Kusters M, Slater A, Betts M, Hompes R, Guy R J, Jones O M, George B D, Lindsey I, Mortensen N J, James D R, Cunningham C
Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.
Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
Colorectal Dis. 2016 Nov;18(11):O397-O404. doi: 10.1111/codi.13409.
Outcomes following treatment for low rectal cancer still remain inferior to those for upper rectal cancer. A clear definition of 'low' rectal cancer is lacking and consensus is more likely using a definition based on MRI criteria. This study aimed to determine disease presentation and treatment outcome of low rectal cancer based on a strict anatomical definition.
A low rectal cancer was defined as one with a lower border below the pelvic attachment of the levator muscles on sagittal MRI. One hundred and eighty consecutive patients with tumours defined by this criterion between 2006 and 2011 were identified from a prospectively managed departmental database.
One hundred and eighteen patients (66%) underwent curative resection and 12 (7%) palliative resection. Eleven patients (6%) were entered into a 'watch and wait' (W&W) protocol; 10 others (5%) were not fit to undergo any operation. Some 26 patients (14%) had nonresectable local or metastatic disease. An R0 resection was the most important factor influencing survival after curative surgery. R+ resections occurred in 12% of non-abdominoperineal excisions, 11% of abdominoperineal excisions and 47% of extended resections. Overall survival was similar in the curative resections compared with the W&W patients. In 23 of the 96 (24%) treated with neoadjuvant chemoradiotherapy there was a persistent clinical or a pathological complete response.
In curative resections, a clear margin is the most important determinant of survival. In 24% of the patients treated with neoadjuvant chemoradiotherapy, surgery could potentially have been avoided. There is scope for improvement in the treatment of locally advanced rectal cancers.
低位直肠癌的治疗效果仍逊于高位直肠癌。目前缺乏对“低位”直肠癌的明确定义，而基于MRI标准的定义更有可能达成共识。本研究旨在根据严格的解剖学定义确定低位直肠癌的疾病表现和治疗结果。
低位直肠癌定义为矢状位MRI上肿瘤下缘低于提肌骨盆附着处。从一个前瞻性管理的科室数据库中识别出2006年至2011年间连续180例符合该标准的肿瘤患者。
118例患者（66%）接受了根治性切除，12例（7%）接受了姑息性切除。11例患者（6%）进入“观察等待”（W&W）方案；另外10例患者（5%）不适合进行任何手术。约26例患者（14%）有不可切除的局部或转移性疾病。R0切除是影响根治性手术后生存的最重要因素。R+切除在非腹会阴切除术中占12%，腹会阴切除术中占11%，扩大切除术中占47%。根治性切除患者与W&W患者的总生存率相似。在96例接受新辅助放化疗的患者中，有23例（24%）出现持续的临床或病理完全缓解。
在根治性切除中，切缘清晰是生存的最重要决定因素。在24%接受新辅助放化疗的患者中，可能避免了手术。局部晚期直肠癌的治疗仍有改进空间。
