Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
Department of Radiotherapy, Leiden University Medical Centre, Leiden, The Netherlands.
Br J Surg. 2016 Aug;103(9):1105-16. doi: 10.1002/bjs.10163. Epub 2016 Jun 15.
Completion total mesorectal excision (TME) is advised for high-risk early (pT1/pT2) rectal cancer following transanal removal. The main objective of this meta-analysis was to determine oncological outcomes of adjuvant (chemo)radiotherapy as a rectum-preserving alternative to completion TME.
A literature search using PubMed, Embase and the Cochrane Library was performed in February 2015. Studies had to include at least ten patients with pT1/pT2 adenocarcinomas that were removed transanally and followed by either adjuvant chemoradiotherapy or completion surgery. A weighted average of the logit proportions was determined for the pooled analyses of subgroups according to treatment modality and pT category.
In total, 14 studies comprising 405 patients treated with adjuvant (chemo)radiotherapy and seven studies comprising 130 patients treated with completion TME were included. Owing to heterogeneity it was not possible to compare the two strategies directly. However, the weighted average local recurrence rate for locally excised pT1/pT2 rectal cancer treated with adjuvant (chemo)radiotherapy was 14 (95 per cent c.i. 11 to 18) per cent, and 7 (4 to 14) per cent following completion TME. The weighted averages for distance recurrence were 9 (6 to 14) and 9 (5 to 16) per cent respectively. Weighted averages for local recurrence rate after adjuvant chemo(radiotherapy) and completion TME for pT1 were 10 (4 to 21) and 6 (3 to 15) per cent respectively. Corresponding averages for pT2 were 15 (11 to 21) and 10 (4 to 22) per cent respectively.
A higher recurrence rate after transanal excision and adjuvant (chemo)radiotherapy must be balanced against the morbidity and mortality associated with mesorectal excision. A reasonable approach is close follow-up and salvage mesorectal surgery as needed.
经肛门切除高危早期（pT1/pT2）直肠癌后，建议行全直肠系膜切除术（TME）。本荟萃分析的主要目的是确定辅助（放）化疗作为保肛替代全直肠系膜切除术的肿瘤学结果。
2015 年 2 月，我们使用 PubMed、Embase 和 Cochrane 图书馆进行了文献检索。研究必须至少包括 10 例经肛门切除的 pT1/pT2 腺癌患者，随后接受辅助放化疗或完成手术。根据治疗方式和 pT 分类，对亚组的汇总分析确定加权平均值的对数比例。
共纳入 14 项研究，共 405 例患者接受辅助（放）化疗治疗，7 项研究，共 130 例患者接受全直肠系膜切除术治疗。由于存在异质性，因此无法直接比较两种策略。然而，经肛门切除的局部 pT1/pT2 直肠癌患者接受辅助（放）化疗治疗的局部复发率为 14%（95%可信区间 11%至 18%），而接受全直肠系膜切除术治疗的局部复发率为 7%（4%至 14%）。远处复发的加权平均值分别为 9%（6%至 14%）和 9%（5%至 16%）。辅助化疗（放疗）和全直肠系膜切除术治疗 pT1 的局部复发率的加权平均值分别为 10%（4%至 21%）和 6%（3%至 15%）。相应的 pT2 平均值分别为 15%（11%至 21%）和 10%（4%至 22%）。
经肛门切除和辅助（放）化疗后复发率较高，必须与直肠系膜切除相关的发病率和死亡率相平衡。一种合理的方法是密切随访，并根据需要进行挽救性直肠系膜手术。
