Kim Jin C, Takahashi Keiichi, Yu Chang S, Kim Hee C, Kim Tae W, Ryu Min H, Kim Jong H, Mori Takeo
Department of *urgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea.
Ann Surg. 2007 Nov;246(5):754-62. doi: 10.1097/SLA.0b013e318070d587.
To evaluate comparative outcome between adjuvant postoperative chemoradiotherapy (postoperative CRT) and lateral pelvic lymph node dissection (LPLD) following total mesorectal excision (TME) in rectal cancer patients.
Although TME results in lower rate of locoregional recurrence compared with conventional surgery, these 2 treatment modalities following TME have not adequately been appraised until the present trend of preoperative chemoradiotherapy.
Between 1995 and 2000, patients with stage II and III rectal cancer underwent TME plus postoperative CRT (n = 309) or LPLD (n = 176). Patients in the postoperative CRT group received 8 cycles of 5-fluorouracil plus leucovorin and 45 Gy pelvic radiotherapy. Patients in the LPLD group underwent lateral lymph node dissection outside the pelvic plexus.
The 5-year overall and disease-free survival rates were 78.3% and 67.3% in the postoperative CRT group, respectively, and 73.9% and 68.6% in the LPLD group, respectively, without significant differences between these groups. Patients in the LPLD group with stage III lower rectal cancer had a locoregional recurrence rate 2.2-fold greater than those in the postoperative CRT group (16.7% vs. 7.5%, P = 0.044). Multivariate analysis showed that APR and advanced T-category (T4) were significantly associated with locoregional recurrence, whereas lymph node metastases, high preoperative serum carcinoembryonic antigen, and APR were significantly associated with shortening of disease-free survival.
Postoperative-CRT and LPLD following TME resulted in comparable survival rates, but the locoregional recurrence rate was higher in the LPLD group. These findings suggest that initial surgery is appropriate for rectal cancer patients who are candidates for low anterior resection without extensive local disease (T1-T3), regardless of lymph node status.
评估直肠癌患者全直肠系膜切除（TME）术后辅助放化疗（术后CRT）与侧方盆腔淋巴结清扫术（LPLD）的比较结果。
尽管与传统手术相比，TME导致局部区域复发率较低，但直到目前术前放化疗的趋势出现之前，这两种TME后的治疗方式尚未得到充分评估。
1995年至2000年期间，II期和III期直肠癌患者接受了TME加术后CRT（n = 309）或LPLD（n = 176）。术后CRT组的患者接受8个周期的5-氟尿嘧啶加亚叶酸以及45 Gy盆腔放疗。LPLD组的患者在盆腔神经丛外进行侧方淋巴结清扫。
术后CRT组的5年总生存率和无病生存率分别为78.3%和67.3%，LPLD组分别为73.9%和68.6%，两组之间无显著差异。LPLD组中III期低位直肠癌患者的局部区域复发率比术后CRT组高2.2倍（16.7%对7.5%，P = 0.044）。多因素分析显示，腹会阴联合切除术（APR）和进展期T分期（T4）与局部区域复发显著相关，而淋巴结转移、术前血清癌胚抗原水平高和APR与无病生存期缩短显著相关。
TME术后CRT和LPLD的生存率相当，但LPLD组的局部区域复发率较高。这些结果表明，对于适合低位前切除术且无广泛局部病变（T1-T3）的直肠癌患者，无论淋巴结状态如何，初始手术都是合适的。
