直肠癌侧方淋巴结清扫中国临床开展的现状

尽管目前东西方对于直肠癌侧方淋巴结清扫仍存争议,但中国学术界依据现有的循证医学证据制定了符合中国国情的侧方淋巴结清扫相关共识、指南和规范。相较于日本,国内侧方淋巴结清扫指征把握更加严格,仅当有明确影像学证据疑诊存在侧方淋巴结转移时,才会选择性进行清扫,常规清扫区域也仅限于髂内和闭孔周围。基于全面了解盆腔解剖结构的前提下,以筋膜为导向的两间隙清扫现已成为中国侧方淋巴结清扫的主流方案,该术式在明确清扫边界、保护神经功能、彻底清除侧方淋巴结等方面具有明显优势。未来随着更多的高质量侧方淋巴结清扫研究的进行,将会有更多的证据来规范直肠癌侧方淋巴结清扫的临床应用。     

中、老年直肠癌患者扩大根治术的临床评价

目的 探讨中、老年直肠癌患者直肠癌扩大根治术的可行性,并分析各组淋巴结的转移规律.方法 接受保留盆腔自主神经的直肠癌扩大根治术97例,其中传统开腹直肠癌扩大根治术85例,腹腔镜辅助下的直肠癌扩大根治术12例,清除淋巴结以常规病理学方法(HE染色)观察.结果 97例患者中有39例发生淋巴结转移,有10例发生了侧方淋巴结转移,共取出淋巴结2 036枚,平均清除淋巴结21.0枚,转移淋巴结169枚,总淋巴结转移率为40.2%(39/97),侧方淋巴结转移率10.3%(10/97).结论 直肠癌的淋巴转移以肿瘤旁直肠系膜转移为主,肠系膜下动脉根部及侧方淋巴结转移率低.中、老年直肠癌患者中分化较差及T3、T4的患者侧方淋巴结转移的可能性明显增加,TME基础上加行侧方淋巴结清扫,无论是传统开腹扩大根治术还是腹腔镜辅助下的扩大根治术对于老年患者都安全可行,并不增加并发症的发生率.     

中日韩中低位直肠癌术前放化疗的理念与策略

关于术前放化疗在中低位直肠癌治疗中选择的理念和策略,中日韩三个国家的医生有些不同。中国的指南接近于美国国立综合癌症网络（National Comprehensive Cancer Network,NCCN）指南,建议对于T3和（或）N＋以上的可切除直肠癌患者,推荐术前放化疗;日本大多数医生对可切除的中低位直肠癌并不积极推荐术前放化疗,根据日本指南推荐,对于腹膜返折下局部进展期直肠癌的标准治疗方式为全直肠系膜切除术＋侧方淋巴结清扫术;韩国的结直肠癌临床实践指南对术前放化疗的推荐与中国和美国指南类似,与中国不同的是,源于韩国政府的法定政策,韩国医生针对直肠癌患者术前放化疗开展的更为积极。     

侧方淋巴结清扫在国内低位直肠癌治疗中应用的Meta分析

目的:评价侧方淋巴结清扫在国内低位直肠癌治疗中应用价值.方法:运用M e t a分析的方法对我国2005-01/2015-09公开发表的有关侧方淋巴结清扫在低位直肠癌中应用的11篇文献资料进行综合分析.结果:侧方清扫组手术时间明显长于未清扫组,合并加权均数差(weighted mean d i ff e r e n c e,W M D)为47.79 m i n,且差异有统计学意义(P0.00001).侧方清扫组手术失血量高于未清扫组,合并加权均数差为27.84 m L,且差异有统计学意义(P0.0001).侧方淋巴结清扫组5年生存率高于未清扫组(59.8%vs 51.3%),差异具有统计学意义P0.05(P=0.02).侧方淋巴结清扫组三年生存率明显高于未清扫组(81.6%vs63.5%),差异具有统计学意义(P0.00001).侧方淋巴结清扫组的局部复发率明显低于未清扫组(8.4%vs 16.9%),差异具有统计学意义(P=0.0003).Ⅰ期及ⅡA期行侧方淋巴结清扫对于局部复发的影响差异无统计学意义(PⅠ期=0.96,PⅡA期=0.05).Ⅲ期低位直肠癌侧方淋巴结清扫组局部复发率明显低于未清扫组(14.5%vs 22.1%),P0.05(P=0.01)差异具有统计学意义.结论:我国低位直肠癌患者行侧方淋巴结清扫能有效的延长患者的5年生存率及3年生存率,降低局部复发率(尤其是Ⅲ期低位直肠癌),改善患者预后,但会增加手术时间及术中出血量.     

盆腔侧壁三维重建技术引导3D腹腔镜在低位进展期直肠癌侧方淋巴结清扫术中的应用

目的 探讨盆腔侧壁三维重建技术引导3D腹腔镜侧方淋巴结清扫术治疗低位进展期直肠癌的效果与安全性。方法 选择80例低位进展期直肠癌患者,根据是否应用盆腔侧壁三维重建技术,分为3D腹腔镜和2D腹腔镜各40例。两组均行直肠系膜全切除联合盆腔侧方淋巴结清扫术,3D腹腔镜采用OsiriX软件对盆腔结构进行三维重建,在3D腹腔镜下进行手术;2D腹腔镜采用2D腹腔镜进行手术。比较两组肿瘤直径、肿瘤距肛缘距离、术中清除淋巴结总数、术中切除术前未标记淋巴结数量、术中出血量、术后并发症及术后住院时间。结果 3D腹腔镜组术中切除淋巴结（12.2±4.6）枚,其中阳性淋巴结（9.1±2.4）枚;2D腹腔镜组切除（9.0±3.6）枚,阳性淋巴结（6.1±1.9）枚;3D腹腔镜淋巴结切除数量较2D腹腔镜多（P<0.05）。3D腹腔镜组术中误夹组织次数（8±3）次,手术持续时间（261±55）min,均低于2D腹腔镜组（P均<0.05）。结论 盆腔侧壁三维重建引导3D腹腔镜下侧方淋巴结清扫术较2D腹腔镜手术节省手术操作时间,减少组织误伤,提高淋巴结清除数量,减少淋巴结遗留,特别适合髂内区存在转移淋巴结的...     

直肠鳞状细胞癌11例临床分析

目的总结直肠鳞状细胞癌的诊断及治疗方法。方法对11例直肠鳞状细胞癌患者的临床资料作回顾性分析。结果本组患者主要症状为血便3例,排便习惯改变8例。术前活检病理检查均诊断为鳞状细胞癌。5例行直肠癌腹会阴联合根治术（APR）,4例行直肠癌低位前切除术（LAR）,1例行直肠癌经肛门局部切除术（LR）,1例术中探查发现肿瘤无法切除而单纯行乙状结肠造瘘术。术中探查发现直肠癌肝脏多发转移及盆腔播散2例,术后病理检查证实存在脉管癌栓4例、淋巴结转移8例。2例接受术前放化疗,5例接受术后放化疗。结论直肠鳞状细胞癌临床表现不典型,确诊依靠活检病理检查。本病易发生脉管癌栓及淋巴结转移,对放化疗敏感,联合手术治疗效果肯定。     

腹腔镜直肠全系膜切除术治疗中、低位直肠癌的临床研究

目的探讨腹腔镜直肠全系膜切除术(TME)治疗中、低位直肠癌的临床疗效。方法选择中、低位直肠癌患者96例,随机分为观察组与对照组各48例,观察组在腹腔镜下行TEM术,对照组则行开腹TME术,对比两组患者临床疗效。结果观察组术后肛门排气时间、住院时间及手术切口长度、术中出血量、术后VAS疼痛评分、围术期并发症发生率、术后性功能及泌尿功能障碍发生率等方面均显著优于对照组(P0.05),而手术时间、保肛率、肿瘤转移及复发率差异均无统计学意义(P0.05)。结论腹腔镜直肠全系膜切除术治疗中、低位直肠癌疗效确切且安全可靠,可在达到传统开腹手术疗效基础上降低并发症发生率。     

直肠癌全直肠系膜切除术后直肠阴道瘘的原因与防治

随着直肠癌保肛手术的推广尤其是直肠癌低位及超低位前切除术开展以及双吻合器的普遍使用，吻合口瘘的发生率略有增加趋势，尤其是女性患者术后直肠阴道瘘有所增加，且不易愈合，对女性病人的生活质量和心理造成严重影响。虽然目前国内针对直肠癌全直肠系膜切除术（TME）后直肠阴道瘘采取了一些防治办法，但效果不甚理想，本文通过对我院行直肠癌TME保肛手术后发生的直肠阴道瘘患者资料进行分析，旨在探讨低位或超低位直肠癌行TME术后直肠阴道瘘发生的病因，需进一步提供切实可行的防治方法。     

精准医疗时代低位直肠癌选择性侧方淋巴结清扫价值与策略

随着生物分析技术、基因测序以及大数据分析工具的出现,医学进入了精准医疗时代。临床影像等技术的进步和发展,肿瘤患者术前精准临床分期判断及分子生物学信息的获得使得个体化的精准医疗成为可能,精准医疗时代对直肠癌的诊治提出了新的要求,不同部位的直肠癌治疗方案亦有所差异。手术治疗仍然是当今治疗直肠癌的主要方式,对于侧方淋巴结清扫问题一直存有争议,究其原因侧方淋巴结转移（lateral pelvic lymph node metastasis,LPLM）是全身系统性转移还是局部转移。笔者认为,低位直肠癌诊治应在充分推广诊疗规范的基础上,通过对数据的分析,筛选行侧方淋巴结手术治疗的获益人群,根据精确的诊断分期控制手术指征与范围,减少不必要的创伤及过度治疗从而真正实现精准医疗。     

腹腔镜低位直肠癌保肛手术与传统开腹手术的疗效对比分析

目的观察腹腔镜低位直肠癌保肛手术与传统开腹手术治疗低位直肠癌的临床疗效。方法对照组实施传统开腹直肠癌(miles)根治术。研究组实施腹腔镜直肠癌保肛术。对比两组手术时间、术中出血量、淋巴结清扫量、术后排气时间、住院时间、术后并发症发生率。对比两组复发率、转移率、3年生存率。结果两组均手术成功。研究组淋巴结清扫量显著优于对照组(P0.05)。两组术中出血量、术后排气时间、手术时间、住院时间,术后并发症发生率无显著差异(P0.05)。研究组复发率、转移率及3年生存率均显著优于对照组(P0.05)。结论腹腔镜低位直肠癌保肛手术能显著增加淋巴结清扫量,遏制复发、转移隐患,提高生存率。     

Laparoscopy-assisted lateral pelvic lymph node dissection for advanced rectal cancer

In Japan, there has been no indication of laparoscopic surgery for advanced lower rectal cancer because of the problem about the treatment of lateral pelvic lymph node metastasis. We report a new technique which allows lateral pelvic lymph node dissection like in open surgery for advanced rectal cancer. After laparoscopic total mesorectal excision for rectal cancer, a surgical incision of approximately 8 cm is placed in the supra-pubic area. Then, the latero-vesical area of the retroperitoneum, latero-vesical space is dissected bluntly with forceps. The external iliac artery and vein are taped and lymph node dissection is performed. As the external iliac vein is pulled internally, fatty tissue including lymph nodes in the obturator space is separated from the psoas major muscle. After completing of such a procedure, the obturator nerve is indentified in the fatty tissue with surrounding lymph nodes. As the external iliac vein is pulled laterally, fatty tissue including lymph nodes in the oburator space is dissected by fat aspiration procedure (FAP) using a suction tip. FAP is helpful to confirm the vascular system, by which the obturator space is skeletonized and anatomical structures are identified clearly.     

Evaluation of lateral lymph node dissection with preoperative chemo-radiotherapy for the treatment of advanced middle to lower rectal cancers

Background and aims This study examined rectal cancers with lateral lymph node (LN) metastases and whether lateral lymph node dissection (LLD) with or without preoperative chemo-radiotherapy (XRT) benefits patients with rectal cancer.Patients and methods A total of 452 consecutive cases of curatively resected pT2, pT3, and pT4 middle to lower rectal cancers were retrospectively analyzed. Of these, 265 patients underwent curative LLD and 155 XRT. Data were evaluated with respect to the cumulative percentage of survival.Results Lateral LN metastases were identified in 7.7% of patients. Of the pT3/pT4 extraperitoneal cancer patients 13.5/18.8% had lateral LN metastases. In the treatment of middle rectal cancers and pT2 extraperitoneal cancers LLD either with or without XRT did not improve survival rate. For the treatment of pT3/pT4 extraperitoneal tumors prior to the introduction of total mesorectal excision (TME) in 1994 LLD plus XRT yielded significantly better survival and local control than conventional surgery without LLD or XRT, although LLD alone did not improve either survival or local recurrence rates. Since 1995 TME with or without subsequent LLD has yielded favorable results for the treatment of extraperitoneal tumors.Conclusion For the treatment of middle rectal cancers and pT2 extraperitoneal cancers LLD either with or without XRT does not improve survival rate. For pT3/pT4 extraperitoneal tumors, which are associated with a high incidence of lateral node metastasis, combining treatment modalities such as TME followed by LLD or XRT followed by TME may be considered.This work was partially supported by a grant-in-aid for scientific research from the Japanese Ministry of Education (no. 11671149)An invited commentary on this paper is available at     

Lateral lymph node dissection for low rectal cancer: Is it necessary?

Rectal cancer constitutes a major public health issue.Total mesorectal excision has remained the gold standard treatment for mid and low rectal tumors since its introduction in the late 1980s.Removal of all lymph nodes located in the mesorectum has indeed improved pathological and oncological outcomes.However,when cancer spreads to the lateral lymph nodes(located along the iliac and obturator arteries)Western and Japanese practices differ.Where the Western guidelines consider this condition as an advanced form of the disease and use neoadjuvant radiochemotherapy liberally,the Japanese guidelines define it as a local disease and proceed to lateral lymph node dissection with or without neoadjuvant treatment.Herein,we review the current literature regarding both therapeutic strategies,with the aim of contributing to potential improvements in treatment and outcome for patients with low and mid rectal cancer.     

Prognostic value of lateral lymph node metastasis for advanced low rectal cancer

AIM： To evaluate the risk factors for lateral lymph node metastasis in patients with advanced low rectal cancer, in order to make the effective selection of patients who could benefit from lateral lymph node dissection, as well as the relationship of lateral lymph node metastasis with local recurrence and survival of patients with advanced low rectal cancer. METHODS： A total of 96 consecutive patients who underwent curative surgery with lateral pelvic lymphadenectomy for advanced lower rectal cancer were retrospectively analyzed. The relation of lateral lymph node metastasis with clinicopathologic characteristics, local recurrence and survival of patients was identified. RESULTS： Lateral lymph node metastasis was observed in 14.6% （14/96） of patients with advanced low rectal cancer. Lateral lymph node metastasis was detected in 10 （25.0%） of 40 patients with tumor diameter ≥ 5 cm and in 4 （7.1%） of 56 patients with tumor diameter 〈 5 cm. The difference between the significant （X^2 = 5.973, P = two groups was statistically 0.015）. Lateral lymph node metastasis was more frequent in patients with 4/4 diameter of tumor infiltration （7 of 10 cases, 70.0%）, compared with patients with 3/4, 2/4 and 1/4 diameter of tumor infiltration （3 of 25 cases, 12.0%; 3 of 45 cases, 6.7%; 1 of 16 cases, 6.3%） （X^2 = 27.944, P = 0.0001）. The lateral lymph node metastasis rate was 30.0% （9 of 30 cases）, 9.1% （4 of 44 cases） and 4.5% （1 of 22cases） for poorly, moderately and well-differentiated carcinoma, respectively. The difference between the three groups was statistically significant （X^2 = 8.569, P = 0.014）. Local recurrence was 18.8% （18 of 96 cases）, 64.3% （9 of 14 cases）, and 11.0% （9 of 82 cases） in patients with advanced low rectal cancer, in those with and without lateral lymph node metastasis, respectively. The difference between the two groups was statistically significant （X^2 = 22.308, P = 0.0001）. Kaplan-Meier survival analysis showed significant impr     

Indication and Benefit of Pelvic Sidewall Dissection for Rectal Cancer

Purpose This study was designed to clarify indication and benefit of pelvic sidewall dissection for rectal cancer. Methods The retrospective, multicenter study collected the data of rectal cancer patients who underwent surgery between 1991 and 1998 and were prospectively followed. Results Of 1,977 patients with rectal cancers, 930 underwent pelvic sidewall dissection without adjuvant radiotherapy. Positive lateral lymph nodes were found in 129. Multivariate analysis disclosed a significantly increased incidence of positive lateral lymph nodes in female gender, lower rectal cancers, non-well-differentiated adenocarcinoma, tumor size of ≥4 cm and T3-T4. The five-year survival rate for 1,977 patients was 79.7 percent. The survival of patients with positive lateral lymph nodes was significantly worse than that of Stage III patients with negative lateral lymph nodes (45.8 vs. 71.2 percent, P<0.0001). Multivariate analysis showed significantly worse prognosis in male gender, pelvic sidewall dissection, lower rectal cancers, T3-T4, perirectal lymph node metastasis, and positive lateral lymph nodes. During the median follow-up time of 57 months, recurrence developed in 19.7 percent: 17 percent in negative and 58.1 percent in positive lateral lymph nodes (P<0.0001). Local recurrence was found in 8 percent: 6.8 percent in negative and 25.6 percent in positive lateral lymph nodes (P<0.0001). Multivariate analysis disclosed that lower rectal cancers, non-well-differentiated adenocarcinoma, T3-T4, perirectal lymph node metastasis, and positive lateral lymph nodes were significantly associated with an increased local recurrence. Conclusions Positive lateral lymph node was the strongest predictor in both survival and local recurrence. Pelvic sidewall dissection may be indicated for patients with T3-T4 lower rectal cancers because of the greater provability of positive lateral lymph nodes. Study Group for Rectal Cancer Surgery of the Japanese Society for Cancer of the Colon and Rectum. Presented at the United States-Japan Clinical Trial Summit Meeting, Maui, Hawaii, February 10–13, 2005.     

Examination of nodal metastases by a clearing method supports pelvic plexus preservation in rectal cancer surgery

PURPOSE: In rectal cancer surgery preservation of urinary and sexual function is attempted by means of operations preserving the autonomic nerves of the pelvic plexus. Emergence of residual cancer because of a more shallow plane of dissection is a problem of concern with these methods, so we examined indications for pelvic plexus preservation. METHODS: We studied 198 patients with rectal carcinoma who underwent abdominopelvic lymphadenectomy. Lymph nodes along the superior hemorrhoidal artery and middle hemorrhoidal artery medial to the pelvic plexus were defined as perirectal nodes, and nodes along the middle hemorrhoidal artery lateral to the pelvic plexus and along the internal iliac artery represented lateral intermediate nodes. Node metastases were examined by the clearing method. RESULTS: Metastasis to perirectal nodes occurred in 12.5 percent in patients with pT1 tumors, 28.9 percent of those with pT2 tumors, and 50.0 percent of those with rectosigmoid junctional cancer. Metastasis to lateral intermediate nodes was absent in patients with pT1 or pT2 tumors and was as low as 2.5 percent in patients with rectosigmoid junctional cancer. CONCLUSIONS: In patients with T1, T2, and rectosigmoid junctional cancer, perirectal node dissection is necessary, but chances of residual cancer should remain minimal when the pelvic plexus is preserved.     

Ultrasonographic examination for lateral lymphatic spread and local recurrence of rectal cancer

PURPOSE: A preoperative evaluation of the lateral lymphatic spread is essential to decide the indication of autonomic nerve preserving operation for rectal cancer. For this evaluation, we used common ultrasonographic examination of the lower abdomen. We also performed this examination on postoperative patients in whom local recurrence had been suspected. Results and effectiveness of examination were evaluated. METHOD: First, we identified arteries in the pelvic cavity (common, external, and internal iliac arteries), and then we sought lymph nodes in the spaces between these arteries, urinary bladder, and rectum. RESULTS: We performed this examination on 40 preoperative patients with rectal cancer and could detect lymph nodes in 12 patients. By the size and features of these lymph nodes, five patients were considered lateral lymphatic spreadpositive. After the operation, resected specimens revealed three patients were pathologically positive, and the two others were false-positive. Only one patient was false-negative. Total accuracy of the examination was 92.5 percent; however, the positive lymph node around middle rectal artery and obturator artery had been overlooked. We also performed this examination on postoperative patients in whom local recurrence had been suspected. In one postoperative patient, a recurrent lesion of 30 × 3.5 cm in size was detected along the right external iliac artery and could be resected by the retroperitoneal surgical approach. CONCLUSION: We consider this examination very effective for detecting lymph node metastasis preoperatively and recurrent lesions in the pelvic cavity.     

Isolated tumor cell in lateral lymph node has no influences on the prognosis of rectal cancer patients

BACKGROUND AND AIMS: The aim of this study was to determine the incidence of isolated tumor cells (ITC) and micrometastasis in lateral lymph nodes of patients with rectal cancer and its possible correlation with prognosis. MATERIALS AND METHODS: One hundred seventy-seven rectal cancer patients who underwent curative resection with lateral lymph node dissection were enrolled. Dissected lymph nodes were examined using hematoxylin-eosin staining (HE) and immunohistochemistry (IHC) with anti-keratin antibody (AE1/AE3). States of lymph node metastasis were divisible into three groups: detectable with HE (HE+), detectable with only IHC (HE-/IHC+), and undetectable even with IHC (IHC-). Almost all the HE-/IHC+ group was classified as ITC consisting of a few tumor cells according to the UICC criteria (ITC+). Survival rates were compared among HE+, ITC+, and IHC-. RESULTS: ITC+ were detected in 24.1% of patients with HE-negative lateral lymph nodes. No significant difference in overall 5-year survival was observed between ITC+ and IHC- patients (76.1 and 82.9%, respectively, p = 0.25). Multivariate analysis showed that perirectal HE+ lymph nodes, but not ITC+ lateral lymph nodes, was an independent prognostic factor. CONCLUSIONS: ITC in lateral lymph nodes does not contribute to the prognosis of rectal cancer in patients who undergo extended lateral lymph node dissection, unlike HE+ lateral lymph node metastasis.     

Distribution of metastatic lymph nodes in colorectal cancer by the modified clearing method

PURPOSE: The aim of this study was to clarify the distribution of lymph node metastasis in colorectal cancer. We also examined the relationship between the primary tumor (T) and the regional node (N) categories of the TNM (primary tumor, regional nodes, metastasis) classification. METHOD: Lymph nodes of surgical specimens in 311 consecutive patients with colorectal cancer were studied using the modified clearing method. RESULTS: Lymph node metastasis was seen in 59.2 percent of the total cases. The upward metastasis rate was 30.7 percent. In the longitudinal spread, most of the lymph node metastasis was seen within 10 cm. On the oral side in rectal cancer, there was no metastasis beyond 4 cm. The lateral metastasis rate in rectal cancer was 8.8 percent and in the lower rectum, the rate of cancer within 6 cm from the anal verge or beyond pT3 was much higher. CONCLUSION: In the TNM classification, there was no significant difference between colon and rectal cancer except pT1 with rectal cancer. In the lower rectal cancer within 6 cm from the anal verge or beyond pT3, there is a high risk of lateral metastasis, and lateral lymph node dissection or radiation therapy should be performed.     

Lateral node dissection and total mesorectal excision for rectal cancer

PURPOSE: Although the existence of lateral lymphatic drainage of the rectum has been verified anatomically, the clinical importance of it has not yet been fully investigated. The lack of a definition of lateral lymphatic flow makes it difficult to analyze and compare data. The aim of this study was to define the concept of lateral lymphatic drainage and explore its relationship to total mesorectal excision and to disclose the incidence and efficacy of dissection of lateral node involvement. METHODS: Review of anatomic and clinical research on lateral lymphatic flow was made to create a definition of lateral lymphatic flow. Based on this review, a three-space dissection was designed and applied. A retrospective analysis was made of 764 patients with rectal cancer treated by a curative three-space dissection operation during 20 years starting in 1975 at Cancer Institute Hospital. RESULTS: Lateral lymphatic flow passes from the lower rectum and through the lateral ligament laterally beyond the mesorectum. It then ascends along the internal iliac artery and, in addition, inside the obturator space. Sixty-six cases proved to have lateral node involvement, which comprised 8.6 percent of all rectal cancer and 16.4 percent of low-lying (lower margin below 5 cm above the dentate line) rectal cancer cases. The five-year survival rate of these 66 cases was 42.4 percent. There were 16 cases that had a solo lateral node involvement. CONCLUSION: Lateral lymphatic flow from low-lying rectal cancer passes outside the boundaries of total mesorectal excision but within the range of curative surgery by three-space dissection.