关于中低位直肠癌侧方淋巴结清扫的争论

直肠癌的侧方淋巴结清扫的范围、指征及疗效,不同国家、不同学派的医生的观点存在一定差异。目前认为侧方清扫主要适用于中低位、病理为低分化或T3~4的直肠癌病人,术前可应用放射性核素显像、腔内超声或PET-CT等评估侧方淋巴结情况。侧方清扫对外科技术要求很高,术中应注意在髂内血管和盆壁及闭孔筋膜之间进行分离,直至暴露闭孔神经,清扫淋巴结总数至少应在10枚以上。目前侧方清扫可以降低肿瘤复发率已得到肯定,但侧方淋巴结清扫已达第3、4站,其必要性国际上仍存在争论。笔者认为侧方淋巴结清扫仍有生命力及存在价值,TME基础上改良清扫或选择性侧方淋巴结清扫。腹腔镜下的TME及侧方清扫等均是直肠癌手术今后若干的方向之一。     

Oncological outcome after lateral pelvic lymphadenectomy for low rectal carcinoma: not only an N-status matter

Tumour deposits (TDs), novel pathological entities, should be considered when estimating the regional and systemic spread of rectal carcinoma and formulating treatment strategies. In fact, TDs may have more severe prognostic impact than lymph node positivity or the lymph node ratio. The assessment of the presence of TDs can be performed only through accurate postoperative pathological examination; however, the detection of TDs is not part of any of the procedures currently used to assess preoperative or intraoperative staging. This review aims to analyse and discuss the impact of TDs on the oncological outcome of patients who undergo surgery for advanced low rectal carcinoma. No prospective study has evaluated the impact of lateral pelvic TDs on oncological outcomes following total mesorectal excision with lateral pelvic lymphadenectomy. Although adequate total mesorectal excision allows for the excision of intramesorectal TDs, lateral pelvic lymph node dissection cannot guarantee the removal of lateral pelvic TDs; moreover, it remains to be determined whether surgical excision of lateral pelvic TDs can impact long-term outcomes. However, the identification of lateral pelvic TDs strengthens the ‘staging effect’ and limits the ‘therapeutic effect’ of lateral pelvic lymphadenectomy, supporting the rationale for the use of neoadjuvant chemoradiotherapy for rectal cancer. When evaluating the oncological outcomes after total mesorectal excision with lateral pelvic lymphadenectomy, the impact of lateral pelvic TDs should be considered.     

Impact of lateral pelvic lymph node dissection on evacuatory and urinary functions following low anterior resection for advanced rectal carcinoma

Background and aim Lateral pelvic lymph node dissection (LPLD) has been reported to be beneficial in terms of survival for locally advanced low rectal carcinoma. However, the impact of LPLD on bowel function has not yet been determined by means of anorectal physiologic investigation.Patients and methods Fifty-seven rectal cancer patients who underwent low anterior resection were evaluated with clinical and physiologic parameters. Of these, 15 patients had LPLD. The postoperative bowel and urinary function were evaluated with patients questionnaire and anorectal manometry before and after the operation.Results The proportion of patients who had pouch reconstruction, adjuvant radiation therapy, and autonomic nerve dissection were significantly higher in the LPLD group. The incidence of evacuatory dysfunction was significantly higher (80% vs 45%) postoperatively in the LPLD group. There was no significant difference in anal sphincter pressures, sensory threshold, and neorectal volumes between the groups postoperatively. In terms of urinary function, use of medication for urination was significantly frequent in the LPLD group. Multivariate analysis identified the level of anastomosis as an independent affecting factor for evacuatory dysfunction and LPLD for urinary dysfunction.Conclusion Although LPLD affected urinary dysfunction, it did not impair postoperative evacuatory function in the early postoperative period.     

Morphological characteristics of lateral pelvic lymph nodes in rectal carcinoma

Aim Macroscopic and imaging indicators for lymph node metastasis have been documented not in lateral pelvic lymph nodes but in mesorectal lymph nodes in patients with rectal carcinoma. We conducted this study to uncover morphological characteristics of lateral pelvic lymph nodes in patients with rectal carcinoma. Materials and methods Fifty-eight patients with locally advanced rectal carcinoma who had total mesorectal excision and lateral pelvic lymph node dissection were studied. Total number of lateral pelvic lymph nodes evaluated was 462, with 538 mesorectal lymph nodes being used for comparison. Factors of lymph nodes evaluated were size (long- and short-axes diameters), shape (ovoid and irregular), and heterogeneity of internal structure. Receiver operating characteristic (ROC) curve analysis was used to compare the diagnostic accuracy of each factor. Results Lateral pelvic lymph node at non-metastatic status appeared to be longer (4.5 vs 3.5 mm) and thinner (2.2 vs 2.6 mm) than mesorectal lymph nodes. ROC curve analysis, for discriminating non-metastatic and metastatic lateral pelvic lymph nodes, revealed that a short-axis diameter appeared to be the most prominent factor with highest area under curve (0.907) and was more reliable than either long-axis diameter (0.811) or shape (0.527) other than internal structure (1.00). A short-axis diameter was an independent risk factor for metastasis by multivariate analysis with an odds ratio of 1.29 (p < 0.0001, 95% confident interval, 1.22–1.36). The most reliable cut-off value was 4 mm with 96% of sensitivity, 68% of specificity, and 82% of overall accuracy. Conclusion Lateral pelvic lymph nodes tended to be longer and thinner than mesorectal lymph nodes at non-metastatic status. A short-axis diameter of 4 mm or larger was the prominent indicator of metastasis in lateral pelvic lymph nodes.     

A narrative review of pelvic lymph node dissection in prostate cancer

Pelvic lymph node dissection (PLND) is an important component in the staging and prognostication of prostate cancer. We performed a narrative review to assess the literature surrounding PLND: (I) the current guideline recommendations and contemporary utilization, (II) the calculation of patient-specific risk to perform PLND using available nomograms, (III) to review the extent of dissection, and its associated outcomes and complications. Due to the improved lymph node yield, better staging, and theoretical improvement in the control of micro-metastatic disease, guidelines have supported the use of (extended-) PLND in patients deemed to be at intermediate or high risk of lymph node involvement (often at a threshold of 5% on modern risk nomograms). However, in practice, real-world utilization of PLND varies considerably due to multiple reasons. Conflicting evidence persists with no clear oncological benefit to PLND, and a small, but important, risk of morbidity. Complications are rare, but include lymphoceles; thromboembolic events; and more rarely, obturator nerve, vascular, and ureteric injury. Furthermore, changing disease incidence and stage migration in the context of earlier detection overall have led to a decreased risk of nodal disease. The trade-offs between the benefits, harms, and risk tolerance/threshold must be carefully considered between each patient and their clinician.     

根治性膀胱切除术中扩大淋巴结清扫术不可滥用

根治性膀胱全切+尿流改道术是目前肌层浸润性膀胱肿瘤的首选治疗,盆腔淋巴结清扫术是其中的必要步骤,其对进行肿瘤准确分期、判断患者预后、提高患者的生存率至关重要,而是否所有膀胱癌患者都应该行扩大淋巴结清扫术学界尚无定论。在此,作者结合文献报道和临床诊治体会,就根治性膀胱切除术中扩大淋巴结清扫术的意义与适应征作一简要探讨。     

中低位直肠癌TME手术结合侧方淋巴结清扫的临床意义研究

目的研究中低位直肠癌行全直肠系膜切除术(TME)结合侧方淋巴结清扫(LLND)的临床意义。方法回顾性分析2013年1月至2014年12月73例中低位直肠癌患者资料,根据不同术式将其分为联合组及TME组两组。TME组患者34例,联合组患者39例,行TME+LLND。临床数据分析使用统计学软件SPSS 24.0,围术期指标等计量资料采用(x±s)表示,独立样本t检验;术后并发症等计数资料采用χ^2检验;用K-M法绘制生存曲线,并采用Log-rank检验分析生存率差异。P<0.05为检验标准。结果TME组手术时间及手术出血量均较联合组少(P<0.05);两组术后排气时间、术后住院时间、并发症发生率、性功能障碍、排尿障碍及术后1年、3年的局部复发率比较,差异均无统计学意义(P>0.05);联合组术后5年的局部复发率为7.7%,低于TME组的26.5%,(P<0.05);TME组术后1、3、5年生存率分别为82.4%、61.8%、52.9%;联合组术后1、3、5年生存率分别为92.3%、82.1%、74.4%,联合组术后生存率优于TME组,差异有统计学意义(P<0.05)。结论中低位直肠癌行TME+LLND术可提高患者的远期生存率,且在手术技巧和精细操作下,保证患者术后生活质量,有积极的临床意义。     

Obesity does not increase the risk of lymph node metastases in patients with clinically localized prostate cancer undergoing radical prostatectomy and extended pelvic lymph node dissection

Objectives: Several studies have shown that obesity is associated with more aggressive prostate cancer (PCa) variants. We hypothesized that obesity, quantified as body mass index (BMI), is associated with a higher risk of lymph node invasion (LNI) in patients undergoing extended pelvic lymph node dissection (ePLND). Methods: Clinical and pathological data were available for 994 consecutive men with PCa treated with radical prostatectomy (RP) and ePLND at a single European tertiary academic centre. Univariable and multivariable logistic regression analyses addressed the rate of LNI. Covariates consisted of pre‐treatment prostate specific antigen (PSA), biopsy Gleason sum, clinical stage history of diabetes mellitus as well as BMI coded as either continuous or categorized (<25, 25.0–29.9, 30 kg/m² or more) variable. Predictive accuracy was assessed with area under curve estimates. Results: Overall LNI was diagnosed in 105 patients (10.6%). Mean number of removed lymph nodes was 18.3 (range 7–60). Of all 994 patients, 372 (37.4%) were normal weight, 518 (52.1%) overweight, and 104 (10.5%) were clinically obese. Prevalence of LNI did not significantly differ across different BMI categories (<25, 25.0–29.9 and 30 kg/m² or more; 9.9, 10.6 and 12.5%, respectively; P = 0.75). In logistic regression models, neither continuously coded nor categorized BMI was a significant predictor of LNI at univariable or multivariable analyses (all P‐values ≥0.1). Moreover, inclusion of BMI with PSA, clinical stage, biopsy Gleason sum and presence of DM did not increase the ability of these variables to predict LNI (82.2% without BMI vs 82.5% and 82.9% with BMI coded as continuous and categorized variable, respectively; all P ≥ 0.4). Conclusions: In men undergoing RP and ePLND, increased BMI was not associated with increased risk of lymph node metastases. Therefore, routinely considering patient BMI in risk stratification schemes or prognostic LNI models may not be warranted.     

The efficacy and safety of lateral lymph node dissection for patients with rectal cancer: A systematic review and meta-analysis

Lateral lymph node metastasis in rectal cancer was first reported in the 1950s, since then, there has been an on-going debate about the value of lateral lymph node dissection (LLND) in the management of rectal cancer. We carried out a systematic review and meta-analysis to evaluate the value of LLND for the patients with rectal cancer. To collect clinical studies for the comparison of LLND and non-LLND in patients with rectal cancer, PubMed, Embase, Cochrane Library, Web of Science, and Google Scholar databases were searched from inception to 2019.A total of 26 studies, including 6865 patients were enrolled. Data processing and statistical analyses were performed using Stata V.15.0 software and Review Manager 5.3 software. Outcome measures included the 5-year survival rate, recurrence rate, perioperative outcomes, urinary function, and male sexual function. Regarding efficacy, our meta-analysis results showed no difference in 5-year disease-free survival rate and local recurrences between the two groups, the Hazard Ratio (HR) and 95% confidence interval (CI) was1.07 and 0.89 to 1.28 (P = 0.496),and the Odds Ratio(OR) and 95% CI were 0.90 and 0.76 to 1.06 (P = 0.208), respectively. Concerning safety, the incidence of urinary dysfunction and male sexual dysfunction was significantly increased in the LLND group (OR = 2.14, 95%CI = 1.21–3.79, P = 0.009), and (OR = 4.19, 95%CI = 1.55–11.33, P = 0.005), respectively. In conclusion, LLND did not improve the long-term prognosis of patients with rectal cancer, and was associated with increased urinary dysfunction and male sexual dysfunction.     

Impact of surgical volume on the rate of lymph node metastases in patients undergoing radical prostatectomy and extended pelvic lymph node dissection for clinically localized prostate cancer

BACKGROUND: Previous trials have shown that the number of procedures done by a single surgeon, that is, surgical volume (SV), is associated with several outcomes after radical prostatectomy (RP). OBJECTIVE: To test the association between SV and the detection of lymph node metastases during extended pelvic lymph node dissection (ePLND). DESIGN, SETTING, AND PARTICIPANTS: The study cohort consisted of 1020 men surgically treated for clinically localized prostate cancer. INTERVENTION: All patients underwent RP and ePLND by a group of six surgeons who were trained by the surgeon with the highest SV. All surgeons performed an anatomically extended PLND, including removal of obturator, external iliac, and hypogastric nodes. MEASUREMENTS: Univariable and multivariable logistic regression models tested the association between SV (either continuously coded or dichotomized according to the most informative cut-off, namely >144 vs /=0.06). Conversely, the surgeon with the highest SV removed more nodes and found more nodal metastases compared with the other surgeons (21.1 vs 17.9 mean number of nodes removed; p<0.001, and 15 vs 9.8% of LNI; p=0.01, respectively). At univariable logistic regression analysis, either continuously coded or dichotomized SV was a significant predictor of LNI (p=0.007 and p<0.001, respectively). In multivariable models, continuously coded as well as dichotomized SV maintained a significant association with the rate of LNI, after accounting for preoperative (p=0.04 and p=0.009, respectively) as well as for postoperative variables (p=0.03 and p=0.002, respectively). CONCLUSIONS: After adjusting for clinical and pathologic case-mix differences, patients treated by the highest-volume surgeons (>144 ePLNDs) were more likely to have LNI than those treated by low-volume surgeons, even though all surgeons used a similar extended template for node removal.     

腹腔镜直肠癌根治术侧方淋巴结清扫术

对腹膜反折以下cT3或N＋的直肠癌行侧方淋巴结清扫术可减少局部复发率及提高生存率。该术式采用五孔法完成,按日本学组提出的三间隙原则进行清扫：①分离保护输尿管及下腹神经,清扫下腹神经丛及下腹神经与髂总动脉、髂内动脉之间的第二间隙淋巴结;②清扫髂内外动脉间及闭孔内的第三间隙淋巴脂肪组织;③切除髂内血管及盆丛神经。应视肿瘤部位、浸润深度以及侧方淋巴结肿大情况,选择性行单或双侧清扫。腹腔镜下完成侧方淋巴结清扫具有视野好、狭小间隙操作方便、出血少等优势,是一种安全可行的手术方式。     

Update on indications for lateral lymph node dissection in the management of lower rectal cancer

The presence of lateral lymph node (LLN) metastasis was associated with higher local recurrence risk in patients with lower rectal cancer. The role of LLN dissection has not been fully determined despite prolonged debate that last for few decades. The practical difference between Japan and the West was the main culprit. Japanese used to rely on surgical removal of LLN as local control while the West believed that LLN dissection could be spared after giving neoadjuvant chemoradiotherapy. As time passed, it is getting more common to combine both treatments. With the quality improvement in magnetic resonance imaging, we can now predict the chance of LLN metastasis and evaluate the treatment response with good accuracy. Few large analyses have been published recently and provided us more insight into this topic. In this review, we summarized and provided an update on the latest evidence. We have proposed a treatment algorithm on the management of LLNs which may help clinical decision and provide idea for further research.     

盆腔侧方淋巴结转移对低位直肠癌预后的影响

Objective To evaluate the prognostic value of lateral pelvic lymph node metastasis on low rectal cancer. Methods One hundred and seventy-six patients with low rectal cancer who underwent radical resection combined with lateral pelvic lymph node dissection between 1994 and 2005 were reviewed. The data of the cases was investigated to define the prognostic value of lateral pelvic lymph node metastasis on the patients. Results Lateral node metastasis occurred in 33 patients (18.8%), and 51.5% of the metastasis occurred in internal iliac nodes or nodes at middle rectal roots and 39.4% in obturator nodes. Age ≤40 years, infiltrative cancer, T3-4 tumor, upward lymph node metastasis were risk factors for lateral node metastasis in low rectal cancer (P ＜ 0.05). The overall 5-year survival rate was 64.1%, and it was 94.1%, 79.1%, 42.1% for patients with TNM stage Ⅰ , Ⅱ , Ⅲ cancer, respectively. Tumor size, depth of infiltration, upward lymph node metastasis, lateral node metastasis was correlated significantly with prognosis (P ＜ 0.05). The 5-year survival rate of the patients without lateral metastasis was 73.6%, which was significant higher than that of patients with lateral metastasis (21.4%, P ＜0.05). Conclusion Lateralpelvic lymph node metastasis is an important prognostic factor for low rectal cancer.