J Natl Compr Canc Netw. 2018 Jul;16(7):822-828. doi: 10.6004/jnccn.2018.7026.
According to Dutch guidelines, locally excised, low-risk, pT1 or ypT0-1 rectal cancer should not necessarily be followed by completion total mesorectal excision (cTME) in contrast to rectal cancers with higher T stages or unfavorable features. This study evaluated cTME after local excision at a national level with possible determinants for decision-making. All patients in the Dutch Colorectal Audit (DCRA) who underwent local excision of rectal cancer between 2012 and 2015 were included. Guideline adherence for performing cTME was determined with univariate and multivariate analyses to identify factors related to noncompliance. According to the guidelines, of 530 included patients, cTME was indicated in 283 (53%), and among those, was performed in 82 (29%). Guideline adherence for performing cTME improved significantly (<.001), from 10% in 2012 to 44% in 2015. Lower Charlson comorbidity index in patients with high-risk pT1 rectal cancer and younger patients (aged 61-70 years vs ≥80 years) with pT≥2 rectal cancer were associated with increased performance of cTME (odds ratio [OR], 13.50; 95% CI, 1.39-131.32, and OR, 6.25; 95% CI, 1.83-21.31, respectively). In this population-based study from the Netherlands, only a minority of patients underwent cTME after local excision of rectal cancer with pathologic features indicating the need for further treatment according to the guidelines. Although the percentage of patients undergoing cTME increased over time, the study indicated a tendency toward rectal-preserving treatment with potential oncologic risks.
根据荷兰指南，与 T 分期更高或具有不良特征的直肠癌相比，局部切除、低危、pT1 或 ypT0-1 直肠肿瘤不一定需要进行补充全直肠系膜切除术（cTME）。本研究在全国范围内评估了局部切除后行 cTME 的情况，并分析了决策的可能决定因素。荷兰结直肠审计（DCRA）纳入了 2012 年至 2015 年间接受局部切除直肠癌的所有患者。通过单变量和多变量分析确定了进行 cTME 的指南依从性，以确定与不遵守相关的因素。根据指南，530 例纳入患者中，283 例（53%）需要行 cTME，其中 82 例（29%）进行了 cTME。行 cTME 的指南依从性显著提高（<.001），从 2012 年的 10%增加到 2015 年的 44%。高危 pT1 直肠肿瘤和 pT≥2 直肠肿瘤中年龄较大（61-70 岁 vs ≥80 岁）患者的 Charlson 合并症指数较低，与 cTME 实施率增加相关（比值比 [OR]，13.50；95%CI，1.39-131.32 和 OR，6.25；95%CI，1.83-21.31）。在这项来自荷兰的基于人群的研究中，仅有少数患者接受了局部切除后的 cTME，尽管这些患者具有根据指南需要进一步治疗的病理特征。尽管随着时间的推移，行 cTME 的患者比例有所增加，但该研究表明了一种倾向于保留直肠的治疗方法，可能存在潜在的肿瘤学风险。
