Borschitz Thomas, Heintz Achim, Junginger Theodor
Clinic of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Langenbeckstrasse 1, D-55131 Mainz, Germany.
Dis Colon Rectum. 2006 Oct;49(10):1492-506; discussion 1500-5. doi: 10.1007/s10350-006-0587-1.
Local excision of early rectal cancer is a controversial issue, which is in part because of differences in the evaluation of histopathologic criteria. This prospective study was designed to determine prognostic factors for recurrences and the need for reoperation.
In 105 of 118 patients with pT1 carcinomas and local excision, results of recurrence rates and ten-year cancer-free survival were studied separately according to different histologic criteria (R0, R1, Rx, R < or = 1 mm, high-/low-risk situation), tumor localization (anterior, posterior, lateral wall and third of rectum), size, and degree of resection (full-thickness/partial wall). Patients were grouped into local excision (n = 89) and local excision followed by reoperation (n = 21). Risk classification was performed by division into "low-risk" carcinomas after local R0-resection (Group A) and unfavorable histologic results after local resection (R1, Rx, R < or = 1 mm, high-risk situation; Group B).
Local recurrence rates after local R0-resection of low-risk carcinomas were 6 percent, whereas patients in Group B with local resection were 39 percent. The recurrence risk in those patients was significantly reduced to 6 percent by reoperation (P = 0.015). In addition, ten-year, cancer-free survival was 93 percent in Group B after reoperation compared with 89 percent in patients of Group A after local excision alone.
Local R0-resection in cases with low-risk pT1 carcinomas represents an oncologically adequate therapy, which results in similar survival rates compared with primary radical surgery of pT1N0M0 rectal carcinomas. High recurrence rates are observed in tumors with unfavorable histologic result (Group B) requiring further treatment. In these cases immediate reoperation reduces the recurrence rate to 6 percent.
早期直肠癌的局部切除是一个存在争议的问题，部分原因是组织病理学标准评估存在差异。本前瞻性研究旨在确定复发的预后因素以及再次手术的必要性。
在118例行局部切除的pT1期癌患者中，选取105例，根据不同的组织学标准（R0、R1、Rx、R≤1mm、高/低风险情况）、肿瘤定位（前壁、后壁、侧壁及直肠的三分之一）、大小和切除程度（全层/部分肠壁），分别研究复发率和十年无癌生存率的结果。患者分为局部切除组（n = 89）和局部切除后再手术组（n = 21）。通过将局部R0切除后的“低风险”癌（A组）与局部切除后组织学结果不佳（R1、Rx、R≤1mm、高风险情况；B组）进行分组来进行风险分类。
低风险癌局部R0切除后的局部复发率为6%，而B组局部切除患者的复发率为39%。再次手术使这些患者的复发风险显著降低至6%（P = 0.015）。此外，B组再次手术后的十年无癌生存率为93%，而A组单纯局部切除患者的十年无癌生存率为89%。
低风险pT1期癌病例的局部R0切除是一种肿瘤学上合适的治疗方法，与pT1N0M0期直肠癌的原发性根治性手术相比，生存率相似。组织学结果不佳的肿瘤（B组）复发率高，需要进一步治疗。在这些病例中，立即再次手术可将复发率降低至6%。
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