Cunningham J D, Enker W, Cohen A
Mount Sinai Medical Center, Department of Surgery, New York, New York, USA.
Dis Colon Rectum. 1997 Apr;40(4):393-400. doi: 10.1007/BF02258382.
Pelvic recurrence is a significant problem following curative resection for rectal cancer. Although treatment options include surgery, chemotherapy, radiotherapy, or any combination of these, the role of surgery remains controversial in management of these patients.
In this study, we have attempted to define the patient with pelvic recurrence following curative rectal surgery who may benefit from reresection.
A review of the prospective colorectal database at Memorial Sloan Kettering Cancer Center (MSKCC) between 1983 and 1991 identified 25 patients who had pelvic recurrence following a curative resection for rectal cancer and 52 patients who had their initial rectal surgery at an outside institution (OI) and their pelvic recurrence treated at MSKCC. Survival was calculated from time of recurrence by the Kaplan-Meier method, and survival comparisons were made by log-rank analysis. There were no differences between the two groups related to age, gender, type of initial surgery, stage, or use of adjuvant therapy.
For the MSKCC group, median time to initial recurrence was 18 months, and median survival was 40 months. Recurrence was symptomatic in 17 patients and asymptomatic in 8 patients. Pain and bleeding accounted for more than one-half of symptomatic recurrences. Of the 17 symptomatic recurrences, 11 (65 percent) had relief of preoperative symptoms. There were no clinical or pathologic factors identified of the primary tumor or recurrence that predicted improved survival following salvage therapy. It was not possible to preoperatively determine which patients could undergo curative reresection. For the OI group, median time to recurrence was 13.7 months, and median survival from time of initial recurrence was 31 months. Curative reresection was the only factor that predicted for improved survival compared with noncurative treatment (P = 0.02). A comparison of the two groups revealed that pelvic recurrence was more likely to be reresected for cure in the OI group vs. the MSKCC group (34/51 vs. 9/25; P < 0.02). There was no survival difference between the two groups when comparing curative with noncurative management of these patients.
Symptoms from recurrent rectal cancer can be palliated with surgery. The only patients who had a survival benefit were those patients in the OI group whose disease could be completely resected. These differences in reresection rates may be attributable to the presence or absence of available planes for dissection around the recurrence in the OI group, as determined by the method of initial curative resection.
盆腔复发是直肠癌根治性切除术后的一个重要问题。尽管治疗选择包括手术、化疗、放疗或这些方法的联合应用，但手术在这些患者管理中的作用仍存在争议。
在本研究中，我们试图明确根治性直肠手术后出现盆腔复发且可能从再次切除中获益的患者。
回顾纪念斯隆凯特琳癌症中心（MSKCC）1983年至1991年的前瞻性结直肠数据库，确定了25例直肠癌根治性切除术后出现盆腔复发的患者以及52例在外部机构（OI）接受初次直肠手术并在MSKCC接受盆腔复发治疗的患者。通过Kaplan-Meier法从复发时间计算生存率，并通过对数秩分析进行生存比较。两组在年龄、性别、初次手术类型、分期或辅助治疗使用方面无差异。
对于MSKCC组，初次复发的中位时间为18个月，中位生存期为40个月。17例患者复发有症状，8例无症状。疼痛和出血占有症状复发的一半以上。在17例有症状的复发中，11例（65%）术前症状得到缓解。未发现原发性肿瘤或复发的临床或病理因素可预测挽救治疗后生存率提高。术前无法确定哪些患者可接受根治性再次切除。对于OI组，复发的中位时间为13.7个月，从初次复发时间起的中位生存期为31个月。与非根治性治疗相比，根治性再次切除是唯一预测生存率提高的因素（P = 0.02）。两组比较显示，OI组与MSKCC组相比，盆腔复发更有可能接受根治性再次切除（34/51对9/25；P < 0.02）。比较这些患者的根治性与非根治性治疗，两组生存率无差异。
复发性直肠癌的症状可通过手术缓解。唯一有生存获益的患者是OI组中疾病可完全切除的患者。再次切除率的这些差异可能归因于OI组中根据初次根治性切除方法确定的复发周围是否存在可分离平面。
