Background:T4 colorectal cancer (CRC) is associated with an increased risk of peritoneal metastases (PM), but it is currently not possible to accurately predict which patients with T4 CRC develop PM. We investigated the occurrence and risk factors for PM in these patients.Methods: A mono-institutional prospective database of 352 patients undergoing T4 primary CRC resection from 2012 to 2021 was reviewed. Clinico-pathological variables potentially associated with synchronous or metachronous PM were tested by univariate and multivariate analyses.Results: The prevalence of synchronous PM was 73/352 (20.7%) and was significantly associated with age (p= 0.037), primary site (p= 0.002), positive nodes (p= 0.005), elevated CA19.9 (p= 0.001), and non-intestinal histology (p= 0.001). After a median follow-up of 35.9 months (95% confidence interval [CI] = 29.5–44.9), metachronous CRC-PM occurred in 36/164 patients (22.0%) with available data, accounting for a three-year cumulative incidence of 21.5% (95% CI = 14.3–28.1). Metachronous CRC-PM occurred in 3/48 patients (6.2%) with negative nodes and normal CEA, as compared with 33/116 patients (28.4%) with positive nodes and/or elevated CEA (p< 0.001). Combined nodal and CEA status (hazard ratio [HR] = 1.27; 95% CI = 1.02–1.59;p= 0.033), postoperative chemotherapy (HR= 0.51; 95% CI = 0.33–0.77;p= 0.001), and positive resection margins (HR = 2.01; 95% CI = 1.20–3.39;p= 0.008) were significantly associated with PM.Conclusions: The peritoneum is a major site for treatment failure in T4 CRC. Patients with normal CEA and negative lymph nodes are associated with a significantly lower risk for metachronous CRC-PM. These findings may help in refining patient selection for integrated approaches aiming at the prevention or early treatment of CRC-PM, which are pending validation in prospective studies.
背景：T4期结直肠癌（CRC）与腹膜转移（PM）风险增加相关，但目前尚无法准确预测哪些T4期CRC患者会发生PM。本研究旨在探讨此类患者PM的发生情况及其危险因素。 方法：回顾性分析2012年至2021年间接受T4期原发性CRC切除术的352例患者的单中心前瞻性数据库。通过单因素和多因素分析，评估与同时性或异时性PM可能相关的临床病理学变量。 结果：同时性PM的发生率为73/352（20.7%），其发生与年龄（p=0.037）、原发部位（p=0.002）、淋巴结阳性（p=0.005）、CA19.9升高（p=0.001）以及非肠型组织学类型（p=0.001）显著相关。中位随访35.9个月（95%置信区间[CI]=29.5–44.9）后，在可获得数据的164例患者中，36例（22.0%）发生异时性CRC-PM，三年累积发生率为21.5%（95% CI=14.3–28.1）。淋巴结阴性且CEA正常的48例患者中，有3例（6.2%）发生异时性CRC-PM；而淋巴结阳性和/或CEA升高的116例患者中，有33例（28.4%）发生异时性CRC-PM（p<0.001）。淋巴结状态与CEA状态的组合（风险比[HR]=1.27；95% CI=1.02–1.59；p=0.033）、术后化疗（HR=0.51；95% CI=0.33–0.77；p=0.001）以及切缘阳性（HR=2.01；95% CI=1.20–3.39；p=0.008）与PM的发生显著相关。 结论：腹膜是T4期CRC治疗失败的主要部位。CEA正常且淋巴结阴性的患者发生异时性CRC-PM的风险显著降低。这些发现可能有助于优化患者选择，以实施旨在预防或早期治疗CRC-PM的综合策略，但尚需在前瞻性研究中进一步验证。
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