Nozawa Hiroaki, Ishihara Soichiro, Fujishiro Mitsuhiro, Kodashima Shinya, Ohtani Kensuke, Yasuda Koji, Nishikawa Takeshi, Tanaka Toshiaki, Tanaka Junichiro, Kiyomatsu Tomomichi, Kawai Kazushige, Hata Keisuke, Kazama Shinsuke, Sunami Eiji, Kitayama Joji, Watanabe Toshiaki
Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan.
Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan.
Surgery. 2016 Mar;159(3):713-20. doi: 10.1016/j.surg.2015.09.008. Epub 2015 Oct 21.
Recent advances in endoscopic therapy, including conventional endoscopic resection and endoscopic submucosal dissection (ESD), have led to a large number of patients with early colorectal cancer (CRC) being cured; however, when resected specimens obtained by these procedures manifest risk factors for lymph node metastasis, additional treatments need to be considered. The aim of our study was to evaluate the outcomes of salvage surgery in CRC patients treated initially by advanced therapeutic endoscopy.
We investigated 145 patients who underwent salvage surgery in our department after endoscopic therapy for CRC between April 2006 and March 2015. Demographic and pathological data, endoscopic procedures, reasons for surgery, and operative outcomes, including perioperative details and recurrence-free and disease-specific survival after surgery, were analyzed. These data were further compared with those of 59 patients with submucosal invasive CRC treated by conventional endoscopic resection/ESD alone and 133 patients treated by surgery alone.
Overall lymph node metastases were observed in 14% of patients who underwent salvage surgery after therapeutic endoscopy and 16% of those who received abdominal surgery alone. In analyses of surgical cases, patients with lymph node metastases more frequently included cases with lymphatic infiltration (63%) and ESD-treated cases (45%) than those without metastases (21%, P < .0001 and 22%, P = .02; respectively). A logistic regression analysis identified lymphatic infiltration as an independent predictive factor for lymph node metastases (odds ratio: 8.77, 95% confidence interval: 2.90-33.31, P < .0001). Long-term outcomes were favorable in both lymphatic infiltration-negative and positive cases. Moreover, survivals were comparable among the different treatment groups.
Because of the high rate of nodal involvement, adequate lymphadenectomy need to be performed in salvage surgery after upfront endoscopic therapy.
包括传统内镜切除术和内镜黏膜下剥离术（ESD）在内的内镜治疗的最新进展，已使大量早期结直肠癌（CRC）患者得以治愈；然而，当通过这些手术获得的切除标本显示有淋巴结转移的风险因素时，就需要考虑额外的治疗。我们研究的目的是评估最初接受先进治疗性内镜检查的CRC患者挽救性手术的结果。
我们调查了2006年4月至2015年3月期间在我科接受CRC内镜治疗后进行挽救性手术的145例患者。分析了人口统计学和病理学数据、内镜手术、手术原因以及手术结果，包括围手术期细节以及术后无复发生存率和疾病特异性生存率。将这些数据与59例仅接受传统内镜切除/ESD治疗的黏膜下浸润性CRC患者以及133例仅接受手术治疗的患者的数据进行了进一步比较。
接受治疗性内镜检查后进行挽救性手术的患者中，14%出现了总体淋巴结转移，而仅接受腹部手术的患者中这一比例为16%。在手术病例分析中，有淋巴结转移的患者比无转移的患者更常出现淋巴管浸润（63%）和ESD治疗的病例（45%）（分别为21%，P <.0001和22%，P =.02）。逻辑回归分析确定淋巴管浸润是淋巴结转移的独立预测因素（优势比：8.77，95%置信区间：2.90 - 33.31，P <.0001）。淋巴管浸润阴性和阳性病例的长期结果均良好。此外，不同治疗组之间的生存率相当。
由于淋巴结受累率高，在前期内镜治疗后的挽救性手术中需要进行充分的淋巴结清扫。
