Bujko Krzysztof, Nowacki Marek P, Nasierowska-Guttmejer Anna, Kepka Lucyna, Winkler-Spytkowska Barbara, Suwiński Rafal, Oledzki Janusz, Stryczyńska Grazyna, Wieczorek Andrzej, Serkies Krystyna, Rogowska Danuta, Tokar Piotr
Department of Radiotherapy, Maria SkŁodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland.
Radiother Oncol. 2005 Sep;76(3):234-40. doi: 10.1016/j.radonc.2005.04.004.
For patients with rectal cancer treated with full thickness local excision the risk of mesorectal nodal metastases has to be very low. The aim was to assess this risk after preoperative radiotherapy in relation to pathological T-category.
Three hundred sixteen patients with resectable cT3-4 low rectal carcinoma were randomised to receive either pre-operative 5 x 5 Gy irradiation with subsequent surgery performed within 7 days or chemoradiation (50.4, 1.8 Gy per fraction plus bolus 5-fluorouracil and leucovorin) followed by surgery after 4-6 weeks. The pathological reports of patients who fulfilled entry criteria and had preoperative irradiation followed by transabdominal surgery were analysed.
Significant downstaging of primary tumour (P<0.001) and of nodal disease (P=0.007) was observed after chemoradiation in comparison with short-course irradiation. In chemoradiation group, for patients with complete pathological response and for ypT1 category, the rate of nodal metastases was low - 5% (95% confidence interval [CI] 0-14%) and 8% (95% CI 0-24%), respectively. The rate of ypN-positive disease in chemoradiation group was similar to that recorded in short-course irradiation group for ypT2 category 26% (95% CI 14-38%) vs. 28% (95% CI 16-40%), P=0.83 and for ypT3-4 category 55% (95% CI 41-69%) vs. 64% (95% CI 54-74%), respectively, P=0.37. For ypT2 category after chemoradiation, the rate of nodal disease remained high even in subgroup with low residual cancer cells density (20%, 95% CI 4-36%).
For patients with tumours downstaged by chemoradiation to ypT0 and ypT1 full thickness local excision may be considered as an acceptable approach, because the risk of mesorectal lymph nodes metastases is low. The selection criteria for preoperative radio(chemo)therapy and local excision are discussed.
对于接受全层局部切除治疗的直肠癌患者，直肠系膜淋巴结转移风险必须非常低。本研究旨在评估术前放疗后该风险与病理T分期的关系。
316例可切除的cT3-4期低位直肠癌患者被随机分为两组，一组接受术前5×5 Gy照射，随后在7天内进行手术；另一组接受放化疗（50.4 Gy，每次1.8 Gy，加推注5-氟尿嘧啶和亚叶酸钙），4-6周后进行手术。对符合入选标准且接受术前放疗并经腹手术的患者的病理报告进行分析。
与短程放疗相比，放化疗后原发肿瘤（P<0.001）和淋巴结疾病（P=0.007）出现显著降期。在放化疗组中，对于病理完全缓解的患者和ypT1期患者，淋巴结转移率较低，分别为5%（95%置信区间[CI] 0-14%）和8%（95% CI 0-24%）。放化疗组ypN阳性疾病发生率与短程放疗组中ypT2期（26%，95% CI 14-38%对28%，95% CI 16-40%，P=0.83）和ypT3-4期（分别为55%，95% CI 41-69%对64%，95% CI 54-74%，P=0.37）的记录相似。对于放化疗后的ypT2期，即使在残留癌细胞密度低的亚组中，淋巴结疾病发生率仍较高（20%，95% CI 4-36%）。
对于经放化疗降期至ypT0和ypT1期的患者，全层局部切除可被视为一种可接受的方法，因为直肠系膜淋巴结转移风险较低。讨论了术前放疗（化疗）和局部切除的选择标准。
