直肠癌侧方淋巴结清扫争议与共识

侧方淋巴结转移是低位直肠癌病人诊治中常见问题，而东西方学者对于中低位直肠癌TME手术是否结合侧方淋巴结清扫仍然存在争议；腹腔镜或机器人辅助侧方淋巴结清扫与开放手术对比的相关研究仍停留在回顾性分析，需要前瞻性队列研究进一步证实各自的优越性；新辅助放化疗能否代替侧方淋巴结清扫目前尚无定论，其与东西方学者对侧方淋巴结转移属于局部还是属于全身的认知有关。     

中低位直肠癌选择性侧方淋巴结清扫策略

侧方淋巴结转移是中低位进展期直肠癌的较常见转移方式,也是亚洲人群新辅助放化疗后常见的局部复发方式,侧方型复发预后极差。侧方肿大淋巴结是放化疗后侧方型复发的独立危险因素,东西方国家关于放化疗与侧方淋巴结清扫等在中低位进展期直肠癌中的应用存在巨大争议。有限的研究显示,对可疑淋巴结转移病人联合应用放化疗与选择性侧方淋巴结清扫,有望进一步降低局部复发率及改善病人生存。对未接受侧方淋巴结清扫的病人,理论上有必要进行更严密的随访,早期发现侧方型复发,及时手术治疗可能带来长期生存。目前,关于新辅助放化疗后侧方淋巴结转移的诊断及选择性侧方淋巴结清扫的手术指征尚无统一意见,亟需大宗病例前瞻性队列研究加以阐明,以进一步改善病人的局部复发及长期生存,并减少因过度手术带来的并发症及生活质量下降。     

下段直肠淋巴引流途径和低位直肠癌侧方淋巴结清扫的必要性

下段直肠癌已被证明存在向上、向下、侧方3个淋巴引流途径，直肠癌通过侧方淋巴引流途径形成的淋巴结转移是其治疗后盆腔复发的重要原因。大量循证医学证据表明，术前同步放化疗并不能彻底清扫侧方转移淋巴结，其阳性残留比例>60%。对术前同步放化疗后仍然存在侧方淋巴结转移的病例，手术清扫转移淋巴结是最重要的治疗手段，甚至是病人获得长期生存的惟一途径。严格掌握侧方淋巴结清扫指征，提高病理学检查准确率，进行规范的淋巴结清扫，通过精准操作降低手术并发症发生率，有望为直肠癌侧方淋巴结转移病人带来局部复发率的下降和生存延长的双重获益。     

直肠癌侧方淋巴结清扫的个性化治疗策略

随着全直肠系膜切除术和新辅助放化疗的广泛应用,中低位直肠癌患者的预后明显改善。近年来随着腹腔镜和机器人手术系统等微创技术应用于直肠癌根治性手术,以及肿瘤分子标志物和基因测序技术的发展,直肠癌治疗已进入个体化精准医疗时代。在这样的时代背景下,关于中低位直肠癌侧方淋巴结清扫必要性的争议愈发引人注目,其包括与新辅助治疗的关系,侧方淋巴结清扫的手术指征、范围及神经保护等多个方面。作为进展期中低位直肠癌重要治疗手段,直面争议,增加侧方淋巴结清扫相关循证医学证据是当务之急。     

低位直肠癌侧方淋巴结清扫相关问题

对于低位直肠癌的治疗，在是否选择侧方淋巴结清扫为标准治疗，或将侧方淋巴结转移视为远隔转移而以放化疗为治疗策略等方面，东西方学者的观点仍存在诸多差异。JCOG0212试验并未证实预防性侧方淋巴结清扫的非劣性，其仍具争议。腹腔镜手术技术、辅助治疗等正在改变低位直肠癌的治疗策略，侧方淋巴结清扫的合理应用仍是未来研究的重要课题。     

直肠癌侧方淋巴结清扫争议与共识

直肠癌盆腔侧方淋巴结清扫是直肠癌手术治疗的重要方式之一,随着新辅助放化疗技术的应用,该术式在欧美及我国已较少开展。目前,对该技术的研究主要来自日本及韩国等国家。而该术式对于降低直肠癌局部复发率及改善病人远期生存是否有意义,尤其是预防性侧方淋巴结清扫的作用,尚存在争议。对于新辅助放化疗后仍有侧方淋巴结转移的病人,目前多主张应行侧方淋巴结清扫,而对于侧方淋巴结转移的诊断有赖于影像学的精确判断。该术式虽是创伤较大的手术,但其目前仍是直肠癌外科手术的重要组成部分,应个体化选择病人并结合腹腔镜及机器人等微创技术,提高治疗效果。     

直肠癌侧方淋巴结清扫手术指征和清扫范围

侧方淋巴结转移是低位直肠癌的重要转移途径，放化疗对其疗效不佳，影响直肠癌病人预后。侧方淋巴结清扫作为一种有效的治疗手段，随着腹腔镜手术的普及和外科医生手术技巧的提高，被越来越广泛的应用于临床。但直肠癌侧方淋巴结清扫领域很多问题尚存争议，制约了该技术的推广和疗效评价，这其中以直肠癌侧方清扫手术指征的把握和清扫范围如何界定最为突出。中日两国学者针对上述问题开展了相关研究并得出了初步结论，但这些结论尚需更高级别的循证医学证据来证实。     

低位直肠癌侧方淋巴结清扫相关问题

对于低位直肠癌的治疗，在是否选择侧方淋巴结清扫为标准治疗，或将侧方淋巴结转移视为远隔转移而以放化疗为治疗策略等方面，东西方学者的观点仍存在诸多差异。JCOG0212试验并未证实预防性侧方淋巴结清扫的非劣性，其仍具争议。腹腔镜手术技术、辅助治疗等正在改变低位直肠癌的治疗策略，侧方淋巴结清扫的合理应用仍是未来研究的重要课题。     

新辅助治疗后直肠癌侧方淋巴结清扫的意义

侧方淋巴结转移是中低位直肠癌转移的重要途径,也是导致直肠癌复发的主要因素。直肠癌侧方淋巴结转移的治疗策略一直是外科领域争论的热点话题。西方学者主张将新辅助放化疗作为治疗侧方淋巴结转移的主要方法,但新辅助治疗并不能完全消除转移至侧方的淋巴结,对于新辅助治疗后仍然存在侧方淋巴结肿大的病例,如果单纯行全直肠系膜切除,势必导致阳性淋巴结残留而无法达到R0切除。对于这部分病例,如何根据具体病情,合理选择治疗策略,有针对性地进行侧方淋巴结清扫以争取R0切除,对进一步降低局部复发,改善预后,提高病人生活质量具有重要意义。     

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手术是直肠癌的主要治疗方式[1-2],而淋巴转移作为直肠癌的重要扩散途径,术中淋巴结清扫不彻底会引起局部复发甚至影响病人的生存期。研究表明,直肠癌向上方及侧方存在跳跃转移,对于Dukes B期和C期病人在全直肠系膜切除(TME)基础上选择性地进行上方及侧方淋巴结清扫即直肠癌扩大根治术是非常重要的。本文将对低位直肠癌行侧方淋巴结清扫争议与进展做一综述。1直肠癌根治术的历史演变     

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??Significance of lateral lymph node dissection in rectal cancer after neoadjuvant chemoradiotherapy LIU Qian??WANG Xi-shan. Department of Colorectal Surgery, National Cancer Center & National Clinical Research Center for Cancer & Cancer Hospital??Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021??China
Corresponding author??WANG Xi-shan??E-mail??fcwpumxh@163.com
Abstract Lateral lymph node metastasis is an important pathway for metastasis of middle and low rectal cancer??and it is also a major factor leading to recurrence of rectal cancer. The treatment strategy for lateral lymph node metastasis of rectal cancer has been a hot topic in the field of surgery. Western scholars oppose lateral lymph node dissection??and neoadjuvant and adjuvant chemoradiotherapy are the main methods for the treatment of lateral lymph node metastasis. For patients with swollen lateral lymph node after neoadjuvanttherapy??if only TME surgery is performed?? it will lead to positive lymph node residue and cannot achieve R0 resection. For this situation??how to choose optimal targeted treatment strategy according to the specific condition??and the LLND for R0 resection is of great significance for further reducing local recurrence??improving prognosis and improving patients' quality of life.     

Lateral pelvic node dissection after neoadjuvant chemoradiation in rectal cancer with right internal iliac node metastasis but without regional node metastasis: A case report

Introduction and importanceTotal mesorectal excision (TME) with lateral pelvic node dissection was routinely done in low clinical T3 rectal tumors below the peritoneal reflection as stated in the Japanese guidelines for colorectal cancer. Our institution follows the same practice in selected patients. This is our first reported case wherein a patient with rectal cancer underwent total mesorectal excision with lateral lymphadenectomy after neoadjuvant treatment with a positive lateral node on histopathology.Case presentationA 49 year old female rectal had rectal adenocarcinoma 4 cm FAV. Pelvic MRI revealed a low rectal tumor abutting the mesorectal fascia anteriorly, anal sphincters not involved, and confluent enlarged right iliac nodes. After neoadjuvant treatment, interval decrease in size of the rectal lesion and the right iliac nodes were noted. Patient underwent partial intersphincteric resection, lateral pelvic node dissection and protective loop ileostomy.Clinical discussionHistopathology revealed a rectal adenocarcinoma with one right internal iliac lymph node was positive for tumor involvement. Circumferential resection margin was 4.0 mm. Patient is currently on 4th cycle of adjuvant chemotherapy. Preoperative chemoradiation could not completely eradicate lateral pelvic node metastasis. Therefore, lateral pelvic node dissection should be considered if lateral pelvic lymph node metastasis is suspected even after neoadjuvant therapy.ConclusionUnlike TME, performance of a routine lateral lymphadenectomy in rectal cancer surgery varies by geographic location. Reports from Asian countries and our practice in our institution shows that it can be performed safely. This could improve the oncologic outcomes of patients especially if combined with neoadjuvant chemoradiotherapy.     

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??Lateral lymph node dissection for rectal cancer: controversy and consensus GUAN Guo-xian??CHI Pan. Department of Colorectal Surgery??Fujian Medical University Union Hospital??Fuzhou 350001??China
Corresponding author??CHI Pan??E-mail??cp3169@163.com
Abstract Lateral lymph node dissection??LLND?? is one of the important operations for the treatment of rectal cancer. With the application of the neoadjuvant chemoradiation therapy??this operation is less performed in the Europe??America and China. Currently??the researches on this operation are mainly from Japan and South Korea. There is controversy of its effect on the lowering the local recurrence and improving the long-term outcomes??especially for the prophylactic LLND. For the patients with suspected lateral lymph node metastasis after neoadjuvant chemoradiotherapy??LLND is commonly indicated. The diagnosis of lateral lymph node metastasis is relied on the precise assessment of imaging. LLND is one kind of massively invasive procedure??but it is one important component of the operations for rectal cancer. Combining with mini-invasive techniques of the laparoscopic and robotic procedures??LLND can be selectively applied to improve the outcomes for the indicated patients.     

低位直肠癌TME原则下侧方淋巴结清除152例

目的：根据低位直肠癌区域淋巴结转移规律,探讨在低位直肠癌治疗中直肠系膜全切除（TME）原则和侧方淋巴结清除范围。方法：收集152例行根治性手术的低位直肠癌患者的临床病理资料,分析区域淋巴结转移情况,遵循TME原则及侧方淋巴结清除方法清除直肠癌区域淋巴结。应用常规病理学方法观察其区域淋巴转移规律。结果：1）侧方淋巴转移是腹膜返折以下直肠癌的转移途径;2）侧方淋巴转移易发生在直肠筋膜后方,并且与浸润深度有关。结论：低位直肠癌应该在TME原则下行侧方淋巴清除,既可以避免转移淋巴结及系膜组织的残留,又可防止过度损伤,提高了生存率,又减少了并发症。     

盆腔侧方淋巴结转移对低位直肠癌预后的影响

目的 探讨盆腔侧方淋巴结转移对低位直肠癌预后的影响.方法 对1994年至2005年行根治性切除联合盆腔侧方淋巴结清扫的176例低位直肠癌患者的资料进行回顾性分析.探讨低位直肠癌患者盆腔侧方淋巴结转移对其预后的影响.结果 全组盆腔侧方淋巴结转移33例(18.8%),其中髂内及直肠中动脉根部淋巴结转移占51.5%,闭孔淋巴结转移占39.4%.年龄≤40岁、浸润型癌、T3-4期、上方淋巴结转移患者的盆腔侧方淋巴结转移率较高(P＜0.05).全组5年生存率为64.1%,TNM分期Ⅰ、Ⅱ、Ⅲ期患者5年生存率分别为94.1%、79.1%、42.1%.癌灶大小、浸润深度、上方淋巴结转移、盆腔侧方淋巴结转移是影响低位直肠癌患者预后的重要因素(P＜0.05).盆腔侧方淋巴结阴性患者5年生存率为73.6%,而侧方淋巴结转移患者为21.4%,两组差异具有统计学意义(P＜0.05).结论 盆腔侧方淋巴结转移是影响低位直肠癌预后的重要因素.