Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea.
Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea.
Int J Colorectal Dis. 2022 Jun;37(6):1289-1300. doi: 10.1007/s00384-022-04165-z. Epub 2022 May 5.
Few studies to date have investigated morphological changes after neoadjuvant treatment (NAT) and their implications in total mesorectal excision (TME). This study was primarily designed to evaluate whether tissue changes associated with NAT affected the quality of TME and additionally to suggest a more objective method evaluating TME quality.
This study enrolled 1322 consecutive patients who underwent curative robot-assisted surgery for rectal cancer. Patients who did and did not receive NAT were subjected to propensity-score matching, yielding 402 patients in each group.
NAT independently reduced complete achievement of TME [odds ratio (OR) = 2.056, p = 0.017]. Intraoperative evaluation identified seven tissue changes significantly associated with NAT, including tumor perforation, mucin pool, necrosis, fibrosis, fat degeneration, and rectal or perirectal edema NAT (p < 0.001-0.05). Tumor perforation (OR = 5.299, p = 0.001) and mucin pool (OR = 14.053, p = 0.002) were independently associated with inappropriate (near-complete + incomplete) TME. Complete TME resulted in significantly reduced local recurrence (4.3% vs 15.3%, p = 0.003) and increased 5-year DFS rate (80.6% vs 67.6%, p = 0.047) compared with inappropriate one. By contrast, two tiers of complete and near-complete TMEs vs incomplete TME did not. Notably, among patients with complete TME, those who received NAT had a lower 5-year DFS than those who did not (77.8% vs 83.3%, p = 0.048).
NAT-associated tissue changes, somewhat interrupting complete TME, may provide unsolved clue to the relative inability of NAT to improve overall survival. The conventional three-tier grading of TME seems to be simplified into two tiers as complete and inappropriate.
目前很少有研究调查新辅助治疗（NAT）后的形态学变化及其对全直肠系膜切除术（TME）的影响。本研究旨在评估与 NAT 相关的组织变化是否会影响 TME 的质量，并提出一种更客观的 TME 质量评估方法。
本研究纳入了 1322 例接受机器人辅助直肠癌根治术的连续患者。对接受和未接受 NAT 的患者进行倾向评分匹配，每组各 402 例。
NAT 独立降低了 TME 的完全实现率[比值比（OR）=2.056，p=0.017]。术中评估发现与 NAT 显著相关的组织变化有 7 种，包括肿瘤穿孔、粘蛋白池、坏死、纤维化、脂肪变性和直肠或直肠周围水肿（p<0.001-0.05）。肿瘤穿孔（OR=5.299，p=0.001）和粘蛋白池（OR=14.053，p=0.002）与不适当（接近完全+不完全）TME 独立相关。与不适当 TME 相比，完全 TME 显著降低了局部复发率（4.3%比 15.3%，p=0.003）和增加了 5 年无病生存率（80.6%比 67.6%，p=0.047）。相比之下，完全和接近完全 TME 与不完全 TME 之间的两个分层并没有差异。值得注意的是，在完全 TME 的患者中，接受 NAT 的患者 5 年无病生存率低于未接受者（77.8%比 83.3%，p=0.048）。
与 NAT 相关的组织变化可能会中断完全 TME，这可能为 NAT 无法提高总生存率的相对能力提供尚未解决的线索。传统的 TME 三级分级似乎可以简化为完全和不适当两级。
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