Valentini Vincenzo, Glimelius Bengt, Minsky Bruce D, Van Cutsem Eric, Bartelink Hanry, Beets-Tan Regina G H, Gerard Jean-Pierre, Kosmidis Paris, Pahlman Lars, Picciocchi Aurelio, Quirke Phil, Tepper Joel, Tonato Maurizio, Van de Velde Cornelius J, Cellini Numa, Latini Paolo
Cattedra di Radioterapia, Università Cattolica S.Cuore, Rome, Italy.
Radiother Oncol. 2005 Sep;76(3):241-50. doi: 10.1016/j.radonc.2005.07.001.
During the past decades staging and treatment of rectal cancer are used different in Europe and in North America. To promote a process to integrate the daily practice with the best evidence of the literature an International Conference was organized in Italy. Agreement between Experts, Centres, and specialists who participated in the Conference are reported.
Five aspects were analyzed and a questionnaire was tailored for this purpose. The questionnaire had 159 questions. During the Conference, at the beginning of each Session, the moderators showed the answers from the Experts and the Centres, and, at the end of the session, the audience voted in all controversial issues. Agreements were scored at three levels: minimum, if it was between 51 and 74% of votes for each group; moderate, between 75 and 94%; large, more than 94%.
The main results are: staging: endoanal ultrasound was considered as mandatory in T staging, in the evaluation of sphincter infiltration, and in the restaging of T after chemoradiotherapy (chRT). Magnetic Resonance Imaging is mandatory in the evaluation of mesorectal fascia infiltration. Endoscopy had a moderate agreement for the definition of tumour location, and the barium enema as optional. Digital rectal examination is complementary for staging and PET-CT investigational for T, N and yT staging. Preoperative radiotherapy: for T4 stage chRT was always the preferred treatment, often with moderate agreement, for any tumour location and N status. For T3, chRT received the same agreement except for high location and N0-N1. For T2 stage, N2 and positive nodes outside the mesorectum, chRT received minimum agreement for low and middle tumours; for high tumours only positive nodes outside the mesorectum was agreed upon. Preoperative radiotherapy, negative specimen and sphincter preservation: chRT was agreed by many for all T stages and N presentations of lower third tumours, except for T1-2 N0-N1. Postoperative treatments: the selection for these treatments often received moderate agreement according to the infiltration of surrounding organs, positive nodal status and circumferential radial margins. Therapy of metastatic disease: an agreement was found for FOLFOX as first-line therapy and for FOLFIRI as second-line, although comparative studies show similar activity of FOLFOX and FOLFIRI regimens.
This process represents an expertise opinion process that may contribute to increased scientific debate and to promote the development of 'guidelines', 'clinical recommendations' and ultimately a Consensus on the evolving approach to rectal cancer treatment.
在过去几十年中，欧洲和北美对直肠癌的分期及治疗方法有所不同。为推动日常实践与文献最佳证据相结合的进程，在意大利组织了一次国际会议。本文报告了参会的专家、中心和专科医生之间达成的共识。
分析了五个方面，并为此专门设计了一份问卷。该问卷有159个问题。在会议期间，每场会议开始时，主持人展示专家和各中心的答案，会议结束时，参会人员就所有有争议的问题进行投票。共识分为三个等级：低共识，即每组投票率在51%至74%之间；中等共识，在75%至94%之间；高共识，超过94%。
主要结果如下：分期：腔内超声在T分期、评估括约肌浸润以及放化疗（chRT）后T分期的重新评估中被认为是必需的。磁共振成像在评估直肠系膜筋膜浸润时是必需的。内镜检查在肿瘤位置定义方面达成中等共识，钡剂灌肠为可选检查。直肠指检是分期的补充检查，PET-CT用于T、N和yT分期的研究。术前放疗：对于T4期，无论肿瘤位置和N分期如何，chRT始终是首选治疗方法，且通常达成中等共识。对于T3期，除高位肿瘤和N0-N1外，chRT达成的共识相同。对于T2期、N2以及直肠系膜外阳性淋巴结，低位和中位肿瘤的chRT达成低共识；对于高位肿瘤，仅直肠系膜外阳性淋巴结达成共识。术前放疗、阴性标本与括约肌保留：对于低位直肠癌的所有T分期和N分期表现，除T1-2 N0-N1外，许多人同意采用chRT。术后治疗：根据周围器官浸润、阳性淋巴结状态和环周切缘情况，这些治疗方法的选择通常达成中等共识。转移性疾病的治疗：尽管比较研究表明FOLFOX和FOLFIRI方案的活性相似，但对于FOLFOX作为一线治疗、FOLFIRI作为二线治疗达成了共识。
这一过程代表了一种专家意见过程，可能有助于增加科学辩论，并促进“指南”“临床建议”的制定，最终就直肠癌治疗的不断发展的方法达成共识。
