Renehan A G
Institute of Cancer Sciences, University of Manchester, Manchester, UK; Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK.
Clin Oncol (R Coll Radiol). 2016 Feb;28(2):103-115. doi: 10.1016/j.clon.2015.11.006. Epub 2015 Dec 9.
Locally advanced primary rectal cancer is variably defined, but generally refers to T3 and T4 tumours. Radical surgery is the mainstay of treatment for these tumours but there is a high-risk for local recurrence. National Institute for Health and Care Excellence (2011) guidelines recommend that patients with these tumours be considered for preoperative chemoradiotherapy and this is the starting point for any discussion, as it is standard care. However, there are many refinements of this pathway and these are the subject of this overview. In surgical terms, there are two broad settings: (i) patients with tumours contained within the mesorectal envelope, or in the lower rectum, limited to invading the sphincter muscles (namely some T2 and most T3 tumours); and (ii) patients with tumours directly invading or adherent to pelvic organs or structures, mainly T4 tumours - here referred to as primary rectal cancer beyond total mesorectal excision (PRC-bTME). Major surgical resection using the principles of TME is the mainstay of treatment for the former. Where anal sphincter sacrifice is indicated for low rectal cancers, variations of abdominoperineal resection - referred to as tailored excision - including the extralevator abdominoperineal excision (ELAPE), are required. There is debate whether or not plastic reconstruction or mesh repair is required after these surgical procedures. To achieve cure in PRC-bTME tumours, most patients require extended multivisceral exenterative surgery, carried out within specialist multidisciplinary centres. The surgical principles governing the treatment of recurrent rectal cancer (RRC) parallel those for PRC-bTME, but typically only half of these patients are suitable for this type of major surgery. Peri-operative morbidity and mortality are considerable after surgery for PRC-bTME and RRC, but unacceptable levels of variation in clinical practice and outcome exist globally. To address this, there are now major efforts to standardise terminology and classifications, to allow appropriate comparisons in future studies.
局部进展期原发性直肠癌的定义存在差异，但一般指T3和T4期肿瘤。根治性手术是这些肿瘤的主要治疗方法，但局部复发风险较高。英国国家卫生与临床优化研究所（2011年）指南建议，这些肿瘤患者应考虑术前放化疗，这是任何讨论的起点，因为这是标准治疗方法。然而，该治疗路径有许多改进之处，这也是本综述的主题。从外科角度来看，有两种大致情况：（i）肿瘤局限于直肠系膜包膜内，或位于低位直肠，仅侵犯括约肌（即部分T2和大多数T3期肿瘤）的患者；（ii）肿瘤直接侵犯或粘连于盆腔器官或结构的患者，主要是T4期肿瘤——此处称为全直肠系膜切除术后原发性直肠癌（PRC-bTME）。采用TME原则进行的 major 手术切除是前者的主要治疗方法。对于低位直肠癌需要牺牲肛门括约肌的情况，需要采用腹会阴联合切除术的变体——称为定制切除术——包括经肛提肌腹会阴联合切除术（ELAPE）。这些手术操作后是否需要进行整形重建或网状修复存在争议。为了治愈PRC-bTME肿瘤，大多数患者需要在专业的多学科中心进行扩大的多脏器切除手术。复发性直肠癌（RRC）的手术治疗原则与PRC-bTME相同，但通常只有一半的患者适合这种 major 手术。PRC-bTME和RRC手术后围手术期的发病率和死亡率都相当高，但全球临床实践和结果的差异水平令人无法接受。为了解决这个问题，目前正在大力努力规范术语和分类，以便在未来的研究中进行适当的比较。
