Fekete Z, Muntean A, Irimie A, Hica S, Resiga L, Todor N, Nagy V
Iuliu Hatieganu University of Medicine and Pharmacy, Department of Oncology, Cluj-Napoca; Ion Chiricuta Institute of Oncology,Cluj-Napoca, Romania.
J BUON. 2013 Oct-Dec;18(4):989-95.
The aim of this study was to analyze the characteristics of patients with rectal cancer operated with a microscopic positive margin (R1) and thus avoid these situations or adapt treatment in these particular cases.
We reviewed all the pathology data of resected specimens from patients with rectal or recto-sigmoid cancer operated with curative intent at the Institute of Oncology "Prof. Dr. Ion Chiricuta" between 2000-2011 (763 patients in 12 years) and the pathology files of patients from other institutions referred for adjuvant treatment to our hospital (318 patients). We included patients with anterior resection, Hartmann's procedure and abdomino-perineal resection, but we excluded patients with local excision and patients with R2/R1 at first, but R0 after re-resection (56 patients). We have identified 31 patients with R1, but had to exclude one case from analysis because this patient was lost to follow-up.
With surgery alone the local relapse (LR) was unavoidable. In the neoadjuvant chemoradiation (CRT) group 85.7% of the patients did not develop LR despite of R1. In the adjuvant CRT cohort 50% of the patients were LR-free at 2 years after conventional radiotherapy (p<0.01).
Based on these results it is concluded that a clear resection margin is extremely important for the local control of rectal cancer, because it cannot be always compensated by adjuvant CRT. In R1 cases neoadjuvant CRT seems to offer better prognosis than adjuvant CRT. To avoid R1 and its consequences a good quality control of total mesorectal excision (TME) is needed and CRT should be done before and not after surgery. R1 after primary surgery needs to be compensated by re-resection if possible, otherwise probably high dose radiotherapy with chemotherapy is needed.
本研究旨在分析显微镜下切缘阳性（R1）的直肠癌患者的特征，从而避免这些情况或在这些特殊病例中调整治疗方案。
我们回顾了2000年至2011年期间在“伊翁·基里库塔教授”肿瘤研究所接受根治性手术的直肠癌或直肠乙状结肠癌患者切除标本的所有病理数据（12年共763例患者），以及转诊至我院接受辅助治疗的其他机构患者的病理档案（318例患者）。我们纳入了接受前切除术、哈特曼手术和腹会阴联合切除术的患者，但最初排除了局部切除术患者以及最初为R2/R1但再次切除后为R0的患者（56例）。我们确定了31例R1患者，但不得不排除1例进行分析，因为该患者失访。
单纯手术时局部复发（LR）不可避免。在新辅助放化疗（CRT）组中，尽管切缘为R1，但85.7%的患者未发生LR。在辅助CRT队列中，50%的患者在常规放疗后2年无LR（p<0.01）。
基于这些结果得出结论，切缘清晰对直肠癌的局部控制极为重要，因为辅助CRT并非总能弥补切缘问题。在R1病例中，新辅助CRT似乎比辅助CRT预后更好。为避免R1及其后果，需要对全直肠系膜切除术（TME）进行良好的质量控制，且CRT应在手术前而非手术后进行。初次手术后若为R1，若可能应通过再次切除来弥补，否则可能需要高剂量放疗联合化疗。
