Luna-Perez P, Rodriguez D, Ortiz N, Labastida S, Delgado S, Herrera L
Surgical Oncology Department, Hospital de Oncologia, Centro Medico Nacional Siglo XXI, IMSS, Mexico City, Mexico.
Surg Oncol. 1995 Aug;4(4):223-9. doi: 10.1016/s0960-7404(10)80039-8.
To determine if pre-operative radiation therapy induces a local response in patients with complete tumour penetration into the rectal wall and allows for anal sphincter preservation, we compared the results from pathological specimens and local recurrences as measurable end-points in patients treated with pre-operative radiation therapy plus low anterior resection vs. those only treated with low anterior resection.
From January 1986 to December 1992, we treated 62 patients with mid-rectal adenocarcinoma (5-10 cm from the anal verge as determined by rigid proctosigmoidoscopy with the patient in the jackknife position). Pre-operative evaluation included: complete blood cell count, chemistry profile and the determination of carcinoembryonic antigen, chest X-ray, barium enema or colonoscopy and CT scan of the abdomen and pelvis. Only tumours potentially curative by resection in patients with performance status 0-2 (ECOG) were included. Twenty-one patients received pre-operative radiation therapy at a dose of 45 Gy delivered to the pelvis; 4-8 weeks later a low anterior resection was performed. Forty-one patients were treated with low anterior resection alone. Surgical specimens were classified according to the Astler-Coller modification of Dukes' classification.
There were 36 males and 26 females, with a mean age of 56 years. The surgical specimens of those treated only with surgery were classified as: A, 5; B1, 4; B2, 15; C1, 2; and C2, 15. Postirradiated specimens: no residual tumour, 3; A, 4; B1, 4; B2, 7; C2, 3. One surgical death occurred in the group who underwent surgery alone. The median follow-up was 50 months in patients treated with surgery alone vs. 62 months in the combined approach group. Local recurrences occurred in 15/40 patients treated with surgery alone and in 2/21 of those treated with the combined approach (P = 0.043). Anal sphincter continence was classified as excellent by 24/40 patients treated with surgery only and by 18/21 patients treated with the combined approach. The 5-year survival period was 58% in the surgery only group and 82% in the group with combined treatment (P = 0.08).
The use of pre-operative radiation therapy plus low anterior resection was associated with a lower rate of local recurrence and with a higher number of surgical specimens with no lymph node metastases. Thus, this combined treatment modality should be further evaluated as a possible treatment of mid-rectal cancers in good surgical candidates selected for sphincter-saving procedures.
为了确定术前放疗是否能使肿瘤完全穿透直肠壁的患者产生局部反应并实现肛门括约肌保留，我们比较了接受术前放疗加低位前切除术的患者与仅接受低位前切除术的患者的病理标本结果和局部复发情况，将其作为可测量的终点指标。
1986年1月至1992年12月，我们治疗了62例直肠中段腺癌患者（在折刀位行硬式直肠乙状结肠镜检查确定距肛缘5 - 10厘米）。术前评估包括：全血细胞计数、生化指标及癌胚抗原测定、胸部X线、钡剂灌肠或结肠镜检查以及腹部和盆腔CT扫描。仅纳入体能状态为0 - 2（ECOG）、有可能通过手术治愈的肿瘤患者。21例患者接受了盆腔45 Gy的术前放疗；4 - 8周后进行低位前切除术。41例患者仅接受低位前切除术。手术标本根据Dukes分类的Astler - Coller改良法进行分类。
男性36例，女性26例，平均年龄56岁。仅接受手术治疗患者的手术标本分类为：A期5例；B1期4例；B2期15例；C1期2例；C2期15例。放疗后标本：无残留肿瘤3例；A期4例；B1期4例；B2期7例；C2期3例。仅接受手术治疗的组发生1例手术死亡。单纯手术治疗患者的中位随访时间为50个月，联合治疗组为62个月。单纯手术治疗的40例患者中有15例发生局部复发，联合治疗的21例患者中有2例发生局部复发（P = 0.043）。仅接受手术治疗的40例患者中有24例、联合治疗的21例患者中有18例肛门括约肌控便功能评定为优。单纯手术治疗组的5年生存率为58%，联合治疗组为82%（P = 0.08）。
术前放疗加低位前切除术的应用与较低的局部复发率以及更多无淋巴结转移的手术标本相关。因此，对于选择保留括约肌手术的合适手术候选者，这种联合治疗方式应作为直肠中段癌的一种可能治疗方法进一步评估。
