Smith Fraser McLean, Ahad Abdul, Perez Rodrigo Oliva, Marks John, Bujko Krzysztof, Heald Richard J
1 Department of Surgery, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom 2 Epsom and St Helier University Hospitals National Health Service Trust, London, United Kingdom 3 Angelita and Joaquim Gama Institute and School of Medicine, University of São Paulo, São Paulo, Brazil 4 Marks Colorectal Associates, Lankenau Hospital, Philadelphia, Pennsylvania, USA 5 Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland 6 Pelican Cancer Centre, Basingstoke, United Kingdom.
Dis Colon Rectum. 2017 Feb;60(2):228-239. doi: 10.1097/DCR.0000000000000749.
Recent evidence shows that the majority of rectal cancers demonstrate occult tumor scatter after neoadjuvant chemoradiotherapy that can extend for several centimeters under adjacent normal-appearing mucosa beside the residual mucosal abnormality or scar.
This systematic review aimed to determine all of the published selection criteria and technical descriptions for local excision to date with regard to this phenomenon.
PubMed, MEDLINE, and Embase were searched using the following key words: rectal cancer, local excision, radiotherapy, and neoadjuvant.
Studies that assessed local excision of rectal cancer after neoadjuvant chemoradiotherapy were included. Duplicate series were excluded from final analysis.
All of the data points were tabulated and analyzed using Microsoft Excel.
Criteria for patient selection, surgical technique, clinical restaging, pathologic assessment, and indications for completion surgery were analyzed.
After exclusions, data from 25 studies that in total evaluated local excision in 1001 patients were included. Compared with the single accepted technique of total mesorectal excision, described techniques for local excision after neoadjuvant therapy demonstrate significant variability in many critical technical issues, such as marking/tattooing original tumor margins before neoadjuvant therapy, using pretreatment tumor size/stage as exclusion criteria, and specifically stating lateral excision margins. Where detailed, the majority of local recurrences occurred in patients with clear pathological margins, yet significant variation existed for pathological assessment and reporting, with few studies detailing R status and some not reporting margin status at all. Significant variability also existed for adverse tumor features that mandated completion surgery, and, importantly, many series describe patients refusing completion surgery where indicated.
We were unable to perform meta-analysis because studies lacked sufficient methodologic homogeneity to synthesize.
The observations from this study prompt additional study, standardization of technique, and cautious use of local excision of rectal cancer in the setting of neoadjuvant chemoradiotherapy.
近期证据表明，大多数直肠癌在新辅助放化疗后显示出隐匿性肿瘤播散，可在残留黏膜异常或瘢痕旁外观正常的相邻黏膜下延伸数厘米。
本系统评价旨在确定迄今为止已发表的关于这一现象的局部切除的所有选择标准和技术描述。
使用以下关键词检索了PubMed、MEDLINE和Embase：直肠癌、局部切除、放疗和新辅助治疗。
纳入评估新辅助放化疗后直肠癌局部切除的研究。重复系列被排除在最终分析之外。
所有数据点均使用Microsoft Excel进行列表和分析。
分析患者选择标准、手术技术、临床再分期、病理评估和完成手术的指征。
排除后，纳入了25项研究的数据，这些研究共评估了1001例患者的局部切除。与公认的全直肠系膜切除术单一技术相比，新辅助治疗后局部切除的描述技术在许多关键技术问题上存在显著差异，例如在新辅助治疗前标记/标记原始肿瘤边缘、使用治疗前肿瘤大小/分期作为排除标准以及明确说明侧切缘。在详细说明的情况下，大多数局部复发发生在病理切缘阴性的患者中，但病理评估和报告存在显著差异，很少有研究详细说明R状态，有些研究根本未报告切缘状态。对于需要完成手术的不良肿瘤特征也存在显著差异，重要的是，许多系列描述了患者在有指征时拒绝完成手术。
由于研究缺乏足够的方法学同质性以进行综合，我们无法进行荟萃分析。
本研究的观察结果促使进一步研究、技术标准化以及在新辅助放化疗背景下谨慎使用直肠癌局部切除。
