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.     

进展期直肠癌淋巴结转移状况与根治术的关系

研究进展期直肠癌淋巴结转移状况,指导手术根治范围。方法：76例直肠癌患者行D3式根治术,按肿瘤旁、肠管纵轴和中枢方向行淋巴结分组,检测侧方和腹膜返折下直肠周围系膜转移淋巴结数,并计算淋巴结转移率。结果：肿瘤旁和肠管纵轴方向边缘动脉旁淋巴结转移率分别为39.5%和9.2%,肛侧端距肿瘤2cm未见转移;沿肠系膜下血管中枢方向淋巴结转移率为18.4%,而肠系膜下动脉(IMA)根部淋巴结转移率为10.5%;侧方淋巴结转移率为11.8%,腹膜返折下直肠周围系膜淋巴结转移率为12.5%。结论：进展期直肠癌可向肠管纵轴和中枢方向淋巴结转移。腹膜返折下直肠癌有侧方淋巴结转移并侵及直肠周围系膜,肿瘤浸润深度超过pT2期和低分化癌者淋巴结转移相应增多。宜行IMA根部结扎整块切除的D3式廓清术,腹膜返折下直肠癌力争行侧方淋巴结清扫和全直肠系膜切除术。     

盆腔侧方淋巴结转移对低位直肠癌预后的影响

目的 探讨盆腔侧方淋巴结转移对低位直肠癌预后的影响.方法 对1994年至2005年行根治性切除联合盆腔侧方淋巴结清扫的176例低位直肠癌患者的资料进行回顾性分析.探讨低位直肠癌患者盆腔侧方淋巴结转移对其预后的影响.结果 全组盆腔侧方淋巴结转移33例(18.8%),其中髂内及直肠中动脉根部淋巴结转移占51.5%,闭孔淋巴结转移占39.4%.年龄≤40岁、浸润型癌、T3-4期、上方淋巴结转移患者的盆腔侧方淋巴结转移率较高(P＜0.05).全组5年生存率为64.1%,TNM分期Ⅰ、Ⅱ、Ⅲ期患者5年生存率分别为94.1%、79.1%、42.1%.癌灶大小、浸润深度、上方淋巴结转移、盆腔侧方淋巴结转移是影响低位直肠癌患者预后的重要因素(P＜0.05).盆腔侧方淋巴结阴性患者5年生存率为73.6%,而侧方淋巴结转移患者为21.4%,两组差异具有统计学意义(P＜0.05).结论 盆腔侧方淋巴结转移是影响低位直肠癌预后的重要因素.     

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手术是直肠癌的主要治疗方式[1-2],而淋巴转移作为直肠癌的重要扩散途径,术中淋巴结清扫不彻底会引起局部复发甚至影响病人的生存期。研究表明,直肠癌向上方及侧方存在跳跃转移,对于Dukes B期和C期病人在全直肠系膜切除(TME)基础上选择性地进行上方及侧方淋巴结清扫即直肠癌扩大根治术是非常重要的。本文将对低位直肠癌行侧方淋巴结清扫争议与进展做一综述。1直肠癌根治术的历史演变     

低位直肠癌直肠系膜、盆腔侧方淋巴结转移规律分析

目的研究低位直肠癌直肠系膜、盆腔侧方淋巴结转移和微转移规律。方法联合运用大组织切片与组织芯片技术,研究67例全直肠系膜切除（total mesorectal excision,TME）、盆腔侧方淋巴结清扫手术标本。结果直肠系膜淋巴结癌转移30例,微转移10例,29.6%转移淋巴结位于直肠系膜外带。肿瘤远端、肿瘤旁和肿瘤近端直肠系膜内淋巴结转移的检出例数分别为4、32和19例,与肿瘤分化程度相关。9例标本存在环周切缘癌浸润（circumferential resection margin involvement,CRMI）,2例见微转移。盆腔侧方淋巴结癌转移、微转移分别为12例和10例,与肿瘤分化程度、浸润深度相关。结论按照TME原则手术,完整切除包裹在盆腔筋膜内的直肠系膜,可提高局部肿瘤廓清率,降低CRMI发生率。低位直肠癌盆腔侧方淋巴结转移较常见,应合理制定手术范围。     

直肠癌侧方淋巴结转移清扫术后的生存分析

目的 回顾性分析腹腔镜直肠癌层面优先入路侧方淋巴结清扫病人侧方淋巴结及肠系膜淋巴结的转移特点及生存预后。方法 收集2017年5月至2022年12月天津市人民医院进行腹腔镜层面优先入路侧方淋巴结清扫的病人临床资料，对病人侧方淋巴结及肠系膜淋巴结的转移情况与生存预后进行分析(应用COX风险模型进行分析),从而探讨侧方淋巴结转移应归属于局部转移还是远处转移。结果 共纳入111例病人，通过COX比例风险模型对“肠系膜(-)侧方(+)”组(20例)和“肠系膜(+)侧方(+)”组(58例)病人的生存数据进行分析显示，“肠系膜(-)侧方(+)”组3年生存率为58%,“肠系膜(+)侧方(+)”组3年生存率为59.8%,与文献报道相比，两组生存曲线与直肠癌淋巴结转移分期的N₂期生存曲线一致，3年生存率与直肠癌N₂期相近。结论 直肠癌侧方淋巴结转移而直肠系膜淋巴结未转移的病人预后可能与直肠癌N₂期的病人相似，优于Ⅳ期直肠癌病人，提示直肠癌侧方淋巴结转移应归属于区域淋巴结转移而非远处转移。     

直肠癌侧方淋巴结清扫的个性化治疗策略

随着全直肠系膜切除术和新辅助放化疗的广泛应用,中低位直肠癌患者的预后明显改善。近年来随着腹腔镜和机器人手术系统等微创技术应用于直肠癌根治性手术,以及肿瘤分子标志物和基因测序技术的发展,直肠癌治疗已进入个体化精准医疗时代。在这样的时代背景下,关于中低位直肠癌侧方淋巴结清扫必要性的争议愈发引人注目,其包括与新辅助治疗的关系,侧方淋巴结清扫的手术指征、范围及神经保护等多个方面。作为进展期中低位直肠癌重要治疗手段,直面争议,增加侧方淋巴结清扫相关循证医学证据是当务之急。     

Miles术直肠标本淋巴结分布及转移研究

目的 探讨超低位直肠癌淋巴结转移、微转移的规律及其对手术方式选择的价值.方法 运用大组织切片、组织芯片研究23例低位直肠癌Miles手术标本.结果 23例标本直肠系膜共检获淋巴结415枚,其中转移淋巴结169枚,微转移59枚;12例标本有淋巴结癌转移,4例为淋巴结微转移.29.0%(49/169)、17.2%(29/169)转移淋巴结分别位于直肠系膜的外带和前区;坐骨直肠窝检出转移或微转移淋巴结占总淋巴结的22%(8/36),坐骨直肠窝淋巴结转移或微转移者占13%(3/23).结论 低位直肠癌存在区域淋巴结转移,各区域受累率不一.括约肌累及、远侧直肠系膜和坐骨直肠窝内淋巴结转移和微转移率不高,Miles手术作为低位直肠癌标准术式的价值应重新评估.     

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     

低位直肠癌常规行No.253淋巴结清扫的争议与共识

低位直肠癌是否常规行No.253淋巴结清扫,目前仍存在诸多争议,且东西方观点有所不同。西方学者更强调全直肠系膜切除（TME）,保证直肠系膜的完整性是手术根治的关键,良好的TME手术质量可降低局部复发率。对于T2以上的低位直肠癌日本学者和我国学者除了强调全直肠系膜切除外,还注重对肠系膜下动脉根部淋巴结（即No.253淋巴结）的清扫（D3根治术）。近年来,低位直肠癌是否常规行No.253淋巴结清扫观点趋于统一：如怀疑No.253淋巴结转移,建议行新辅助化疗,或术中行快速冰冻病理学检查,如证实No.253淋巴结转移则进行彻底的清扫。对于分期在T2以内的低位直肠癌,若术前检查和术中探查No.253淋巴结阴性则不作为低位直肠癌的常规清扫范围,因为在清扫No.253淋巴结时很容易损伤腰内脏神经和肠系膜下神经丛,造成术后泌尿生殖功能障碍。多数学者认为对于T2以内的低位直肠癌不常规行No.253淋巴结清扫,而对于T3以上的低位直肠癌如术前检查怀疑No.253淋巴结发生转移,则更强调新辅助放化疗联合TME及行No.253淋巴结清扫的D3根治术。     

Lateral Lymph Node Dissection for Lower Rectal Cancer

The mainstay of surgical therapy for rectal cancer is colectomy (including lesions) with lymph node dissection. The lymphatic spread of rectal cancer can proceed in two directions: medially toward the origin of the inferior mesenteric artery or laterally toward the pelvis aslong the internal iliac artery. To prevent postoperative recurrence, lymph nodes situated along these two axes should be adequately dissected, leaving no residual cancer cells. In Japan, the standard procedure for advanced lower rectal cancer is mesorectal excision and lateral lymph node dissection with autonomic nerve preservation. In Europe and North America, lateral lymph node dissection used to be performed, but it led to increased blood loss, complications, and dysfunction, with no improvement in survival. Lateral lymph node dissection is thus no longer performed. Instead, multidisciplinary therapy combining mesorectal excision with preoperative chemoradiotherapy is now the standard treatment for advanced rectal cancer. Although lateral lymph node dissection decreases the rate of local recurrence similar to preoperative chemoradiotherapy, whether it contributes to improved survival remains unclear. In addition, it is unlikely that prophylactic lateral lymph node dissection is required in all patients with rectal cancer. Definition of the indications for lateral lymph node dissection is thus an important concern.     

Potential prognostic benefit of lateral pelvic node dissection for rectal cancer located below the peritoneal reflection

OBJECTIVE: To identify the parameters related to the effective selection of patients who could receive prognostic benefit from lateral pelvic node dissection. BACKGROUND: Accurate preoperative diagnosis of lateral nodal involvement (LNI) remains difficult, and the indications for lateral lymph node dissection have been controversial. PATIENTS AND METHODS: A total of 244 consecutive patients who underwent potentially curative surgery with lateral dissection for advanced lower rectal cancer (1985-2000) were reviewed. Patients were stratified into groups based on various parameters, and the therapeutic value index for survival benefit was compared among groups. The therapeutic index of lateral dissection was calculated by multiplying the frequency of metastasis to the lateral area and the cancer-related 5-year survival rate of patients with metastasis to the lateral area, irrespective of metastasis to other areas (mesorectal, superior rectal artery [SRA], and inferior mesenteric artery [IMA] areas). RESULTS: LNI was observed in 41 patients (17%); and 88% of them had nodal involvement in the region along the internal iliac/pudendal artery or in the obturator region ("vulnerable field"). The cancer-related 5-year survival rate among the patients with LNI was 42%; the therapeutic index for lateral dissection was calculated as 7.0 patients, which was much higher than that of lymphadenectomy of the SRA area (1.6 patients) and the IMA area (0.4 patients), and almost comparable to that of lymphadenectomy of the upward mesorectal area (6.9 patients). Although it was possible to select groups at high and low risk for LNI based on several parameters related to tumor aggressiveness, such as tumor differentiation in biopsy specimens, the therapeutic value index was not significantly different between these groups. Unlike these parameters, the diameter of the largest lymph node in the "vulnerable field," which was positively correlated with the rate of LNI but irrelevant to the prognosis, was able to successfully stratify patients by therapeutic index. CONCLUSIONS: Advanced lower rectal cancer patients having LNI in the lateral pelvic area are likely to receive prognostic benefit from lymphadenectomy. The most efficient means of determining the effectiveness of lateral dissection preoperatively is to estimate the nodal diameter in the "vulnerable" lateral regions by diagnostic imaging.     

Survival benefit of lateral lymph node dissection according to the region of involvement and the number of lateral lymph nodes involved

Purpose

The effectiveness of lateral lymph node dissection for extending the survival of patients with advanced lower rectal cancer remains unclear. The purpose of this study was to clarify the survival benefit of lateral lymph node dissection according to the region of involvement and the number of lateral lymph nodes involved.

Methods

We reviewed 131 consecutive patients with advanced lower rectal cancer, who had undergone curative resection with total mesorectal excision plus extended lateral lymph node dissection at Wakayama Medical University Hospital. Twenty-six (19.1 %) of these patients had lateral lymph involvement. We performed univariate and multivariate analyses for the 3-year disease-free and overall survival of these patients.

Results

Multivariate analysis revealed that the number (>1) and the region (common iliac artery region or external iliac artery region) of lateral lymph node metastasis are independent predictive factors for recurrence and survival. The Kaplan–Meier analysis demonstrated that patients with one lymph node metastasis in the internal iliac artery or obturator region had better survival.

Conclusions

Lateral lymph node dissection resulted in survival benefit for patients with single lateral lymph node involvement in the internal iliac artery region or the obturator region.     

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。     

Treatment of lateral node metastasis from lower rectal cancer

Lateral lymphatics of the rectum originate in the area where branches of the inferior hypogastric plexus and the middle rectal vessels from the internal iliac vessels enter the mesorectum below the level of the peritoneal reflection in the pelvis, then reach the bifurcation of iliac vessels along the internal iliac vessels. Among lateral lymph nodes, the middle rectal, obturator, and internal iliac lymph nodes are important from the viewpoint of both the incidence of metastais and treatment effects. Although total mesorectal excision (TME) had become the standard surgical treatment for rectal cancer by the 1990s, this technique does not treat lateral node metastasis. A randomized clinical trial of TME versus D3 lymphadenectomy (JCOG0212) was started in 2003, and the registration of 701 patients with lower rectal cancer was completed in August 2010. The results of this clinical trial are highly anticipated. In Japan, where the rate of local recurrence after surgery is low, patients at high risk of local recurrence such as those with lateral node metastasis, T4 disease, and multiple lymph node metastases in the mesorectum should be selected to receive preoperative chemoradiation. Japanese surgeons who treat rectal cancers are in an advantageous position because they have the additional measure of lateral node dissection along with TME and chemoradiotherapy.     

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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。     

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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.     

Compatibility, indications, and limits of nerve sparing technique in lateral pelvic lymphadenectomy for advanced rectal carcinoma

The aim of radical surgical treatment of rectal cancer is to control the spread and prevent recurrence of the disease. In an attempt to improve the results of treatment of locally advanced rectal cancer, we advocate an extended surgical approach consisting of total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique with resection of autonomic nerves whenever these fibers are affected by locally advanced tumor. Nine cases (9.2%) in a personal series of 98 patients with rectal carcinoma, operated on over the period from January 1992 to December 1997, underwent total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique procedures for locally advanced extraperitoneal disease. In 7 patients with stage II or III disease, the 5-year survival rate was 80% and the 5-year disease-free survival rate 66.7% after a mean follow-up of 55 months. None of them experienced local recurrence, but one patient died of diffuse metastatic disease 50 months after surgery. One patient with stage IV rectal cancer died of disease 13 months postoperatively, while another patient with the same stage of disease is still alive with disease 26 months after surgery. One patient underwent liver resection for a solitary metastasis 25 months after the primary operation. Two patients suffered postoperatively from urinary retention with mild irregular flow at urodynamic testing, but no long-term urinary disturbances persisted. Retrograde ejaculation occurred postoperatively in one of the two patients who experienced urinary disorders, and another patient had erection disturbances. These sexual dysfunctions did not improve during long-term follow-up. Total mesorectal excision, lateral pelvic lymphadenectomy, and the nerve sparing technique, with resection of the autonomic nerves whenever these fibers are involved, allow satisfactory results to be achieved in terms of survival and functional outcome in patients with locally advanced rectal cancer. In western subjects, however, this procedure is safe only after careful patient selection.     

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??Lateral lymph node dissection via lateral vascular approach with en-bloc dissection of laparoscopic total mesorectal excision for advanced middle and low rectal cancer LIANG Jian-wei, LIU Qian, ZHOU Si-cheng, et al. National Cancer Center & National Clinical Research Center for Cancer & Cancer Hospital??Chinese Academy of Medical Sciences and Peking Union Medical College??Beijing 100021??China
Corresponding authors: LIU Qian??E-mail: fcwpumch@163.com??WANG Xi-shan??E-mail: wxshan1208@126.com
Abstract Objective To investigate the feasibility and safety of the en-bloc resection via lateral vascular approach combined with lateral lymph node dissection (LLND). Methods The clinical and pathological data of 72 cases of laparoscopic total mesorectal excision resection of rectal cancer combined with LLND via lateral vascular approach were retrospectively analyzed. There were 38 cases of preoperative chemoradiotherapy??9 patients with neochemotherapy??25 cases without preoperative treatment. All patients were diagnosed with lateral lymph node metastasis by MRI or PET-CT before treatment. The first step of LLND was performed by the distal of external iliac artery??then high ligation the inferior mesenteric vascular and opened the left Toldt’ space??and the final step was the total mesorectal excision. All of the spacemen were en-bloc dissection of the later lymph node with the rectal cancer. Results There were 19 cases of bilateral LLND??28 cases with unilateral left LLND??25 cases on the right side. The harvested pelvic lymph node detection was 8.3??19.4% of lateral lymph node metastasis rate??14/72????12 cases of unilateral lateral lymph node metastasis??2 cases of bilateral metastasis??and 7 patients combined viscera resection??9.7%??. The operative time was 281.4??145~600??min and the intraoperative blood loss was 89.7??30~1200??mL. A total of 11 cases??15.3%??had surgical complications and no surgical death. The positive rate of lateral pelvic lymph node in preoperative chemoradiotherapy patients was 23.7% ??9/38????and 22.2%??2/9??in the neochemotherapy group. Conclusion Laparoscopic resection of rectal cancer combined with LLND via transvascular lateral approach is safe and feasible??and not increase in operative complications.