低位直肠癌保留神经的腹膜外侧方扩大清扫的效果分析

目的 探讨低位直肠癌保留神经的腹膜外侧方扩大清扫对患者术后生存率、排尿功能和性功能的影响。方法 回顾性分析我院1996年1月至2000年6月期间收治的392例进展期低位直肠癌实施保留神经的根治性切除术患者的临床资料，其中行腹腔内清扫173例，腹腔内加腹膜外侧方清扫219例，2组患者在年龄、性别、浸润肠壁深度及肿瘤病理组织学类型方面差异无统计学意义。结果 腹腔内加腹膜外侧方清扫组侧方淋巴结转移率为17．8％（39／219），侧方盆壁非连续性癌灶转移率为5，9％（13／219）。术后发生排尿功能障碍：腹腔内清扫组7例（4．0％），腹腔内加腹膜外侧方清扫组113例（51．6％），2组比较差异有统计学意义（P〈0．01）；性功能障碍：腹腔内清扫组93例男性患者中有12例（12．9％），腹腔内加腹膜外侧方清扫组119例男性患者中有62例（52．1％），2组比较差异有统计学意义（P〈0．01）；局部复发率：腹腔内清扫组为16．2％（28／173），腹腔内加腹膜外侧方清扫组为9．6％（21／219），2组比较差异有统计学意义（P〈0．05）；5年生存率：腹腔内清扫组为49．1％（85／173），腹腔内加腹膜外侧方清扫组为59．4％（130／219），2组比较差异有统计学意义（P〈0．05）。结论 低位直肠癌保留神经的腹膜外侧方扩大清扫，可以减少局部复发，提高患者5年生存率，但也会影响患者术后排尿和男性性机能。     

Radical resection with autonomic nerve preservation and lymph node dissection techniques in lower rectal cancer surgery and its results: the impact of lateral lymph node dissection

Lateral lymph node metastases occur in 9% of rectal cancer patients. For cancers localized in the lower rectum below peritoneal reflection, the frequency increases to 13% of all cases and to 25.5% in those of Dukes' stage C. The most important technique in colorectal surgery for decreasing local failure in the pelvis is lateral lymph node dissection. Today, however, it is also regarded as crucial that with perfect lymph node dissection of the lateral area outside of the pelvic plexus, the postoperative functions of urination and sexual ability are preserved. Since 1988 we have performed autonomic nerve-preserving curative resection (ANP) with lateral dissection in most patients with advanced lower rectal cancer. The mean 5-year survival rate of patients with lateral lymph node metastasis from the lower rectum was 37.5%, improving from 32.1% to 43.4% during this period. In cases of ANP with lateral dissection the local recurrence rate was 4.8% overall and 7.4% in the Dukes' C group. Postoperative urinary function has been good or fair in all ANP patients. Sexual function remained problematic, especially regarding male ejaculation. We describe our method for preserving the autonomic nervous system in the pelvis and for achieving complete dissection in the lateral area. Received: 20 August 1998 / Accepted: 14 October 1998     

侧方淋巴结清扫对进展期低位直肠癌预后的影响

目的 应用治疗指数(therapeutic index,TX)(TX=肿瘤相关5年生存率×区域淋巴结转移的概率)评估侧方淋巴结清扣对于改善进展期低位直肠癌预后的价值.方法 回顾性分析直肠癌行根治性切除+全直肠系膜切除+侧方淋巴结清扫的96例进展期低位直肠癌患者的临床资料.结果 进展期低位直肠癌直肠系膜淋巴结、直肠上动脉旁淋巴结、肠系膜下动脉旁淋巴结和侧方淋巴结转移率分别为21%(20/96),13%(12/96),10%(10/96)和15%(14/96).检出直肠系膜淋巴结、直肠上动脉旁淋巴结、肠系膜下动脉旁淋巴结和侧方淋巴结转移阳性的进展期低位直肠癌患者5年生存率分别为35%,25%,20%和36%.TX:清扫直肠系膜淋巴结和侧方淋巴结的TX分别为7.4和5.4,明显高于清扫直肠上动脉和肠系膜下动脉旁淋巴结的3.3和2.0.侧方淋巴结转移阳性者术后局部复发率为64%(9/14),TX明显高于侧方淋巴结转移阴性者的11%(9/82)(x2=22.308/P=0.000).Kaplan-Meier生存分析显示,侧方淋巴结转移阳性患者平均生存期为(38.0±6.7)个月(95%置信区间:24.8～51.2个月),明显短于侧方淋巴结转移阴性的(80.9±2.1)个月(95%置信区间:76.7～85.1个月),两者差异有统计学意义. 结论侧方淋巴结清扫可降低进展期低位直肠癌根治性切除术后局部复发率以及改善预后.除全直肠系膜切除外,进展期低位直肠癌术中还应进行侧方淋巴结清扫.     

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目的　研究角蛋白19(Keratin 19)的表达与直肠癌所导致直肠系膜内淋巴结微转移的关系。探讨其在预测直肠癌淋巴结微转移中的应用价值。方法　用免疫组化SP法检测2 0 0 2年3～8月收治的80例DukesA ,B ,C ,D期直肠癌组织及其系膜内12 0枚和直肠系膜外5 1枚转移淋巴结中Keratin 19的表达情况,分析其与直肠癌淋巴结转移的相关性。结果　(1)在80例直肠癌病人中,5 7例腺癌上皮Keratin 19表达强于其正常直肠腺上皮Keratin 19的表达,免疫组化染色转移淋巴结的表达程度强于其癌组织表达(P <0 .0 1) ;(2 )有2 5例直肠癌病人直肠系膜内淋巴结HE染色阴性,而免疫组化Keratin 19蛋白染色于其中9例病人的系膜内和系膜外淋巴结分别有11枚(9. 17% )和5枚(9 8% )染色阳性;(3) 80例直肠癌病人直肠系膜淋巴结内癌细胞免疫组化染色平均灰度值与直肠癌原发灶癌细胞免疫组化染色平均灰度值相关性分析显示有相关性(P <0 . 0 1)。结论　80例直肠癌病人直肠系膜淋巴结内转移癌细胞Keratin 19蛋白表达强于直肠癌原发灶癌细胞的表达,直肠癌细胞Ker atin 19蛋白的阳性表达与直肠癌淋巴结微转移呈正相关关系。Keratin 19在DukesC/D期直肠癌内的表达显著高于其在DukesA/B期内的表达。Keratin 19在直肠癌细胞内的表达与病人年龄无明显关     

进展期低位直肠癌侧方淋巴结转移的临床研究

目的 分析进展期低位直肠癌侧方淋巴结转移的危险因素,探讨侧方淋巴结转移对局部复发及预后的影响.方法 回顾性分析行根治性切除+侧方淋巴结清扫的96例进展期低位直肠癌的临床资料,探讨侧方淋巴结转移与临床病理特征、局部复发和预后的相关性.结果 进展期低位直肠癌侧方淋巴结转移率为14.6%(14/96).肿瘤直径≥5 cm者侧方淋巴结转移率为25.0%,明显高于肿瘤直径＜5 cm者的7.1%(P＜0.05).侵犯肠壁周径1/4、2/4和3/4者侧方淋巴结转移率分别为6.3%、6.7%和12.0%,明显低于侵犯肠壁周径4/4者的70.0%(P＜0.05).低分化直肠癌侧方淋巴结转移率为30.0%,明显高于高分化和中分化直肠癌的4.5%和9.1%(P＜0.05).进展期低位直肠癌根治性切除术后局部复发率为18.8%(18/96).侧方淋巴结转移阳性者术后局部复发率为64.3%,明显高于侧方淋巴结转移阴性者的11.0%(P＜0.05).Kaplan-Meier生存分析显示,侧方淋巴结转移阳性患者平均生存期为(38.0±6.7)个月,明显短于无侧方淋巴结转移的(80.9±2.1)个月(P＜0.05).结论 肿瘤直径、侵犯肠壁周径和肿瘤分化程度是进展期低位直肠癌侧方淋巴结转移的重要危险因素.侧方淋巴结转移与进展期低位直肠癌局部复发及预后密切相关.     

Autonomic nerve-sparing surgery combined with preoperative radio-chemotherapy in advanced lower rectal cancer patients

Since 1985, we have studied autonomic nerve-sparing surgery combined with preoperative radiochemotherapy in patients with advanced rectal cancer to preserve genitourinary function without compromising radicality. The aim of this study was to evaluate postoperative genitourinary function and prognosis. A total of 84 patients with advanced rectal cancer underwent curative surgery combined with preoperative radio-chemotherapy. Of them, 76 underwent curative nerve-sparing surgery using radiation (42.6 Gy) and tegafur suppository. Postoperative genitourinary function, survival, and pelvic recurrence were investigated in these patients. The 5-year and 10-year disease-free survival rate was 80.7%, and the pelvic recurrence rate was 7.9% in patients receiving curative nerve-sparing surgery combined with radio-chemotherapy. All of these patients could micturate spontaneously, but preservation of sexual function was not as successful. Although this combined therapy is useful for curability and good postoperative quality of life, a new approach is needed to preserve sexual function.     

Sentinel lymph node mapping in colorectal cancer

Sentinel lymph node mapping has already been accepted as part of the treatment for malignant melanomas of the skin and in breast carcinomas. The status of lymph nodes is an important prognostic marker in colorectal carcinoma as well. The authors tried the feasibility of this technique in colorectal carcinomas. The technique is analogous to the one used in breast cancer and melanoma: 2 ml of 2.5% Patentblau dye was given subserosally around the tumor. After resection the specimen was immediately sent to pathology where the lymph nodes were removed. This technique has been tried on 31 patients, 22 with colonic and 9 with rectal tumors. Of these patients, 15 were Dukes stage C, 14 were Dukes stage B and 2 were Dukes stage A. An average 4.3 blue lymph nodes were found in colon tumors and 5.4 in rectal tumors and an average 14 unstained lymph nodes were found in colon tumors, and 7 in rectal tumors. The blue nodes were predictive of the nodal status in 9 of the 15 Dukes stage C patients. In these cases the blue lymph nodes contained metastases and there were 2 cases where metastases were limited to the blue lymph nodes. SUMMARY: The authors found a high false negative rate for lymphatic mapping with the vital dye technique, therefore they try to change the method according to that used by Saha et al. The aim of sentinel node identification in colorectal carcinomas would be improved staging rather than reducing of the extent of lymphadenectomy. The role of lymphatic mapping in large bowel cancers needs further investigations. Until the results are reliable, as many lymph nodes as possible have to be excited and sent for histology.     

Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer

BACKGROUND: Lateral lymph node metastases occur in some patients with low rectal cancer and may cause local recurrence after total mesorectal excision. The aims of this study were to identify risk factors for lateral node metastases in patients with pathological tumour (pT) stage 3 or pT4 low rectal adenocarcinoma, and to evaluate the prognostic significance of lateral node metastases. METHODS: A retrospective analysis was performed of the outcome of 237 patients with pT3 or pT4 low rectal adenocarcinoma who underwent R0 resection with systematic lateral node dissection. RESULTS: Lateral lymph node metastases were found in 41 patients (17.3 per cent). Increased risk of lateral lymph node metastases was associated with a distal tumour margin close to the anal margin, histological type other than well or moderately differentiated adenocarcinoma, and the presence of mesenteric lymph node metastases. Patients with lateral node metastases had a significantly shorter postoperative survival (5-year survival rate 42 versus 71.6 per cent; P < 0.001) and an increased risk of local recurrence (44 versus 11.7 per cent; P < 0.001) compared with those without lateral node metastases. CONCLUSION: Tumour site, histological type and the presence of mesenteric lymph node metastasis are factors predicting the risk of lateral node metastasis. The poor prognosis of patients with lateral lymph node metastases after systematic lateral dissection suggests the need for adjuvant therapy.     

Effect of preoperative radiochemotherapy on lymph node retrieval after resection of rectal cancer

HYPOTHESIS: Preoperative radiochemotherapy for advanced rectal cancer results in fewer lymph nodes detected in the tumor-bearing specimen. DESIGN: Nonrandomized control trial with analysis of a prospective perioperative database. SETTING: Department of Surgery of a large-volume university hospital. PATIENTS: All patients who underwent conventional open surgery to cure rectal cancer between January 1, 1996, and March 31, 2001. INTERVENTIONS: During the study period 184 patients (81%, control group) underwent surgery without receiving preoperative radiochemotherapy. Forty-two patients (19%, study group) who had advanced rectal cancer (modified Dukes stages B [tumors that have penetrated the muscle layer of the bowel wall or have gone through the bowel] or C [tumors that have spread to the lymph nodes in the same region]) received preoperative radiochemotherapy (2 cycles of fluorouracil, 4500 rad) during this period. Most patients underwent anterior rectal resection in both groups (77.7% of those who did not receive preoperative radiochemotherapy and 71.8% of those who did), the remaining patients were treated with abdominoperineal resection. RESULTS: A mean (SEM) of 19 (1) lymph nodes per specimen were detected in the control patients, while significantly fewer lymph nodes were detected in study patients (13 [1]; P<.05). The rate of inadequate lymph node staging (pNx) increased from 7% in the control group to 12% in the study group (P =.06). Pathological lymph node staging disclosed that significantly more study patients who received preoperative radiochemotherapy had modified Dukes stage A (tumors that are found only in the inner wall or rectum) cancer when compared with the control group (17% vs 0%, respectively; P<.05). CONCLUSIONS: Preoperative radiochemotherapy for advanced rectal cancer results in a significant decrease of lymph nodes detected within the tumor-bearing specimen. Preoperative radiochemotherapy induces significant downstaging with fewer positive lymph nodes and more patients presenting with Dukes stage A rectal cancer. Great care must be taken to remove an adequate number of lymph nodes and more sophisticated pathological techniques of lymph node detection are required since the tumors of ever-increasing numbers of patients are inadequately classified.     

Impact of upward lymph node dissection on survival rates in advanced lower rectal carcinoma

BACKGROUND/AIMS: This study investigated appropriate level of upward lymph node (LN) dissection in advanced lower rectal carcinoma. METHODS: A total of 285 consecutive patients with stage II/III lower rectal carcinoma were analyzed. LN dissection was classified as follows: division of the root of the superior rectal artery (UD2), division of the root of the inferior mesenteric artery (UD3) and UD3 with para-aortic LN dissection (UD4). RESULTS: LN metastases at the root of the inferior mesenteric artery were found in 4 patients. Their prognoses were worse than those of the other stage III patients (p = 0.011). On the other hand, LN metastases along the superior rectal artery were discovered in 14 patients, whose 5-year overall survival rate was 61.2%. By removing the LNs either UD2 or UD3/4, a similar survival rate was achieved in stage III patients with LN metastases along the superior rectal artery. CONCLUSION: Survival of a minority with metastatic LNs at the root of the inferior mesenteric artery was poor. Additionally, survival is no worse in patients with positive LN along the superior rectal artery as long as these positive nodes are resected by either UD2 or UD3/4. Low ligation is adequate for advanced lower rectal carcinoma.     

Interstitial radiation therapy for carcinoma of the prostate

Pelvic lymph node dissection and iodine 125 implantation has been systematically utilized at Memorial Sloan-Kettering Cancer Center (MSKCC) since 1970 as one form of management of selected patients with stage B or stage C prostatic cancer. Experience with the technique is reviewed on the basis of previously published data and on the basis of a five-year follow-up of the first 100 patients. The operative procedure has been generally well tolerated, with a low morbidity, with a mortality rate of 0.67% (2/300), and with minimal adverse effects on urinary, rectal, and sexual functions. Thirty-six percent of the patients had regional lymph node metastasis, and such was associated with a 71% incidence of distant metastasis at five years. However, at five years 14% of patients with positive nodes remain free of evidence of neoplasm, and 38% of patients with negative lymph nodes have evidence of bone metastasis. At five years, 11% of patients have evidence of local recurrence only; 19%, distant metastasis only; and 32%, both local recurrence and distant metastasis. Five-year survival without stratification relative to lymph node involvement is 100% (16/16) for stage B1, 88% (23/26) for stage B2, 66% (6/10) for stage B3, 33% (2/6) for stage C1, 53% (17/32) for stage C2, and 1/1 for stage C3, but endocrine therapy has presumably contributed to such survival in those patients developing intractable local recurrence and/or symptomatic distant metastasis within the five-year follow-up.     

低位直肠癌保肛扩大根治手术

探讨扩大根治术在低位直肠癌保肛手术中的临床意义。方法:在265例低位直肠癌中选择158例实施保肛手术,对其中62例在扩大根治术同时完成保肛手术。结果:总转移率54.8％。上方淋巴结转移率53.4％,侧方淋巴结转移率17.2％,下方淋巴结转移率0％,转移度9.1％。术后随访结果:扩大保肛组;3年生存率73.1％,局部复发率0％;一般保肛组:3年生存率65.2％,局部复发率5.16％。排便功能:优占80％,可占16.5％,差占3.5％。结论:扩大根治术可有效防止低位直肠癌保肛术后局部复发,术后排便功能良好,不增加手术合并症。     

套入式结肠直肠黏膜吻合保肛术对青年男性低位直肠癌术后性功能的影响

目的 探讨套入式结肠直肠黏膜吻合保肛术对青年男性低位直肠癌患者术后性功能的影响.方法 对68例低位直肠癌青年男性患者行套入式结肠直肠黏膜吻合术,分别于术前及术后调查其性功能.结果 68例患者中术后性功能障碍共发生22例,发生率32.35%,其中勃起障碍15例,射精障碍7例.6例Dukes A期患者均未发生性功能障碍,Dukes B期及C期患者术后性功能障碍发生率分别为26.67%及38.30%,两者差异有统计学意义(P＜0.05).结论 套入式结肠直肠黏膜吻合术可以很好地保护青年男性低位直肠癌患者的性功能,是一安全、有效的保肛术式.     

Factors influencing lymph node retrieval in colorectal cancer and its effect on survival

Introduction:  NICE has set standards for lymph node (LN) harvest in surgery for colorectal cancer (CRC). We report the effect of the operating surgeon and reporting pathologist on lymph node yield and the role of LN yield on survival.
Method:  Data on all patients with CRC treated in a single unit between 1999 and 2004 were collected in the ACPGBI database. Lymph node harvest was identified for each of three surgeons and three pathologists. Actuarial survival of all patients with Dukes' stage B with greater than or less than 8 reported LNs and Dukes' stage C were compared using log-rank test (Kaplan–Meier method).
Results:  A total of 380 cases had a curative resection with a unit median LN retrieval of 13.
There was no difference in survival between Dukes' stage B <8 LN (mean 42 months, 95% CI 29–55) and Dukes stage C (mean 45 months, 95% CI 29–51), log-rank P =  0.7618. Survival between Dukes stage B (8 LN and Dukes C was significantly different (mean 58 months, 95% CI 53–64 vs 45 months, 95% CI 29–51), log-rank P =  0.006.
 

     

直肠癌系膜淋巴结转移的临床病理学研究

目的探讨直肠癌系膜淋巴结转移的规律。方法 2 6例患者取淋巴结 4 4 3枚 ,应用淋巴结显示液处理全直肠系膜切除的直肠癌标本 ,对切取的淋巴结进行病理检测。结果 2 3例(88 5 % )患者的 1 2 8枚 (2 8 9% )淋巴结发现肿瘤转移 ,淋巴结直径≤ 0 5cm者 76枚 (5 9% )。转移病例中 ,后壁直肠癌 1 4例 ,71枚淋巴结有肿瘤转移 ,6 8枚分布于直肠上动脉旁。侧壁直肠癌 9例 ,5 7枚淋巴结有肿瘤转移 ,其中同侧直肠上动脉分支旁转移 2 9枚 ,对侧 7枚 ,同侧直肠中动脉旁转移4枚、对侧无转移。结论后壁直肠癌转移主要为上行扩散 ,侧壁直肠癌可伴有侧方淋巴结受累 ,并以肿瘤同侧淋巴结转移为主     

侧方淋巴结清除在直肠癌根治术中的临床意义

目的：探讨侧方淋巴清除在直肠癌根治术中的临床意义。方法：对36例低位进展期直肠癌患者行根治术，清除上方3组淋巴结的同时行侧方淋巴结清除，对分组淋巴结的转移情况进行评价。结果：36例中有19例有侧方淋巴结转移，其中侧方淋巴转移5例，占阳性淋巴结病例的26．3％（5／19），占全部病例的13．9％（5／36），结论：为保证根治手术的彻底性，减少肿瘤复发，对腹膜返折部以下的进展期直肠癌除上方淋巴结必须清除达第3站外，有必要同时进行侧方淋巴清除。     

Comparative outcome between chemoradiotherapy and lateral pelvic lymph node dissection following total mesorectal excision in rectal cancer

OBJECTIVE: To evaluate comparative outcome between adjuvant postoperative chemoradiotherapy (postoperative CRT) and lateral pelvic lymph node dissection (LPLD) following total mesorectal excision (TME) in rectal cancer patients. BACKGROUND: Although TME results in lower rate of locoregional recurrence compared with conventional surgery, these 2 treatment modalities following TME have not adequately been appraised until the present trend of preoperative chemoradiotherapy. PATIENTS AND METHODS: Between 1995 and 2000, patients with stage II and III rectal cancer underwent TME plus postoperative CRT (n = 309) or LPLD (n = 176). Patients in the postoperative CRT group received 8 cycles of 5-fluorouracil plus leucovorin and 45 Gy pelvic radiotherapy. Patients in the LPLD group underwent lateral lymph node dissection outside the pelvic plexus. RESULTS: The 5-year overall and disease-free survival rates were 78.3% and 67.3% in the postoperative CRT group, respectively, and 73.9% and 68.6% in the LPLD group, respectively, without significant differences between these groups. Patients in the LPLD group with stage III lower rectal cancer had a locoregional recurrence rate 2.2-fold greater than those in the postoperative CRT group (16.7% vs. 7.5%, P = 0.044). Multivariate analysis showed that APR and advanced T-category (T4) were significantly associated with locoregional recurrence, whereas lymph node metastases, high preoperative serum carcinoembryonic antigen, and APR were significantly associated with shortening of disease-free survival. CONCLUSIONS: Postoperative-CRT and LPLD following TME resulted in comparable survival rates, but the locoregional recurrence rate was higher in the LPLD group. These findings suggest that initial surgery is appropriate for rectal cancer patients who are candidates for low anterior resection without extensive local disease (T1-T3), regardless of lymph node status.     

Prophylactic Lymph Node Dissection in Papillary Thyroid Carcinoma: Is There a Place for Lateral Neck Dissection?

Background

Cervical lymph node (LN) metastases are common in patients with papillary thyroid carcinoma (PTC), and they have a negative impact on recurrence. The management of preoperatively node-negative (N0) PTC is still controversial. The aim of our study was to describe the results of a prophylactic bilateral lymph node dissection (LND) and to investigate its impact on recurrence.

Methods

From 2003 to 2011, we analyzed 603 consecutive preoperatively N0 PTC patients. For each patient, we reviewed demographics data, tumor characteristics, pattern and risk factors of LN metastasis, and outcome.

Results

Lymph node metastases were found in 23 % of patients: 19 % in the central compartment and 8 % in the lateral compartment, including 1 % in the lateral compartment on the opposite side from the tumor. Multivariate analysis showed that hyperthyroidism and extrathyroidal invasion of the tumor were significantly associated with LN metastasis. Further analysis showed that localization of the tumor in the upper third of the thyroid lobe and metastatic LN in the central compartment were independent risk factors for lateral LN metastasis. During the 4.3-year follow-up, 23 recurrences were observed (4 %), including 5 in the central compartment. Recurrence rates were 2 % in the N0 group, 5 % in N1a patients, and 22 % in N1b patients (p < 0.001).

Conclusions

In preoperatively N0 PTC patients, LN metastases are frequent in central and ipsilateral lateral compartments. Prophylactic LND in the central and ipsilateral lateral compartments should therefore be recommended in the presence of PTC to identify high-risk patients.     

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??Selective lateral pelvic lymph node dissection for mid-low rectal cancer WEI Ming-tian??WANG Zi-qiang. Department of Gastrointestinal Surgery??West China Hospital??Chengdu 610041??China
Corresponding author??WANG Zi-qiang??E-mail??wangzqzyh@163.com
Abstract Lateral pelvic lymph node metastasis is not uncommon in patients with advanced mid-low rectal cancer??and is also the cause of lateral recurrence. The latter has been indicated to be the most common kind of local recurrences in Asian reports. Presence of enlarged lateral lymph nodes at presentation is an independent risk factor for lateral pelvic recurrence after chemoradiotherapy (CRT) and total mesorectal excision. Controversy exists between Asian and western countries with respect to the use of CRT and lateral lymph node dissection (LLND) in the management of mid-low advanced rectal cancer. Primary reports indicated that thecombination of CRT and LLND was likely to be superior to either of the two strategies and provided more favourable local control and survival. So far??there is no consensus on the criteria to diagnose lateral lymph node metastases (LLNM) and the indication for selective LLND. More multicenter prospective cohort studies are warrant to address the issues, before we can provide better health care to the patients to improve their survival??as well as to avoid unnecessary LLND??which has been associated with more surgical complications and poorer quality of life.     

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目的 探讨中下段直肠癌侧方淋巴结转移规律及影响因素。方法 对1995－2000年行侧方淋巴结清扫的105例直肠癌病人进行回顾性分析。结果 中下段直肠癌侧方转移率为21％，肿瘤的大小、部位、病理分型、分化程度及浸润深度是影响侧方转移的重要因素。在侧方淋巴结转移阳性病人中，单纯闭孔及髂内淋巴结转移阳性病人占54．5％，单纯髂外及髂总淋巴结转移阳性病人为18．1％。侧方淋巴结转移阴性病人术后局部复发率为6．7％，阳性病人为36．3％。行侧方清扫局部复发率较传统术式由17．6％降至11．4％。侧方转移阴性病人平均生存期为88个月，阳性病人为37个月，二者差异有显著性。结论 侧方淋巴转移是中下段直肠癌淋巴转移的重要途径。闭孔和髂内淋巴结是侧方淋巴结清扫中需要着重清扫的部位。侧方淋巴清扫较传统术式可明显降低局部复发率。