低位直肠癌选择性侧方淋巴结清扫研究进展

盆腔侧方淋巴结(Lateral pelvic lymph node,LPLN)是低位直肠癌患者常见的局部转移部位,同时也是术后局部复发的主要部位,然而目前对于LPLN转移的治疗方案仍没有明确的定论.同时LPLN的转移应被看作是局部而不是全身,新辅助放化疗(Chemoradiotherapy,CRT)并不能替代手术清扫,...     

局部治疗在直肠癌盆腔侧方淋巴结转移中的作用北大核心CSCD

盆腔侧方淋巴结(LPLN)转移是直肠癌预后不佳因素, 在低位、T3-T4期、直肠系膜淋巴结阳性情况下更常见, 但无准确预测转移的因素。高分辨率MRI是目前诊断LPLN转移的首选手段, 但阈值选择仍不明确。局部进展期直肠癌的侧方淋巴结转移治疗模式在全球存在分歧, 欧美国家主张放化疗联合直肠全系膜切除术, 而日本推荐直肠全系膜切除术联合LPLN清扫。放疗与手术联合可取得很好的局控, 利用放疗前、后MRI的侧方淋巴结信息, 可筛选出高危患者进行强化治疗, 如放化疗后行LPLN清扫或LPLN区放疗推量。目前各种手段在治疗LPLN转移方面的作用仍缺乏高质量证据, 尚需更多的研究来改善治疗策略。     

102例直肠癌侧方淋巴结转移患者临床病理特点及生存预后分析

Objective To investigate the therapeutic effect and prognostic significance of lateral lymph node dissection (LPLND) in patients with lateral lymph node (LPLN) metastasis. Methods The clinicopathological data of rectal cancer patients who underwent total mesorectal excision (TME) combined with LPLND and pathologically confirmed as LPLN metastasis after operation were retrospectively analyzed. The clinicopathological characteristics and metastasis rules of patients with LPLN metastasis were discussed, and the survival prognosis after LPLND was analyzed. Results A total of 102 rectal cancer patients with pathologically confirmed LPLN metastasis were included. The common sites of LPLN metastasis were internal iliac vessels lymph nodes (n=68, 66.7%), followed by obturator lymph nodes (n=44, 43.1%), and common iliac vessels or external iliac vessels lymph nodes (n=12, 11.8%). There were 10 patients (9.8%) with bilateral LPLN metastases, and the mean number of LPLN metastases was 2.2±2.4, among which 16 patients (15.7%) had LPLN metastases number≥2. The 3-year OS (66.8% vs. 7.7%, P<0.001) and DFS (39.1% vs. 10.5%, P=0.012) of patients with LPLN metastases to the external iliac or common iliac lymph node were significantly lower than those with metastases to the internal iliac or obturator lymph node. The multivariate analysis showed that LPLN metastasis to external iliac or common iliac lymph node was an independent risk factor both for OS (HR=3.53; 95%CI: 1.50-8.31; P=0.004) and DFS (HR=2.40; 95%CI: 1.05-5.47; P=0.037). Conclusion LPLN mainly metastasizes to the internal iliac or obturator lymph node areas. The survival of patients with metastasis to the external iliac or common iliac lymph node cannot be improved by LPLND, and thus systemic comprehensive treatment is often the optimal treatment option. © 2023, CHINA RESEARCH ON PREVENTION AND TREATMENT. All rights reserved.     

侧方淋巴结转移的中低位局部晚期直肠癌治疗现状

中低位局部晚期(Ⅱ-Ⅲ期)直肠癌侧方淋巴结转移(LLN)率高、预后差。目前, 关于LLN治疗方案东西方争议较大:以日本为代表的东方学者认为LLN是区域性疾病, 当肿瘤位于腹膜返折下且侵及肌层时无论有无LLN, 均推荐预防性盆腔侧方淋巴结清扫(LPLND);而欧美学者认为LLN是全身性疾病, 推荐新辅助放化疗(nCRT)联合全直肠系膜切除(TME)。然而, 近年来有研究发现, nCRT或LPLND均不能显著降低LLN患者的局部复发率, 而nCRT联合LPLND治疗的预后更好, 也有研究发现增加转移淋巴结放疗剂量可以提高局部控制率。本文综述了该类人群的治疗现状, 以期为临床治疗提供依据。     

中低位直肠癌伴盆壁淋巴结肿大的处置争议与思考

目的 对中低位直肠癌盆壁淋巴结肿大的流行病学、诊断及治疗进行综述。方法 检索2020-01-01-2023-03-01中国知网和PubMed中低位直肠癌盆壁淋巴结或侧方淋巴结相关文献。中文检索词为“直肠癌、盆壁淋巴结、侧方淋巴结”,英文检索词为“rectal cancer, pelvic lymph node, lateral lymph node”。共检索到相关文献151篇。纳入标准：(1)盆壁淋巴结的解剖、引流和影像学研究;(2)盆壁淋巴结或侧方淋巴结的相关临床研究及综述。排除标准：低质量文献。根据纳入和排除标准,最终纳入46篇文献(中文7篇,英文39篇)。结果 中低位直肠癌常伴有盆壁淋巴结肿大。盆壁淋巴结作为侧方淋巴结的一部分,影像学检查中根据其直径、形态和信号判断其转移的风险。但其灵敏度和特异度较差,故目前临床上尚无统一的诊断标准。盆壁肿大淋巴结的治疗有新辅助放化疗、侧方淋巴结清扫(LLND)以及新辅助放化疗+LLND 3种策略。对于无高危因素的直肠癌患者不推荐行预防性LLND。针对新辅助放化疗后淋巴结的变化情况,采取个体化治疗,行全直肠系膜切除术(TME)+LLND或单纯行T...     

全直肠系膜切除术联合侧方淋巴结清扫术治疗中低位直肠癌侧方淋巴结转移的疗效

目的:探讨侧方淋巴结清扫术(lateral lymph node dissection, LLND)对侧方淋巴结(lateral lymph node, LLN)转移直肠癌患者的治疗价值和LLN转移位置对生存预后的影响。方法:自2015年01月至2020年01月,回顾性收集分析在中国医学科学院肿瘤医院行全直肠系膜切除术(total mesorectal excision, TME)+LLND的临床怀疑LLN转移的中低位直肠癌患者与同时期行TME根治性切除的直肠癌患者的资料。根据手术方式,分为TME+LLND组(n=129)与TME组(n=362)。倾向得分匹配后,两组各有125例患者成功匹配。本研究的长期随访终点是3年局部复发率(local recurrence, LR)和3年无复发生存率(recurrence-free survival, RFS)。结果:TME+LLND组手术时间明显长于TME组(356.1 vs 244.8 min,P<0.001),而术后并发症并无明显增加(16.0 vs 12.0,P=0.362)。预后方面,TME+LLND与TME两组间3年LR率无明显...     

低位直肠癌淋巴结转移的分析

目的:探讨腹膜返折以下直肠癌淋巴结转移的规律及其临床价值。方法:对行侧方淋巴结清扫的 182例低位直肠癌病人进行回顾性分析。结果:腹膜返折以下直肠癌存在侧方淋巴结转移,转移率为16％,低分化腺癌及粘液腺癌侧方淋巴结转移率高。结论:侧方淋巴结转移是腹膜返折以下直肠癌淋巴转移的重要途径,低位进展期直肠癌应在上方淋巴结清扫的同时行侧方淋巴结清扫。     

低位直肠癌淋巴结转移的分析

目的:探讨腹膜返折以下直肠癌淋巴结转移的规律及其临床价值.方法:对行侧方淋巴结清扫的182例低位直肠癌病人进行回顾性分析.结果:腹膜返折以下直肠癌存在侧方淋巴结转移,转移率为16%,低分化腺癌及粘液腺癌侧方淋巴结转移率高.结论:侧方淋巴结转移是腹膜返折以下直肠癌淋巴转移的重要途径,低位进展期直肠癌应在上方淋巴结清扫的同时行侧方淋巴结清扫.     

结直肠癌腹主动脉旁淋巴结转移的研究进展

淋巴结转移是影响结直肠癌预后的重要因素之一。结直肠癌腹主动脉旁淋巴结转移（para-aortic lymph node metastasis,PALNM）是结直肠癌不常见的转移模式。由于其发病率相比肝转移和肺转移低,相关的研究均存在一定的局限性,因此对于结直肠癌PALNM的诊断及治疗尚存争议。腹主动脉旁淋巴结清扫（para-aortic lymph node dissection,PALND）术可以为判断腹主动脉旁淋巴结有无转移提供病理依据,也可以改善部分患者的预后。虽然对于结直肠癌肝转移和（或）肺转移进行积极的手术切除已经得到普遍认同,但对于结直肠癌合并PALNM的最佳手术治疗策略仍未明确。是否进行PALND,需要权衡其安全性、有效性、复发率与其所带来的生存获益之间的关系。本文将就有关结直肠癌PALNM的研究治疗进展进行综述。      

低位直肠癌侧方淋巴结清扫术的价值综述

直肠癌是常见的下消化道恶性肿瘤之一，外科手术是目前主要的治疗方法。但局部复发及转移又是术后残废的主要原因。低位直肠癌病死率较高，其原因是多方面的（如血道播散、淋巴转移及局部复发），其中淋巴结转移是主要的原因。目前学术界对低位直肠癌行全直肠系膜切除（total mesorectal exeision，TME）以求根治达成共识，但对其侧方淋巴结的清扫能否降低患者复发率及提高术后的生存率存在分歧。     

What Is the Role of Lateral Lymph Node Excision in Patients with Locally Advanced Rectal Cancer Who Received Preoperative Chemoradiotherapy?

In the era of preoperative chemoradiotherapy (CRT) for rectal cancer, the role of lateral pelvic lymph node dissection (LPLND) has become much more complicated because preoperative CRT affects both the lateral pelvic lymph nodes (LPLN) and the main tumor. Most previous studies do not demonstrate the benefits of LPLND following preoperative CRT in comparison with total mesorectal excision, although some authors have argued that selective LPLND is beneficial. LPLN treatment strategies differ depending on whether the disease was considered systemic metastatic disease or local disease which can be treated using surgical resection. The role of LPLND in rectal cancer is better evaluated on the basis of its oncologic impact rather than technical feasibility. Here, we review LPLN metastasis status in rectal cancer, whether LPLN metastasis is systemic or local disease, and studies on the use of LPLND to treat rectal cancer.     

Lateral pelvic lymph node dissection in the management of locally advanced low rectal cancer: Summary of the current evidence

Lateral pelvic lymph nodes (LPLN) are a major site for local recurrence following curative resection for low locally advanced rectal cancer. Ongoing advances in imaging techniques have improved predicting LPLN metastasis (LPLNM) during pre-operative staging. However, there is ongoing debate on optimal management of this subgroup of patients with variation between guidance of different societies. In Japan, LPLNM is considered as local disease and addressed by lateral pelvic node dissection (LPLND) in addition to total mesorectal excision (TME). However, in the west, LPLNM is considered as metastatic disease and those patients are offered neoadjuvant chemoradiotherapy (nCRT) followed by TME surgery. The potential surgical risks and morbidity associated with LPLND as well as the uncertainty of the oncological outcome have raised the concern that patients with locally advanced low rectal cancer with LPLNM could be over or under-treated.A comprehensive review of literature was performed, summarizing the current evidence on available modalities for predicting LPLNM, the role of LPLND in the management of advanced low rectal cancer and the available surgical approaches with their impact on surgical and oncological outcomes.LPLND is associated with increased operative time, blood loss and post-operative morbidity. The potential benefits for local disease control and survival still awaits high quality studies. There has been increasing number of reports of the use minimally invasive approaches in LPLND in an attempt to reduce post-operative complications.There is need for high quality evidence to define the role of LPLND in management of patients with advanced low rectal cancer.     

Lateral pelvic lymph nodes for rectal cancer: A review of diagnosis and management

The current status and future prospects for diagnosis and treatment of lateral pelvic lymph node (LPLN) metastasis of rectal cancer are described in this review. Magnetic resonance imaging (MRI) is recommended for the diagnosis of LPLN metastasis. A LPLN-positive status on MRI is a strong risk factor for metastasis, and evaluation by MRI is important for deciding treatment strategy. LPLN dissection (LPLD) has an advantage of reducing recurrence in the lateral pelvis but also has a disadvantage of complications; therefore, LPLD may not be appropriate for cases that are less likely to have LPLN metastasis. Radiation therapy (RT) and chemoradiation therapy (CRT) have limited effects in cases with suspected LPLN metastasis, but a combination of preoperative CRT and LPLD may improve the treatment outcome. Thus, RT and CRT plus selective LPLD may be a rational strategy to omit unnecessary LPLD and produce a favorable treatment outcome.     

Surgical management of extra-regional lymph node metastasis in colorectal cancer

One of the major problems in rectal cancer surgery is local recurrence, found in an average of 21% to 46% cases in 1990. However, the advent of chemo-radiotherapy (CRT) and total mesorectal excision (TME) improve local control and enhances survival rates in colorectal cancer (CRC). Regional lymph node involvement is determined to be an independent prognostic factor in local recurrence; however, extra-regional lymph node (ERLN) metastasis has a higher recurrence rate (up to 58.1%). Lack of supportive data in management of ERLN metastasis in CRC has added further strain and challenges to structure a unique treatment strategy. ERLN refers to extra-mesenteric involvement either in the para-aortic lymph node (PALN) or the lateral pelvic lymph node (LPLN). Treatment of ERLN metastasis is challenging because of the shortage of the resources. Here, we will outline and summarize approaches and management of ERLN metastasis. We also aim to clarify the role of surgical intervention in CRC     

Predictive factors of pathological lateral pelvic lymph node metastasis in patients without clinical lateral pelvic lymph node metastasis (clinical stage II/III): The analysis of data from the clinical trial (JCOG0212)

BackgroundMesorectal excision (ME) is the standard surgical procedure for lower rectal cancer. However, in Japan, total or tumor-specific ME with lateral pelvic lymph node dissection (LLND) is the standard surgical procedure for patients with clinical stages II or III lower rectal cancer, because lateral pelvic lymph node metastasis occasionally occurs in these patients. The aim of study was to elucidate the predictive factors of pathological lateral pelvic lymph node metastasis in patients without clinical lateral pelvic lymph node metastasis.MethodsData form the clinical trial (JCOG0212) was analyzed. The JCOG0212 was a randomized controlled trial to confirm the non-inferiority of mesorectal excision alone to mesorectal excision with lateral lymph node dissection for clinical stage II/III patients who don't have clinical lateral pelvic lymph node metastasis in terms of relapse free survival. This study was conducted at a multitude of institution33 major hospitals in Japan. Among the 351 patients who underwent lateral lymph node dissection in the JCOG0212 study, 328 patients were included in this study. Associations between pathological lateral pelvic lymph node metastasis and preoperative and postoperative factors were investigated. The preoperative factors were age, sex, clinical stage, tumor location, distance from anal verge, tumor size, and short-axis diameter of lateral pelvic lymph node on computed tomography and the postoperative factors were pathological T, pathological N, and histological grade.ResultsAmong the 328 patients, 24 (7.3%) had pathological lateral pelvic lymph node metastasis. In multivariable analysis of the preoperative factors, patient age (p = 0.067), tumor location (p = 0.025), and short-axis diameter of lateral pelvic lymph node (p = 0.002) were significantly associated with pathological lateral pelvic lymph node metastasis.ConclusionsPatient age, tumor location, and short-axis diameter of lateral pelvic lymph node were predictive factors of pathological lateral pelvic lymph node metastasis.     

Learning curve analysis for lateral pelvic lymph node dissection in rectal cancers – Outcomes improve with experience

IntroductionLateral pelvic lymph node dissection (LPLND) is a technically challenging procedure and its learning curve has not been analysed against an oncologically relevant outcome. The purpose of the study was to determine the learning curve for LPLND in rectal cancers using nodal retrieval as performance measure.MethodsConsecutive LPLND for rectal adenocarcinomas from a single institution were retrospectively analysed. Cumulative sum (CUSUM) control charts were used to detect difference in performance with respect to lymph node yield. Negative binomial regression was used to determine factors influencing nodal harvest using Incidence Risk Ratios (IRR). Separate CUSUM curves were generated for open and minimally invasive surgeries (MIS).ResultsOne-hundred and twenty patients were included and all received preoperative radiation. MIS was used in 53.3%. Median lymph node yield was 6 with 20% nodal positivity. Increasing experience (IRR – 1.196) and MIS (IRR – 1.586) were the only factors that influenced nodal harvest. CUSUM charts revealed that learning curve was achieved after the 83rd case overall and after the 19 operations in MIS. There was a 20% increase in nodal yield after every 30 MIS LPLND performed.ConclusionsLearning curve for LPLND is relatively long and only increasing experience and minimally invasive operations increased nodal yield.     

核磁共振诊断直肠癌盆腔侧方淋巴结转移价值的Meta分析

目的 系统评价磁共振成像（MRI）对直肠癌盆腔侧方淋巴结转移的诊断价值。方法 计算机检索EMbase、PubMed、The Cochrane Library、CNKI和WanFang Data数据库,搜集磁共振诊断直肠癌盆腔侧方淋巴结转移的相关文献,检索时限均从建库至2019年3月。由两位研究者独立筛选文献、提取资料和评价偏倚风险后,采用Stata 15软件进行统计分析,计算其合并敏感度（Sen合并）、特异性（Spe合并）、诊断比值比（DOR）等,绘制汇总受试者工作特征（SROC）曲线并计算曲线下面积（AUC）。结果 共纳入11个研究,包含1 059例患者。Meta分析结果显示,磁共振诊断侧方淋巴结转移的合并Sen、Spe、+LR、–LR、DOR分别为0.77（95%CI: 0.38~0.88）、0.77（95%CI: 0.69~0.83）、3.3（95%CI: 2.4~4.5）、0.3（95%CI: 0.23~0.41）、11（95%CI: 6~18）,SROC曲线下面积为0.83（95%CI:0.80~0.86）。结论 以淋巴结短径为诊断标准,MRI诊断直肠癌侧方淋巴结转移的敏感度和特异性一般;但在没有更佳的影像学筛查条件下,MRI仍然是被推荐的检查手段。