Minsky B D
Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA.
Colorectal Dis. 2003 Sep;5(5):416-22. doi: 10.1046/j.1463-1318.2003.00504.x.
In North America there are two conventional treatments for clinically resectable rectal cancer. First is surgery and, if the tumour is T3 and/or N1-2, this is followed by postoperative combined modality therapy. The second, for patients with ultrasound T3 or clinical T4 disease, is pre-operative combined modality therapy followed by surgery and postoperative chemotherapy. Pre-operative therapy (most commonly combined modality therapy) has gained acceptance as a standard adjuvant therapy. The potential advantages of this approach compared with postoperative therapy include less acute toxicity and enhanced sphincter preservation. Recently completed randomized trials in the US and Germany will provide a definitive answer to this theory. In contrast to the combined modality approach to pre-operative therapy a number of European centres advocate an intensive short course of radiation (5 Gy x 5 followed one week later by surgery). The only randomized trial which has revealed a significant advantage in survival is the Swedish Rectal Cancer Trial. The Dutch CKVO 95-04 TME trial did not confirm a survival advantage and two metanalyses report conflicting results. Due to selection bias, it is not possible accurately to compare the local recurrence and survival results of intensive short course radiation with conventional pre-operative combined modality therapy. The intensive short course radiation approach is not used in North America due to its higher toxicity and lack of sphincter preservation. In the Dutch trial the 5-year local recurrence was 12% with TME and was significantly decreased to 6% with pre-operative radiation. The 5-year local recurrence rate in the 324 patients with stage III disease who underwent a TME alone with negative margins was 20%. Therefore, despite TME surgery, radiation therapy is still a necessary component in the adjuvant management of rectal cancer.
在北美，临床上可切除的直肠癌有两种传统治疗方法。第一种是手术治疗，如果肿瘤为T3和/或N1-2期，则术后进行综合治疗。第二种，对于超声检查为T3期或临床诊断为T4期的患者，先进行术前综合治疗，然后手术，术后进行化疗。术前治疗（最常见的是综合治疗）已被公认为标准的辅助治疗方法。与术后治疗相比，这种方法的潜在优势包括急性毒性较小和括约肌保留率提高。美国和德国最近完成的随机试验将为这一理论提供明确答案。与术前综合治疗方法不同，一些欧洲中心主张采用强化短程放疗（5 Gy×5，一周后进行手术）。唯一一项显示出生存显著优势的随机试验是瑞典直肠癌试验。荷兰CKVO 95-04 TME试验未证实生存优势，两项荟萃分析报告的结果相互矛盾。由于存在选择偏倚，无法准确比较强化短程放疗与传统术前综合治疗的局部复发率和生存率结果。由于毒性较高且无法保留括约肌，北美未采用强化短程放疗方法。在荷兰的试验中，TME组的5年局部复发率为12%，术前放疗组显著降至6%。324例III期疾病患者仅接受切缘阴性的TME手术，其5年局部复发率为20%。因此，尽管有TME手术，放疗仍是直肠癌辅助治疗中必不可少的组成部分。
