术前放疗联合全直肠系膜切除术治疗可切除性直肠癌临床疗效的系统评价

目的评价术前放疗联合全直肠系膜切除术（TME）治疗局部可切除直肠癌的临床疗效。方法全面检索1982年1月至2009年4月间发表的评价术前放疗的前瞻性临床随机对照试验研究,按纳入和排除标准筛选,提取人选试验的基本特征和临床疗效数据。对研究目的相同的多项随机对照试验的临床数据采用RevMan4．2软件进行定量合并．对不符合定量合并要求的数据作统计描述。结果符合选择标准的临床随机对照试验9项。短程术前放疗联合规范的TME手术组治疗直肠癌的2年局部复发率为2．4％,低于单纯TME手术组的8．2％（P〈0．01）。术前放疗患者的4年总生存率和无病生存率与术前常规分割放化疗患者相比,差异无统计学意义（P〉0．05）：两组患者的局部复发率差异也无统计学意义（RR=1．16,95％C10．37～3．61,P=0．80）。术前高剂量放疗组完全缓解率显著高于低剂量组（16．0％比2．0％,P〈0．05）．保肛手术率提高3．9％。结论TME术前放疗可降低直肠癌术后局部复发的风险。     

Impact of radiotherapy on local recurrence of rectal cancer in Norway

BACKGROUND: The purpose of this study was to analyse the impact of radiotherapy on local recurrence of rectal cancer in Norway after the national implementation of total mesorectal excision (TME). METHODS: This was a prospective national cohort study of 4113 patients undergoing major resection of rectal carcinoma between November 1993 and December 2001. RESULTS: The proportion of patients who had radiotherapy before or after operation increased from 4.6 per cent in 1994 to 23.0 per cent in 2001. The cumulative 5-year local recurrence rate decreased from 16.2 to 10.7 per cent. Multivariable analysis showed that preoperative radiotherapy significantly reduced local recurrence (hazard ratio 0.59 (95 per cent confidence interval 0.39 to 0.87)). The use of preoperative radiotherapy in patients from a local hospital offering radiotherapy was 50 per cent higher than that for patients from a hospital without such services (P = 0.003); cumulative 5-year local recurrence rates for these patients were 10.6 and 15.8 per cent respectively (P < 0.001). CONCLUSION: Following national implementation of TME for rectal cancer, increased use of preoperative radiotherapy appeared to reduce recurrence rates further.     

Preoperative radiotherapy improves survival for patients undergoing total mesorectal excision for stage T3 low rectal cancers

OBJECTIVE: To examine the effect of preoperative radiotherapy (PRT) on patients who undergo rectal resection with total mesorectal excision (TME) for stage T3 low rectal cancers. SUMMARY BACKGROUND DATA: Evidence for the value of PRT before rectal cancer surgery is weakened by variability in the use of TME. Many surgeons have concluded that PRT is unnecessary for small rectal tumors if TME is performed, but there are no prospective data to support this opinion. METHODS: Since 1980, 2,200 patients with rectal cancer have been enrolled in a prospective database. Of these, 259 underwent curative anterior or abdominoperineal resection with TME for pathologically confirmed T3 lesions within 8 cm of the anal verge. Patients were grouped by receiving PRT (n = 92) or not receiving PRT (n = 167). Five-year overall survival and 5-year local recurrence rates were evaluated. RESULTS: Overall survival was increased from 52% in patients not receiving PRT to 63% in those receiving PRT. PRT increased overall survival for node-negative patients from 58% to 82%, with no benefit for node-positive patients. There was no significant difference in local recurrence rates. When categorized by tumor size, there was no difference in overall survival or local recurrence for 0- to 2-cm tumors or those larger than 5 cm, but PRT increased overall survival from 50% to 72% for patients with 2- to 5-cm tumors. Similar results were observed for patients with tumors staged as T3 on preoperative endoluminal ultrasound. CONCLUSIONS: Patients with pT3 low rectal cancers undergoing resection with TME have an improved survival with PRT. The effect is most beneficial for patients with node-negative and 2- to 5-cm tumors, although this group may include larger and node-positive tumors that have been downstaged by PRT. PRT should be advocated for all patients with T3 rectal cancers less than 8 cm from the anal verge, even if the surgery includes a properly performed TME.     

New approaches in the management of rectal carcinoma result in reduced local recurrence rate and improved survival.

OBJECTIVE: To find out whether total mesorectal excision (TME) technique alone or combined with preoperative radiotherapy reduces local recurrence rate and improves survival. DESIGN: Partly retrospective (the first period), partly prospective (the second period) study. SETTING: University hospital, Helsinki, Finland. SUBJECTS: 144 patients between 1980 and 1990 and 61 patients between 1991 and 1997 with rectal cancer, who underwent major curative surgery. Interventions: A conventional surgical technique was used during the first period and TME alone or combined with preoperative radiotherapy when appropriate during the second period. MAIN OUTCOME MEASURES: Postoperative morbidity and mortality, local recurrence rate, and 5-year survival. RESULTS: After anterior resection 4/76 of the patients (5%) during the first period and 8/43 (19%) during the second period developed anastomotic leaks. Operative 30-day mortality was 1% (n = 1) and 0, respectively. Actuarial local recurrence rate was 17% in the first period and 9% in the second period. Actuarial crude 5-year survival improved from 55% to 78% and cancer-specific survival from 67% to 86% between the two study periods. CONCLUSIONS: Despite an increased number of anastomotic complications TME is safe. Refinement of the surgical technique together with preoperative radiotherapy yields lower local recurrence rates and an improved survival compared with conventional surgery alone.     

Rectal carcinoma treated with short-term preoperative radiotherapy followed by abdominoperineal resection. Significantly more presacral abscesses with absence of local recurrence

BACKGROUND: Treatment of choice for rectal carcinoma is short-term preoperative radiotherapy (5 x 5 Gy) followed by a total mesorectal excision (TME) of the rectum. This treatment has led to a reduction in local recurrence 2 years after surgery from 8.2 to 2.4%. Side effects of this treatment seem to be marginal and of no consequence. After introduction of short-term preoperative radiotherapy we noticed a rise in the postoperative presacral abscess formation which is difficult to treat and results in readmissions and prolonged hospital stay. Research was needed to investigate whether short-term preoperative radiotherapy can be held accountable for the presumed rise in presacral abscess formation in the treatment of rectal carcinoma. METHODS: A retrospective study was performed over the period January 2000-October 2004. Two groups were formed. Group 1 existed of 30 patients who underwent a TME of the rectum without short-term preoperative radiotherapy. Group two existed of 35 patients who underwent a TME of the rectum with short-term preoperative radiotherapy. RESULTS: Statistical analysis showed a significant increase in presacral abscess formation (13 vs. 40%) after introduction of short-term preoperative radiotherapy. Radiotherapy proved to be an important risk factor. Reduction in incidence of local recurrence was not evident. CONCLUSION: We found a significant increase in presacral abscess formation strongly suggestive due to the introduction of short-term preoperative radiotherapy in the treatment of rectal carcinoma. We noticed no reduction in incidence of local recurrence. We advocate that additional research is needed in order to formulate extra patient selection criteria for the use of preoperative radiotherapy in the treatment of rectal cancer.     

Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients

OBJECTIVE: This study aims to review the operative results and oncological outcomes of anterior resection for rectal and rectosigmoid cancer. Comparison was made between patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer, when a 4- to 5-cm mesorectal margin could be achieved. Risk factors for local recurrence and survival were also analyzed. SUMMARY BACKGROUND DATA: Anterior resection has become the preferred treatment option rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. METHODS: Resection of primary rectal and rectosigmoid cancer was performed in 786 patients from August 1993 to July 2002. Of these, 622 patients (395 men and 227 women; median age, 67 years) underwent anterior resection. The technique of perimesorectal dissection was used. Patients with mid and distal rectal cancer were treated with TME while PME was performed for those with more proximal tumors. Prospective data on the postoperative results and oncological outcomes were reviewed. Risk factors for anastomotic leakage, local recurrence, and survival of the patients were analyzed with univariate and multivariate analysis. RESULTS: The median level of the tumor was 8 cm from the anal verge (range, 2.5-20 cm) and curative resection was performed in 563 patients (90.5%). TME was performed in 396 patients (63.7%). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8% and 32.6%, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1% and 1.3% of patients with TME and PME, respectively (P < 0.001). Independent factors for a higher anastomotic leakage rate were TME, the male gender, the absence of stoma, and the increased blood loss. The 5-year actuarial local recurrence rate was 9.7%. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. The 5-year cancer-specific survival was 74.5%. The independent factors for poor survival were the advanced stage of the disease and the presence of lymphovascular and perineural invasion. CONCLUSIONS: Anterior resection with mesorectal excision is a safe option and can be performed in the majority of patients with rectal cancer. The local recurrence rate was 9.7% and the cancer-specific survival was 74.5%. When the tumor requires a TME, this procedure is more complex and has a higher leakage rate than in those higher tumors where PME provides adequate mesorectal clearance. By performing TME in patients with mid and distal rectal cancer, the local control and survival of these patients are similar to those of patients with proximal cancers where adequate clearance can be achieved by PME.     

Factors that influence the adequacy of total mesorectal excision for rectal cancer

OBJECTIVE: In 1997 with the start of CRO7 trial it was agreed that adequacy of surgical resection of rectal cancer would be determined by a pathologically determined grading of the mesorectum the so called total mesorectal excision score (TME score). Scores ranged from 1-3 with 3 being a perfect specimen. The aim of this study was to investigate factors which may influence TME scores and establish if local recurrence is related to them. METHOD: Data on all patients undergoing resectional surgery for rectal cancer in our unit are entered prospectively onto a database. Pathology reports of those patients who underwent total mesorectal excision were examined and the TME scores added to the database. Categorical variables were analysed using the chi2 test, continuous variables using ANOVA. Statistical significance was taken as P < 0.05. RESULTS: Between January 2000 and June 2005, 518 patients underwent surgery for adenocarcinoma of the rectum, of these, 287 patients had a total mesorectal excision for mid or lower third tumours under the care of seven colorectal surgeons. All resected specimens were scored by a Consultant GI pathologist. Two hundred and fourteen patients underwent anterior resection and 73 underwent abdomino-perineal resection. The median age of the patients was 73 years (range 38-95 years). One hundred and ninety-four patients were male. Seventy-eight patients were treated with preoperative radiotherapy, 59 short course and 19 long course. TME scores were TME1 n = 30, TME2 n = 99, TME3 n = 158. Fifteen patients developed local pelvic recurrence at 2 years. Total mesorectal excision scores were not statistically influenced by Dukes' stage, width of tumour, preoperative radiotherapy or grade of surgeon. Male patients were statistically more likely to have a TME score of 2 or 3 compared with female P = 0.04. Patients undergoing an anterior resection were statistically more likely to have a TME score of 2 or 3 compared with abdomino-perineal resection P = 0.0001.Tumours with a circumferential resection margin (CRM) of more than 1 mm were more likely to have a TME score of 2 or 3 score (P = 0.0001). There was no relationship between TME and local recurrence (P = 0.966). CONCLUSION: There is no relationship between the TME score in patients undergoing resectional surgery for adenocarcinoma of the rectum and the development of local recurrence at 2 years. Other factors such as CRM involvement are more likely to have an impact on local recurrence. The factors that influence the quality of TME are the operative procedure of anterior resection, male gender and CRM positivity. There appear to be no deleterious effects on the TME score by Specialist Registrars performing the operation under Consultant supervision. While TME scores may be an index of a technical performance, they appear to have little role in predicting future outcomes.     

Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit

Despite improved surgical treatment strategies for rectal cancer, 5-15% of all patients will develop local recurrences. After conservative surgery, circumferential resection margin (CRM) involvement is a strong predictor of local recurrence. The consequences of a positive CRM after total mesorectal excision (TME) have not been evaluated in a large patient population. In a nationwide randomized multicenter trial comparing preoperative radiotherapy and TME versus TME alone for rectal cancer, CRM involvement was determined according to trial protocol. In this study we analyze the criteria by which the CRM needs to be assessed to predict local recurrence for nonirradiated patients (n = 656, median follow-up 35 months). CRM involvement is a strong predictor for local recurrence after TME. A margin of < or = 2 mm is associated with a local recurrence risk of 16% compared with 5.8% in patients with more mesorectal tissue surrounding the tumor (p <0.0001). In addition, patients with margins < or = 1 mm have an increased risk for distant metastases (37.6% vs 12.7%, p <0.0001) as well as shorter survival. The prognostic value of CRM involvement is independent of TNM classification. Accurate determination of CRM in rectal cancer is important for determination of local recurrence risk, which might subsequently be prevented by additional therapy. In contrast to earlier studies, we show that an increased risk is present when margins are < or = 2 mm.     

Low rates of local recurrence after surgical resection of rectal cancer suggest a selective policy for preoperative radiotherapy

Aim Preoperative short‐course radiotherapy (SCRT) is increasingly recommended to reduce local recurrence after surgery for rectal cancer. Its avoidance may be beneficial, however, if the risk of local recurrence is low. We report a single centre experience which suggests that selective rather than uniform use of SCRT may be the best approach. Method Analysis was carried out on a prospectively collected unselected series of 1606 patients with rectal cancer treated in one centre. Follow‐up was 97% complete. SCRT was performed selectively and all patients had a mesorectal excision. Results Among 940 patients undergoing a potentially curative major resection the operative mortality was 4.6%, the permanent stoma rate 23% and the crude 5‐year survival 61%. The local recurrence rate after curative anterior resection was 2.9% and 7.7% after abdominoperineal excision. The overall local recurrence rate after a potentially curative major resection was 4.0%. Conclusion The routine use of preoperative radiotherapy for rectal cancer is probably not justified where local recurrence after curative rectal resection is uncommon.     

Recurrence and survival after surgical management of rectal cancer.

BACKGROUND: Reported local recurrence rates for rectal cancer are significantly reduced using a combination of superior surgical technique, in the form of total mesorectal excision, and routine radiotherapy. In an attempt to determine the effectiveness of current local management strategies, a review of Vancouver Island Cancer Centre patients with rectal cancer was performed and the overall local recurrence rate was identified. METHODS: We retrospectively reviewed the charts of 272 rectal cancer patients from 1988 to 1998. Two hundred and twenty-nine patients met inclusion criteria. Analysis of patient factors included age, gender, type of surgery, and adjuvant therapy. Tumors were assessed for level, stage, and grade. Local recurrence and distant metastases were also documented. Variables influencing local recurrence in this group were identified and disease-free and actuarial survival determined. RESULTS: Of 229 patients analyzed, 12.7% (29) had local recurrences. Variables influencing local recurrence were number of positive lymph nodes, vascular invasion, and neural invasion. There was no significant difference in local recurrence between patients having anterior resection and those having abdominoperineal resection. None of the patients who received preoperative radiotherapy had a local recurrence. Actuarial disease-free survival was 87% at 5 years. CONCLUSIONS: Limiting local recurrence is one of the most important goals in the treatment of rectal cancer. It is essential to identify those patients with "high risk" tumors as identified by endorectal ultrasound or pathologic features. These patients comprise the group most likely to benefit from a routine mesorectal excision combined with adjuvant radiotherapy.