Nagtegaal Iris D, van de Velde Cornelius J H, Marijnen Corrie A M, van Krieken Jan H J M, Quirke Philip
Department of Pathology, University Medical Centre, St Radboud, Nijmegen, the Netherlands.
J Clin Oncol. 2005 Dec 20;23(36):9257-64. doi: 10.1200/JCO.2005.02.9231.
Despite the major improvements that have been made due to total mesorectal excision (TME), low rectal cancer still remains a challenge.
By investigating a prospective randomized rectal cancer trial in which surgeons had undergone training in TME the factors responsible for the poor outcome were determined and a new method for assessing the quality of surgery was tested.
Survival differed greatly between abdominoperineal resection (APR) and anterior resection (AR; 38.5% v 57.6%, P = .008). Low rectal carcinomas have a higher frequency of circumferential margin involvement (26.5% v 12.6%, P < .001). More positive margins were present in the patients operated with APR (30.4%) compared to AR (10.7%, P = .002). Furthermore, more perforations were present in these specimens (13.7% v 2.5%, P < .001). The plane of resection lies within the sphincteric muscle, the submucosa or lumen in more than 1/3 of the APR cases, and in the remainder lay on the sphincteric muscles.
We systematically described and investigated the pathologic properties of low rectal cancer in general, and APR in particular, in a prospective randomized trial including surgeons who had been trained in TME. The poor prognosis of the patients with an APR is ascribed to the resection plane of the operation leading to a high frequency of margin involvement by tumor and perforation with this current surgical technique. The clinical results of this operation could be greatly improved by adopting different surgical techniques and possibly greater use of radiochemotherapy.
尽管全直肠系膜切除术（TME）已带来重大改进，但低位直肠癌仍然是一项挑战。
通过调查一项前瞻性随机直肠癌试验（其中外科医生接受了TME培训），确定了导致不良结果的因素，并测试了一种评估手术质量的新方法。
腹会阴联合切除术（APR）和前切除术（AR）的生存率差异很大（38.5%对57.6%，P = 0.008）。低位直肠癌环周切缘受累的频率更高（26.5%对12.6%，P < 0.001）。与AR组（10.7%，P = 0.002）相比，接受APR手术的患者切缘阳性更多（30.4%）。此外，这些标本中的穿孔更多（13.7%对2.5%，P < 0.001）。在超过1/3的APR病例中，切除平面位于括约肌、黏膜下层或管腔内，其余位于括约肌上。
我们在一项前瞻性随机试验中系统地描述和研究了低位直肠癌的病理特性，特别是APR的病理特性，该试验纳入了接受过TME培训的外科医生。APR患者预后不良归因于手术的切除平面，导致肿瘤侵犯切缘和穿孔的频率较高，采用目前的手术技术。通过采用不同的手术技术并可能更多地使用放化疗，该手术的临床结果可能会得到极大改善。
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