Rouanet P, Dravet F, Dubois J B, Saint Aubert B, Veyrac M, Ychou M, Solassol C, Pujol H
Service de Chirurgie, Hôpital Saint-Eloi, Centre Val d'Aurelle, Montpellier.
Ann Chir. 1994;48(6):512-9.
This prospective study was designed to evaluate morbidity and functional and oncological outcomes in patients with carcinoma of the distal third of the rectum treated by high-dose radiation therapy followed by conservative surgery. Twenty-two patients with adenocarcinoma of the distal third of the rectum treated after June 1990 were included in the study. Mean distances separating the tumor from the upper edge of the levator ani muscle and from the anal verge were 17 mm and 47 mm, respectively. None of the tumors were fixed; preoperative stage, established by endoscopic ultrasound, was T2 in 12 patients and T3 in 10. Patients received induction radiation therapy in two series delivered three weeks apart (40 Gy on the pelvis, then 20 Gy on the tumor only) followed by surgical resection (proctectomy with colo-anal anastomosis in 17 cases and amputation in five). After radiation, two tumors were negative for malignant cells, 12 were Astler-Coller B1, two were B2, and six were C2. Mean safety margin after colo-anal anastomosis was 16.8 mm; all the resection margins were negative. Mortality and morbidity were not increased by the high-dose radiation protocol. Conservation of the sphincter was possible in 80% of patients. All the patients were continent. Functional outcome was rated good in 77% of cases, fair in 9% and poor in 4%. During the mean follow-up of 24 months, there were three disease-related deaths, including one due to a strictly regional recurrence; metastatic dissemination to the lungs occurred in two patients and the remaining 17 patients (80%) were disease-free. These data suggest that high-dose radiation therapy followed by conservative surgery ensures satisfactory functional outcomes in patients with carcinomas of the distal rectum. Evaluation of oncological outcomes will require a longer follow-up.
本前瞻性研究旨在评估接受高剂量放射治疗后行保守手术的直肠远端三分之一癌患者的发病率、功能及肿瘤学结局。1990年6月后接受治疗的22例直肠远端三分之一腺癌患者纳入本研究。肿瘤距肛提肌上缘和肛缘的平均距离分别为17mm和47mm。所有肿瘤均未固定；经内镜超声确定的术前分期为，12例患者为T2期，10例为T3期。患者接受诱导放射治疗，分两个疗程，间隔三周进行（盆腔照射40Gy，然后仅对肿瘤照射20Gy），随后进行手术切除（17例行结肠肛管吻合直肠切除术，5例行截肢术）。放疗后，2例肿瘤恶性细胞阴性，12例为Astler-Coller B1期，2例为B2期，6例为C2期。结肠肛管吻合术后的平均安全切缘为16.8mm；所有切除切缘均为阴性。高剂量放疗方案未增加死亡率和发病率。80%的患者可保留括约肌。所有患者均能自主控制排便。77%的病例功能结局评定为良好，9%为中等，4%为差。在平均24个月的随访期间，有3例与疾病相关的死亡，包括1例因严格的局部复发；2例患者发生肺转移，其余17例患者（80%）无疾病复发。这些数据表明，高剂量放射治疗后行保守手术可确保直肠远端癌患者获得满意的功能结局。肿瘤学结局的评估需要更长时间的随访。
