仅新辅助（化疗）放疗联合全直肠系膜切除术不足以预防扩大淋巴结中的侧方局部复发：低位 cT3/4 直肠癌患者多中心侧方淋巴结研究的结果。

Neoadjuvant (Chemo)radiotherapy With Total Mesorectal Excision Only Is Not Sufficient to Prevent Lateral Local Recurrence in Enlarged Nodes: Results of the Multicenter Lateral Node Study of Patients With Low cT3/4 Rectal Cancer.

机构信息

1 Leiden University Medical Center, Leiden, the Netherlands.

2 Nagoya University Graduate School of Medicine, Nagoya, Japan.

出版信息

J Clin Oncol. 2019 Jan 1;37(1):33-43. doi: 10.1200/JCO.18.00032. Epub 2018 Nov 7.

DOI:10.1200/JCO.18.00032

PMID:30403572

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC6366816/

Abstract

PURPOSE

Improvements in magnetic resonance imaging (MRI), total mesorectal excision (TME) surgery, and the use of (chemo)radiotherapy ([C]RT) have improved local control of rectal cancer; however, we have been unable to eradicate local recurrence (LR). Even in the face of TME and negative resection margins (R0), a significant proportion of patients with enlarged lateral lymph nodes (LLNs) suffer from lateral LR (LLR). Japanese studies suggest that the addition of an LLN dissection (LLND) could reduce LLR. This multicenter pooled analysis aims to ascertain whether LLNs actually pose a problem and whether LLND results in fewer LLRs.

PATIENTS AND METHODS

Data from 1,216 consecutive patients with cT3/T4 rectal cancers up to 8 cm from the anal verge who underwent surgery in a 5-year period were collected. LLND was performed in 142 patients (12%). MRIs were re-evaluated with a standardized protocol to assess LLN features.

RESULTS

On pretreatment MRI, 703 patients (58%) had visible LLN, and 192 (16%) had a short axis of at least 7 mm. One hundred eight patients developed LR (5-year LR rate, 10.0%), of which 59 (54%) were LLRs (5-year LLR rate, 5.5%). After multivariable analyses, LLNs with a short axis of at least 7 mm resulted in a significantly higher risk of LLR (hazard ratio, 2.060; P = .045) compared with LLNs of less than 7 mm. In patients with LLNs at least 7 mm, (C)RT plus TME plus LLND resulted in a 5-year LLR of 5.7%, which was significantly lower than that in patients who underwent (C)RT plus TME (5-year LLR, 19.5%; P = .042).

CONCLUSION

LLR is still a significant problem after (C)RT plus TME in LLNs with a short axis at least 7 mm on pretreatment MRI. The addition of LLND results in a significantly lower LLR rate.

摘要

目的

磁共振成像（MRI）、全直肠系膜切除术（TME）和放化疗（[C]RT）的改进提高了直肠癌的局部控制率；然而，我们仍未能根除局部复发（LR）。即使在 TME 和阴性切缘（R0）的情况下，相当一部分外侧淋巴结（LLN）肿大的患者仍会发生侧方 LR（LLR）。日本的研究表明，增加 LLN 清扫（LLND）可降低 LLR。这项多中心汇总分析旨在确定 LLN 是否确实存在问题，以及 LLND 是否会导致更少的 LLR。

患者和方法

收集了 5 年内连续接受手术治疗的 1216 例距离肛缘 8cm 以内的 cT3/T4 直肠癌患者的数据。142 例患者（12%）进行了 LLND。采用标准化方案重新评估 MRI 以评估 LLN 特征。

结果

在预处理 MRI 上，703 例患者（58%）可见 LLN，192 例患者（16%）的短轴至少为 7mm。108 例患者发生 LR（5 年 LR 率为 10.0%），其中 59 例（54%）为 LLR（5 年 LLR 率为 5.5%）。多变量分析后，短轴至少为 7mm 的 LLN 与 LLR 的风险显著相关（风险比，2.060；P =.045）。对于 LLN 短轴至少为 7mm 的患者，（C）RT 加 TME 加 LLND 导致 5 年 LLR 为 5.7%，显著低于接受（C）RT 加 TME 的患者（5 年 LLR，19.5%；P =.042）。