Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
Eur J Surg Oncol. 2010 May;36(5):470-6. doi: 10.1016/j.ejso.2009.11.011. Epub 2010 Jan 21.
In patients from the Dutch TME trial patterns of local recurrence (LR) in rectal cancer were studied. The purpose was to reconstruct the most likely mechanisms of LR and the effect of preoperative radiotherapy.
1417 patients were analyzed; 713 were randomized into preoperative radiotherapy and total mesorectal excision (RT + TME), 704 into TME alone. Of the 114 patients with LR, the subsites of LR were determined and related to tumor and treatment factors.
Overall 5-year LR-rate was 4.6% in the RT + TME group and 11.0% in the TME group. Presacral local recurrences occurred most in both groups. Radiotherapy reduced anastomotic LR significantly, except when after low anterior resection (LAR) distal margins were less than 5 mm. Abdominoperineal resection (APR) mainly resulted in presacral LR. Even after resection with a negative circumferential resection margin, LR-rates were high. Thirty percent of the patients had advanced tumors, which resulted in 58% of all LRs. Lateral LR comprised 20% of all LR. Presacral and lateral LR resulted in a poor prognosis, in contrast to anterior or anastomotic LRs with a relatively good prognosis.
RT reduces LR in all subsites and is especially effective in preventing anastomotic LR after LAR. APR-surgery mainly results in presacral LR, which may be prevented by a wider resection. In the TME trial many advanced tumors were included, rather requiring chemoradiotherapy instead of RT. Currently, with good imaging techniques, better selection can take place. Especially lateral LR might be a problem in the future.
在荷兰 TME 试验的患者中，研究了直肠癌局部复发（LR）的模式。目的是重建 LR 最可能的机制以及术前放疗的效果。
分析了 1417 例患者；713 例随机分为术前放疗和全直肠系膜切除术（RT+TME），704 例单独接受 TME。在 114 例 LR 患者中，确定了 LR 的亚部位，并与肿瘤和治疗因素相关。
总体而言，RT+TME 组 5 年 LR 率为 4.6%，TME 组为 11.0%。两组均以直肠前局部复发为主。放疗显著降低吻合口 LR，低位前切除（LAR）时远切缘小于 5mm 除外。腹会阴切除术（APR）主要导致直肠前 LR。即使在切除时环周切缘阴性，LR 率也很高。30%的患者有晚期肿瘤，导致所有 LR 的 58%。侧方 LR 占所有 LR 的 20%。与前或吻合口 LR 相比，直肠前和侧方 LR 预后较差，而前或吻合口 LR 预后相对较好。
RT 降低了所有亚部位的 LR，尤其是在 LAR 后预防吻合口 LR 方面效果显著。APR 手术主要导致直肠前 LR，可以通过更广泛的切除来预防。在 TME 试验中，包括了许多晚期肿瘤，而不是需要放化疗。目前，随着影像学技术的进步，可以进行更好的选择。特别是侧方 LR 可能是未来的一个问题。
