Belluco Claudio, Forlin Marco, Olivieri Matteo, Cannizzaro Renato, Canzonieri Vincenzo, Buonadonna Angela, Bidoli Ettore, Matrone Fabio, Bertola Giulio, De Paoli Antonino
Department of Surgical Oncology, CRO-IRCCS, National Cancer Institute, Aviano, Italy.
Department of Gastroenterology, CRO-IRCCS, National Cancer Institute, Aviano, Italy.
Ann Surg Oncol. 2016 Dec;23(13):4302-4309. doi: 10.1245/s10434-016-5451-5. Epub 2016 Aug 3.
Organ preservation strategies are under investigation for patients with locally advanced rectal cancer (LARC) who achieve a complete pathologic response in the primary tumor (ypT0) after neoadjuvant chemoradiation therapy (CRT). This study explored the value of this approach for cN+ patients.
Data were retrieved from our institutional prospective rectal cancer database. Tumors with mesorectal lymph nodes larger than 5 mm shown on endorectal ultrasonography, pelvic magnetic resonance imaging, or both were staged as cN+.
The study population comprised 226 patients (142 men and 84 women; median age, 64 years) with LARC who underwent CRT followed by surgery including total mesorectal excision (TME) (n = 179) and full-thickness local excision (LE) (n = 47) between 1996 and 2013. At staging, 123 patients (54.4 %) were cN+. In 65 cases (28.7 %), ypCR was observed. Metastatic mesorectal lymph nodes (ypN+) were detected in 41.6 % of the cN+ patients and in 2.8 % of the cN0 patients (P < 0.01). Among the cN+ patients, 16 % of the ypT0 cases were ypN+ compared with 51.8 % of the no-ypT0 cases (P < 0.01). Among the cN+ patients who underwent TME, the 5-year disease-specific survival (DSS) and disease-free survival (DFS) rates were respectively 100 and 91.6 % for the ypT0 patients compared with 71.2 and 58.0 % for the no-ypT0 patients (P = 0.01). Among the ypN+ patients, the 5-year DSS and DFS rates were both 100 % for the ypT0 cases compared with 59.1 and 43.3 % for the no-ypT0 patients. Among the cN+ and ypT0 patients, the 5-year DSS and DFS were respectively 100 and 85.7 % for the TME patients compared with 100 and 91.6 % for the LE patients. In the multivariate analysis, ypT0 was the only independent prognostic factor.
Protocols aimed at organ preservation in LARC that achieve ypT0 after CRT can be offered also to cN+ patients.
对于局部晚期直肠癌（LARC）患者，在新辅助放化疗（CRT）后原发肿瘤达到完全病理缓解（ypT0）的器官保留策略正在研究中。本研究探讨了该方法对cN+患者的价值。
从我们机构的前瞻性直肠癌数据库中检索数据。经直肠超声、盆腔磁共振成像或两者显示直肠系膜淋巴结大于5mm的肿瘤分期为cN+。
研究人群包括226例LARC患者（142例男性和84例女性；中位年龄64岁），他们在1996年至2013年间接受了CRT，随后接受了包括全直肠系膜切除术（TME）（n = 179）和全层局部切除术（LE）（n = 47）的手术。分期时，123例患者（54.4%）为cN+。65例（28.7%）观察到ypCR。41.6%的cN+患者和2.8%的cN0患者检测到转移性直肠系膜淋巴结（ypN+）（P < 0.01）。在cN+患者中，ypT0病例的16%为ypN+，而非ypT0病例为51.8%（P < 0.01）。在接受TME的cN+患者中，ypT0患者的5年疾病特异性生存率（DSS）和无病生存率（DFS）分别为100%和91.6%，而非ypT0患者分别为71.2%和58.0%（P = 0.01）。在ypN+患者中，ypT0病例的5年DSS和DFS均为100%，而非ypT0患者分别为59.1%和43.3%。在cN+和ypT0患者中，TME患者的5年DSS和DFS分别为100%和85.7%，而LE患者分别为100%和91.6%。在多变量分析中，ypT0是唯一的独立预后因素。
对于CRT后达到ypT0的LARC患者，旨在保留器官的方案也可应用于cN+患者。
