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대장암 환자의 수술 전 내시경적 폐색이 수술 후 예후에 미치는 영향
나영현(Young Hyun Na),이선일(Sun Il Lee),강상희(Sang Hee Kang),홍광대(Kwang Dae Hong),문홍영(Hong Young Moon) 대한종양외과학회 2012 Korean Journal of Clinical Oncology Vol.8 No.2
목적 : 대장암의 재발 고위험인들 중 장폐색 여부는 수술 전 예측 가능하여 환자 선별과 수술전 치료의 도입에 중요한 선택인자가 되리라 여겨지나, 그 동안 임상적 기계적 장폐색에 비해 부분적 폐색 혹은 내시경적 폐색에 대한 연구가 많지 않아. 연구자들은 내시경적 장폐색 유무가 미치는 영향을 연구하였다. 대상 및 방법 : 2003년 1월 1일부터 2006년 12월 31일까지 단일 병원에서 근치적 절제수술을 받은 대장암 환자 들 중 2기 및 3기 환자 315명을 대상으로 후향적 연구를 시행하였으며 폐색의 임상소견이 없으나 대장 내시경이 종양의 근위부로 통과하지 못하는 경우를 내시경적 폐색으로 정의하였다. 결과 : 남녀비는 1.4:1이었으며 평균연령은 62.0세였다. 폐색 여부에 따라 비교하였을 때, 종양의 크기와 위치, 침윤도, 수술전 CEA(carcinoembryogenic antigen)는 유의한 차이를 보였으나 림프절 전이 여부는 유의하지 않았다. 또한, 폐색성 결장암의 41.1%가 침윤형 혹은 윤형이었으며 이는 비폐색성 결장암의 23.4%에서만 관찰되었다 (p<0.05). 5년 무병생존율은 85.8%(2기)와 70.7%(3기)였으며 2기 및 3기 결장암과 3기 직장암에서는 폐색여부에 따른 차이가 없었으나, 2기 직장암에서는 유의한 차이를 보였다. 결론 : 내시경적 폐색은 2기 직장암에서 유의한 재발 위험 인자로 추정되는 바, 이러한 환자들에 대해 수술전 방사선 치료 등의 추가적 요법을 고려해야 하겠다. Purpose : The colorectal cancer has better prognosis rather than other gastrointestinal malignancy by the development of operation procedure and adjuvant therapy. But the high-risk patients have a high recurrence rate and a poor prognosis, so more interest and the development of new treatment modality for high-risk patients is needed. Now some high-risk factors of the colorectal cancer ? lymph node metastasis and lymphatic/vascular invasion ? were difficult to estimate preoperatively. The colon obstruction is considered to be a factor which is predictable preoperatively and helpful for patient. There were fewer studies about oncologic outcome of partial or endoscopic colon obstruction than complete colon obstruction, so we investigate the prognostic impact of endoscopic obstruction on colorectal cancer. Materials and Methods : Retrospective analysis of 317 patients with surgically resected stage Ⅱ and Ⅲ colorectal cancer in Korea University Guro Hospital from 1st January 2003 to 31st December 2006 was performed for preoperative colon obstruction and postoperative prognosis. Statistical analysis was performed using SPSS® 12.0 Chi-square test and t-test were used for comparing each variables. OS analysis was performed using Kaplan-Meier curves with long-rank testing. P<0.05 was considered statistically significant. Result : Gender (Male : Female) of whole patients was 1.4:1. Mean age was 62.0(year). Comparison of clinical features and pathologic findings according to the presence of obstruction demonstrated a significant difference in size, location, infiltration, and preoperative CEA (carcinoembryogenic antigen), yet showed no major difference in age, sex, the timing of surgery, and lymph node metastasis. When the left colon was compared with the right colon while excluding the rectum, difference was found between the sizes of the tumor, but no difference was found in the presence of obstruction. According to the comparison based on the shape of the tumor, 41.1% of the obstructive colon cancer was infiltrating or encircling, and these findings were observed in 23.4% of nonobstructive colon cancer (p<0.05). There were 69 recurrences during the monitoring, and the 5-year disease-free survival rate for stage Ⅱ and stage Ⅲ were 85.5% and 70.7% respectively. Comparing the disease-free survival rate according to the location of the lesion and presence of obstruction, it showed no difference in stage Ⅲ colon and rectal cancer, but a significant difference was found in stage Ⅱ rectal cancer. When compared according to the types of obstruction, the 5-year disease-free survival rates for no obstruction, endoscopic obstruction, and complete obstruction were 77.2%, 70.9%, and 67.1%, respectively. There were no differences between them. Conclusion : Endoscopic obstruction is a significant risk factor for recurrence in stage Ⅱ rectal cancer compared to colon cancer and for those patients, adjuvant treatment such as pre-operative radiotherapy is needed.
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