直肠癌新辅助放化疗后选择性侧方淋巴结清扫。
Selective lateral lymph node dissection after neoadjuvant chemoradiotherapy in rectal cancer.
机构信息
Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China.
Departments of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD 21218, United States.
出版信息
World J Gastroenterol. 2020 Jun 7;26(21):2877-2888. doi: 10.3748/wjg.v26.i21.2877.
BACKGROUND
Lateral lymph node metastasis is one of the leading causes of local recurrence in patients with advanced mid or low rectal cancer. Neoadjuvant chemoradiotherapy (NCRT) can effectively reduce the postoperative recurrence rate; thus, NCRT with total mesorectal excision (TME) is the most widely accepted standard of care for rectal cancer. The addition of lateral lymph node dissection (LLND) after NCRT remains a controversial topic.
AIM
To investigate the surgical outcomes of TME plus LLND, and the possible risk factors for lateral lymph node metastasis after NCRT.
METHODS
This retrospective study reviewed 89 consecutive patients with clinical stage II-III mid or low rectal cancer who underwent TME and LLND from June 2016 to October 2018. In the NCRT group, TME plus LLND was performed in patients with short axis (SA) of the lateral lymph node greater than 5 mm. In the non-NCRT group, TME plus LLND was performed in patients with SA of the lateral lymph node greater than 10 mm. Data regarding patient demographics, clinical workup, surgical procedure, complications, and outcomes were collected. Multivariate logistic regression analysis was performed to evaluate the possible risk factors for lateral lymph node metastasis in NCRT patients.
RESULTS
LLN metastasis was pathologically confirmed in 35 patients (39.3%): 26 (41.3%) in the NCRT group and 9 (34.6%) in the non-NCRT group. The most common site of metastasis was around the obturator nerve (21/35) followed by the internal iliac artery region (12/35). In the NCRT patients, 46% of patients with SA of LLN greater than 7 mm were positive. The postoperative 30-d mortality rate was 0%. Two (2.2%) patients suffered from lateral local recurrence in the 2-year follow up. Multivariate analysis showed that cT4 stage (odds ratio [OR] = 5.124, 95% confidence interval [CI]: 1.419-18.508; = 0.013), poor differentiation type (OR = 4.014, 95%CI: 1.038-15.520; = 0.044), and SA ≥ 7 mm (OR = 7.539, 95%CI: 1.487-38.214; = 0.015) were statistically significant risk factors associated with LLN metastasis.
CONCLUSION
NCRT is not sufficient as a stand-alone therapy to eradicate LLN metastasis in lower rectal cancer patients and surgeons should consider performing selective LLND in patients with greater LLN SA diameter, poorer histological differentiation, or advanced T stage. Selective LLND for NCRT patients can have a favorable oncological outcome.
背景
侧方淋巴结转移是中低位局部进展期直肠癌患者局部复发的主要原因之一。新辅助放化疗（NCRT）可有效降低术后复发率；因此，NCRT 联合全直肠系膜切除术（TME）是目前直肠癌最广泛接受的标准治疗方法。NCRT 后行侧方淋巴结清扫术（LLND）仍存在争议。
目的
探讨 TME 加 LLND 的手术效果及 NCRT 后侧方淋巴结转移的可能危险因素。
方法
本回顾性研究纳入 2016 年 6 月至 2018 年 10 月间 89 例临床 II-III 期中低位直肠癌患者，均行 TME 和 LLND。NCRT 组中，侧方淋巴结短轴（SA）大于 5mm 时行 TME 加 LLND；非 NCRT 组中，侧方淋巴结 SA 大于 10mm 时行 TME 加 LLND。收集患者人口统计学、临床检查、手术过程、并发症和结局等数据。采用多因素 logistic 回归分析评估 NCRT 患者侧方淋巴结转移的可能危险因素。
结果
35 例（39.3%）患者经病理证实存在 LLN 转移：NCRT 组 26 例（41.3%），非 NCRT 组 9 例（34.6%）。转移最常见的部位是闭孔神经周围（21/35），其次是髂内动脉区域（12/35）。在 NCRT 患者中，SA 大于 7mm 的患者中有 46%为阳性。术后 30 天死亡率为 0%。2 例（2.2%）患者在 2 年随访中出现侧方局部复发。多因素分析显示 T4 期（比值比 [OR] = 5.124，95%置信区间 [CI]：1.419-18.508； = 0.013）、低分化型（OR = 4.014，95%CI：1.038-15.520； = 0.044）和 SA≥7mm（OR = 7.539，95%CI：1.487-38.214； = 0.015）是与 LLN 转移相关的统计学显著危险因素。
结论
NCRT 作为单独的治疗方法不足以清除低位直肠癌患者的 LLN 转移，外科医生应考虑在侧方淋巴结 SA 直径较大、组织学分化较差或 T 期较晚的患者中选择性行 LLND。对 NCRT 患者行选择性 LLND 可获得良好的肿瘤学结果。
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