Kiss L, Kiss R, Porr P J, Nica C, Nica C, Bardac O, Tănăsescu C, Bărbulescu B, Bundache M, Ilie S, Maniu D, Zaharie S I, Hulpuş R
I-st Surgical Clinic, Emergency Academic Hospital Sibiu, Romania.
Chirurgia (Bucur). 2011 May-Jun;106(3):347-52.
Pelvic recurrence following conventional rectal resection for cancer is common. Preoperative iradiation has been shown in prospective randomized studies to halve this risk.
This multiinstitutional study aimed to assess the necesity of total mesorectal excision in rectal cancer.
Pathological resections from 50 consecutive patients with adenocarcinoma of the rectum within 12 cm of the anal verge who underwent currative resection incorporating total mesorectal excision were examined. The resection specimen was examined by one of two pathologists. Some 50 total mesorectal excision specimens were examined following rectal excision for cancer. Some 38 had total mesorectal excision as a component of a low anterior resection and 12 with abdomino-perineal resection. "Cure" was defined as absence of metastatic disease and the excision of entire macroscopic tumor tissue with negative proximal and distal borders. TME was performed as described by Heald et al. The mesorectum was evaluated for lymph nodes and tumor deposists in three areas: deep to the tumor, in the proximal mesorectum and in the distal mesorectum.
Six patients had Dukes A lesions. Of 21 patients with Dukes B tumors, five had discrete foci of adenocarcinoma in the mesorectum, with no evidence of lymph node metastasis. Dukes C lesions were more heterogeneous, but 12 out of 23 patients had distinct mesorectal deposists in addition to mesorectal node involvement. Circumferential margin involvement was rare, but mesorectal tumor deposits were present in 17 of 44 patients with pT3 tumors, and 23 of 44 had mesorectal nodal involvement. No patient with a pT2 tumor had mesorectal involvement. Failure to excise the mesorectum completely has the potential to leave gross or microscopic residual disease that may in theory predispose to local failure.
Total mesorectal excision is necessary to avoid incomplete pathological evaluation of the mesorectum and understaging of rectal cancer.
常规直肠癌切除术后盆腔复发很常见。前瞻性随机研究表明，术前放疗可使这种风险减半。
这项多机构研究旨在评估直肠癌全直肠系膜切除术的必要性。
对50例距肛缘12厘米以内的直肠腺癌患者进行了根治性切除，其中包括全直肠系膜切除术，并对其病理切除标本进行了检查。切除标本由两名病理学家之一进行检查。约50例直肠癌切除术后的全直肠系膜切除标本接受了检查。其中约38例将全直肠系膜切除术作为低位前切除术的一部分，12例进行了腹会阴联合切除术。“治愈”定义为无转移性疾病，且切除整个肉眼可见的肿瘤组织，切缘近端和远端均为阴性。全直肠系膜切除术按照希尔德等人描述的方法进行。在三个区域评估直肠系膜的淋巴结和肿瘤沉积物：肿瘤深部、直肠系膜近端和直肠系膜远端。
6例患者为杜克A期病变。在21例杜克B期肿瘤患者中，5例在直肠系膜中有离散的腺癌病灶，无淋巴结转移证据。杜克C期病变更为异质性，但23例患者中有12例除直肠系膜淋巴结受累外，还有明显的直肠系膜沉积物。切缘周径受累很少见，但在44例pT3肿瘤患者中，17例有直肠系膜肿瘤沉积物，44例中有23例有直肠系膜淋巴结受累。没有pT2肿瘤患者出现直肠系膜受累。未能完全切除直肠系膜有可能留下大体或显微镜下的残留病灶，理论上可能导致局部复发。
全直肠系膜切除术对于避免直肠系膜的病理评估不完整和直肠癌分期不足是必要的。
