic excision on right-sided colon cancer.
METHODS
We did a population-based cohort study involving prospective data collected from four hospitals in Denmark. We compared the oncological outcome data of patients at one centre performing central lymph node dissection and vascular division after almost complete exposure of the proximal part of the superior mesenteric vein (ie, the complete mesocolic excision group) with three other centres performing conventional resections with unstandardised and limited lymph node dissection (ie, non-complete mesocolic excision; control group). We included data for all patients in the Capital Region of Denmark undergoing elective curative-intent right-sided colon resections for stages I-III colon cancer, as categorised by the Union for International Cancer Control (UICC; 5th edition), from June 1, 2008, to Dec 31, 2013. Patients were followed-up for 5·2 years after surgery. The primary outcome was the cumulative incidence of recurrence after 5·2 years of surgery. Inverse probability of treatment weighting and competing risk analyses were used to estimate the possible causal effects of complete mesocolic excision. This study is registered with ClinicalTrials.gov, number NCT03754075.
FINDINGS
1069 patients (813 in the control group and 256 in the complete mesocolic excision group) underwent curative-intent elective surgery for right-sided colon cancer during the study period. None of the patients were lost to follow-up regarding survival or recurrence status, and consequently no patient was censored in the analyses. The 5·2-year cumulative incidence of recurrence was 9·7% (95% CI 6·3-13·1) in the complete mesocolic excision group compared with 17·9% (15·3-20·5) in the control group, and the absolute risk reduction of complete mesocolic excision after 5·2 years was 8·2% (95% CI 4·0-12·4; p=0·00015). In the control group, 145 (18%) of 813 patients were diagnosed with a recurrence and 281 (35%) died during follow-up, whereas in the complete mesocolic excision group 25 (10%) of 256 patients were diagnosed with a recurrence and 75 (29%) died during follow-up.
INTERPRETATION
This study shows a causal treatment effect of central mesocolic lymph node excision on risk of recurrence after resection for right-sided colon adenocarcinoma. Complete mesocolic excision has the potential to reduce the risk of recurrence and improve long-term outcome after resection for all UICC stages I-III of right-sided colon adenocarcinomas.
FUNDING
The Tvergaard Fund, Helen Rude Fund, Krista and Viggo Petersen Fund, Olga Bryde Nielsen Fund, and Else and Mogens Wedell-Wedellsborg Fund.
背景
在完全结肠系膜切除术中进行广泛淋巴结清扫的益处仍存在争议，尽管最近的研究表明其与长期预后改善有关。然而，这些研究均没有意向治疗设计，也没有旨在显示因果效应；因此，在本研究中，我们旨在评估完全结肠系膜切除对右侧结肠癌的因果肿瘤治疗效果。
方法
我们进行了一项基于人群的队列研究，纳入了来自丹麦 4 家医院的前瞻性数据。我们比较了一个中心在几乎完全暴露肠系膜上静脉近端后进行中央淋巴结清扫和血管分离的患者的肿瘤学结果数据（即完全结肠系膜切除组）与另外 3 个中心进行的常规切除和非标准化、有限淋巴结清扫（即非完全结肠系膜切除；对照组）的患者的肿瘤学结果数据。我们纳入了丹麦首都大区所有接受 I-III 期结肠癌根治性切除术的患者数据，这些患者按照国际抗癌联盟（UICC；第 5 版）进行了分类，研究时间为 2008 年 6 月 1 日至 2013 年 12 月 31 日。患者在手术后随访 5.2 年。主要结局是手术后 5.2 年的复发累积发生率。采用逆概率治疗加权和竞争风险分析来估计完全结肠系膜切除的可能因果效应。本研究在 ClinicalTrials.gov 注册，编号为 NCT03754075。
结果
在研究期间，1069 例（对照组 813 例，完全结肠系膜切除组 256 例）患者接受了右侧结肠癌的根治性择期手术。所有患者均未失访，因此在分析中没有患者被删失。完全结肠系膜切除组 5.2 年的累积复发率为 9.7%（95%CI 6.3-13.1），对照组为 17.9%（15.3-20.5），完全结肠系膜切除后 5.2 年的绝对风险降低为 8.2%（95%CI 4.0-12.4；p=0.00015）。对照组 813 例患者中有 145 例（18%）被诊断为复发，281 例（35%）在随访期间死亡，而完全结肠系膜切除组 256 例患者中有 25 例（10%）被诊断为复发，75 例（29%）在随访期间死亡。
结论
本研究显示中央结肠系膜淋巴结切除对右侧结肠癌切除后复发风险具有因果治疗效果。完全结肠系膜切除有可能降低所有 UICC I-III 期右侧结肠癌患者的复发风险并改善长期预后。
资金来源
Tvergaard 基金、Helen Rude 基金、Krista 和 Viggo Petersen 基金、Olga Bryde Nielsen 基金和 Else 和 Mogens Wedell-Wedellsborg 基金。
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