Mei Shi-Wen, Liu Zheng, Wang Zheng, Pei Wei, Wei Fang-Ze, Chen Jia-Nan, Wang Zhi-Jie, Shen Hai-Yu, Li Juan, Zhao Fu-Qiang, Wang Xi-Shan, Liu Qian
Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
World J Clin Cases. 2020 Dec 26;8(24):6229-6242. doi: 10.12998/wjcc.v8.i24.6229.
Conventional clinical guidelines recommend that at least 12 lymph nodes should be removed during radical rectal cancer surgery to achieve accurate staging. The current application of neoadjuvant therapy has changed the number of lymph node dissection.
To investigate factors affecting the number of lymph nodes dissected after neoadjuvant chemoradiotherapy in locally advanced rectal cancer and to evaluate the relationship of the total number of retrieved lymph nodes (TLN) with disease-free survival (DFS) and overall survival (OS).
A total of 231 patients with locally advanced rectal cancer from 2015 to 2017 were included in this study. According to the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) tumor-node-metastasis (TNM) classification system and the NCCN guidelines for rectal cancer, the patients were divided into two groups: group A (TLN ≥ 12, = 177) and group B (TLN < 12, = 54). Factors influencing lymph node retrieval were analyzed by univariate and binary logistic regression analysis. DFS and OS were evaluated by Kaplan-Meier curves and Cox regression models.
The median number of lymph nodes dissected was 18 (range, 12-45) in group A and 8 (range, 2-11) in group B. The lymph node ratio (number of positive lymph nodes/total number of lymph nodes) ( = 0.039) and the interval between neoadjuvant therapy and radical surgery ( = 0.002) were independent factors of the TLN. However,TLN was not associated with sex, age, ASA score, clinical T or N stage, pathological T stage, tumor response grade (Dworak), downstaging, pathological complete response, radiotherapy dose, preoperative concurrent chemotherapy regimen, tumor distance from anal verge, multivisceral resection, preoperative carcinoembryonic antigen level, perineural invasion, intravascular tumor embolus or degree of differentiation. The pathological T stage ( < 0.001) and TLN ( < 0.001) were independent factors of DFS, and pathological T stage ( = 0.011) and perineural invasion ( = 0.002) were independent factors of OS. In addition, the risk of distant recurrence was greater for TLN < 12 ( = 0.009).
A shorter interval to surgery after neoadjuvant chemoradiotherapy for rectal cancer under indications may cause increased number of lymph nodes harvested. Tumor shrinkage and more extensive lymph node retrieval may lead to a more favorable prognosis.
传统临床指南建议，在直肠癌根治术中应至少切除12枚淋巴结以实现准确分期。新辅助治疗的当前应用改变了淋巴结清扫的数量。
探讨影响局部晚期直肠癌新辅助放化疗后淋巴结清扫数量的因素，并评估获取淋巴结总数（TLN）与无病生存期（DFS）和总生存期（OS）的关系。
本研究纳入了2015年至2017年共231例局部晚期直肠癌患者。根据美国癌症联合委员会（AJCC）/国际癌症控制联盟（UICC）肿瘤-淋巴结-转移（TNM）分类系统和NCCN直肠癌指南，将患者分为两组：A组（TLN≥12，n = 177）和B组（TLN < 12，n = 54）。通过单因素和二元逻辑回归分析来分析影响淋巴结获取的因素。通过Kaplan-Meier曲线和Cox回归模型评估DFS和OS。
A组淋巴结清扫的中位数为18枚（范围12 - 45枚），B组为8枚（范围2 - 11枚）。淋巴结比率（阳性淋巴结数/淋巴结总数）（P = 0.039）和新辅助治疗与根治性手术之间的间隔时间（P = 0.002）是TLN的独立影响因素。然而，TLN与性别、年龄、美国麻醉医师协会（ASA）评分、临床T或N分期、病理T分期、肿瘤反应分级（德瓦克分级）、降期、病理完全缓解、放疗剂量、术前同步化疗方案、肿瘤距肛缘距离、多脏器切除、术前癌胚抗原水平、神经侵犯、血管内肿瘤栓子或分化程度无关。病理T分期（P < 0.001）和TLN（P < 0.001）是DFS的独立影响因素，病理T分期（P = 0.011）和神经侵犯（P = 0.002）是OS的独立影响因素。此外，TLN < 12时远处复发风险更高（P = 0.009）。
在有指征的情况下，直肠癌新辅助放化疗后至手术的间隔时间较短可能会使获取的淋巴结数量增加。肿瘤缩小和更广泛的淋巴结获取可能会带来更有利的预后。
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