Rougier P, Mitry E, Clavéro-Fabri M C, Penna C, Nordlinger B
Hôpital Ambroise Paré, Boulogne, France.
Ann Chir. 1999;53(10):1011-8.
Adjuvant chemotherapy appears to be active in stage II-III rectal cancers; the NSAPB R01 trial demonstrated a survival advantage for patients receiving chemotherapy using the MOF protocol and 3 meta-analyses are in favor of the efficacy of adjuvant chemotherapy in rectal cancer. Three randomized trials have also demonstrated that combinations of radiation and chemotherapy are superior to surgery alone or adjuvant radiotherapy and demonstrated the major role of systemic chemotherapy combined with radiotherapy. However this efficacy of adjuvant chemotherapy alone or combined with radiation therapy is still debated and specific trials must be conducted to test the value of chemotherapy using more active regimens than those previously tested and taking into account the quality of surgery and radiotherapy; such trials are in progress, especially the trial conducted by the EORTC and the FFCD. The efficacy of neoadjuvant chemotherapy has never been clearly demonstrated, although a combination of radiotherapy and chemotherapy as first-line treatment for locally advanced rectal cancer and in the case of synchronous metastasis seems to facilitate surgical resection. It is a reasonable and tolerable approach with manageable toxicity which gives substantial results in 2/3 of patients. This strategy also allows better selection of patients likely to benefit from surgical resection of their primary tumor and in some cases of their synchronous metastases. However, the efficacy of perioperative treatments should not decrease the quality of the surgical resection and especially mesorectal excision as well as the need for high quality pathological examination which must be very thorough with analysis of a sufficient number of lymph nodes. The efficacy of combined treatment in advanced rectal cancers is a major argument in favor of the multidisciplinary coordination required for optimal treatment of patients with rectal cancer.
辅助化疗在II - III期直肠癌中似乎具有活性；NSAPB R01试验证明，采用MOF方案接受化疗的患者具有生存优势，并且三项荟萃分析支持辅助化疗在直肠癌中的疗效。三项随机试验还表明，放疗与化疗联合优于单纯手术或辅助放疗，并证明了全身化疗联合放疗的主要作用。然而，单纯辅助化疗或联合放疗的疗效仍存在争议，必须进行特定试验，以测试使用比先前试验更积极的方案进行化疗的价值，并考虑手术和放疗的质量；此类试验正在进行中，尤其是欧洲癌症研究与治疗组织（EORTC）和法国癌症研究与治疗协会（FFCD）开展的试验。新辅助化疗的疗效从未得到明确证实，尽管放疗与化疗联合作为局部晚期直肠癌的一线治疗以及在同步转移的情况下似乎有助于手术切除。这是一种合理且可耐受的方法，毒性可控，在三分之二的患者中能取得显著效果。该策略还能更好地筛选可能从原发肿瘤以及某些情况下同步转移灶的手术切除中获益的患者。然而，围手术期治疗的疗效不应降低手术切除的质量，尤其是直肠系膜切除的质量，以及高质量病理检查的必要性，病理检查必须非常彻底，要对足够数量的淋巴结进行分析。晚期直肠癌联合治疗的疗效是支持对直肠癌患者进行最佳治疗所需多学科协作的一个主要论据。
