直肠癌侧方淋巴结清扫的研究进展与相关争议

盆腔侧方淋巴结（lateral pelvic lymph node,LPLN）是中低位直肠癌常见的淋巴回流通路,有14%～30%的局部中晚期直肠癌患者同时合并LPLN转移。然而,术前诊断的遗漏和不规范的治疗是导致术后LPLN复发的常见原因,同时也是诊疗中的难点之一。目前,侧方淋巴结清扫术（lateral pelvic lymph node dissection,LPLND）的价值与意义,在国际上尚存争议。近些年来,新辅助放化疗（neoadjuvant chemoradiotherapy,nCRT）与LPLND相互替代的治疗模式趋于融合,逐渐形成了一套精确化、个体化的治疗策略。同时,随着外科器械设备的更新与淋巴结示踪剂技术的不断发展,使得以往制约LPLND的因素逐渐消失,可逐渐在临床推广开展。但针对直肠癌LPLN转移的治疗策略、nCRT后LPLND的适应证、预后价值、有效清扫范围、安全性仍存在诸多问题,需深入研究。      

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,...     

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。     

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.     

盆腔淋巴结清扫在低位直肠癌手术中的应用与评价

在低位直肠癌的外科治疗中，侧方淋巴结清扫的作用观点不一。西方外科专家对包括闭孔窝淋巴结清扫在内的系统的侧方淋巴结清扫持消极态度。2008NCCN中国版直肠癌临床实践指南中明确指出，淋巴结清扫：①尽可能把清扫范围外可疑转移淋巴结切除或活检；②如果无临床可疑转移淋巴结，不推荐扩大的淋巴清扫术。我们认为，只有临床上怀疑有盆腔侧方淋巴结转移病灶才是支持实施侧方淋巴清扫的最佳指标，即实施侧方淋巴清扫的最佳依据是根据术前评估中侧方区域的淋巴结是否肿大。     

国外低位直肠癌侧方转移淋巴结的清扫

目前国外对腹膜反折下低位进展期直肠癌的外科治疗研究集中在手术方式的合理选择、切除肿瘤远端肠管范围和保留肛门括约肌手术。有关清扫区域淋巴结转移范围 ,特别是侧方（平行）淋巴结转移的清扫不断增加。为了深入了解对局部复发率高的低位直肠癌术后复发的控制程度及提高５年生存率 ,本文对国外的有关进展作一概述。１直肠癌侧方淋巴结的转移率腹膜反折下（Ｒｂ）直肠的淋巴引流 ,虽主要向上方但也向下方和两侧髂内血管淋巴结输出 ,因而直肠癌发生部位的划分 ,应以腹膜反折为界（距肛缘约７ｃｍ左右）较为合理、实用。从局部解剖学角度而…     

侧方淋巴结清扫在低位直肠癌治疗中的临床意义

外科手术仍是治疗直肠癌最主要的手段.直肠癌根治术的失败原因多为血道播散、淋巴转移和局部复发,这些因素都是危及直肠癌患者术后生活质量的问题.我院自1997年起开始对低位直肠癌淋巴结转移规律进行研究,现就侧方淋巴结清扫(侧方清扫)在低位直肠癌治疗的临床意义加以总结.     

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...     

中低位直肠癌腹腔镜与开放全系膜切除合并侧方淋巴结清扫围手术期临床分析北大核心CSCD

目的比较中低位直肠癌患者在腹腔镜与开放全直肠系膜切除术(TME)基础上行侧方淋巴结清扫的围手术期临床结果,以探讨腹腔镜盆腔淋巴结清扫术的可行性及安全性。方法对浙江省肿瘤医院同期16例腹腔镜及55例开放侧方淋巴结清扫术患者临床资料进行回顾性分析,比较了两组间围手术期手术时间、术中出血量、侧方淋巴结清扫数目、术后并发症及术后住院时间。结果腹腔镜组与开放组患者基础临床特征相似。两组患者均无围手术期死亡。腹腔镜组患者无中转开腹手术。腹腔镜组比开放组手术时间显著延长(218.6±71.6 min vs.181.3±57.9 min,P=0.035)、术中出血量显著减少(190.6±80.1 ml vs.344.9±295.2 ml,P=0.044)。腹腔镜组与开放组清扫的侧方淋巴结数目(9.8±6.1枚vs.11.0±9.7枚,P=0.642)、侧方淋巴结转移阳性率(25.0%vs.34.5%,P=0.556)、术后并发症发生率(25.0%vs.20.0%,P=0.666)、术后住院时间(10.9±3.5天vs.13.8±7.1天,P=0.125)差异均无统计学意义。侧方淋巴结转移与肿瘤低分化(P=0.001)、阳性脉管瘤栓(P=0.011)和神经侵犯(P=0.002)相关,但与术前是否行放化疗(P=0.479)及肿瘤大小(P=0.907)无关。结论腹腔镜直肠癌全系膜切除术基础上的侧方淋巴结清扫是安全可行的,并能达到和传统开放手术同样的围手术期临床效果。     

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.     

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.     

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.     

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.     

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.     

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     

对Ⅲ期低位直肠癌行择区扩大淋巴结清扫的临床意义

背景与目的：目前对于Ⅲ期低位直肠癌的淋巴结清扫范围存在争议：日本学者多主张行择区扩大清扫双侧髂总、髂内、髂外和闭孔淋巴结脂肪组织;欧美学者则多主张行全直肠系膜切除术,辅以新辅助治疗。本研究旨在探讨对Ⅲ期低位直肠癌行择区扩大淋巴结清扫的临床意义。方法：对31例Ⅲ期低位直肠癌的病例(术前影像学分期,术后经病理证实)行择区扩大淋巴结清扫,即顺序清扫双侧髂总、髂内、髂外和闭孔淋巴结脂肪组织,尽量保留盆腔自主神经,除非神经受到肿瘤浸润,并与35例行传统根治术的低位直肠癌的病例进行比较。结果：行择区扩大淋巴结清扫组内有5例侧方淋巴结阳性(低分化腺癌4例、黏液细胞癌1例,较高、中分化腺癌有明显差异)。行择区扩大淋巴结清扫组在性功能障碍、排尿困难发生率及手术时间上与行传统根治术组差异有统计学意义(P＜0.05),行择区扩大淋巴结清扫组在吻合口瘘和手术失血量上与行传统根治术组差异无统计学意义(P＞0.05),但择区扩大淋巴结清扫组在盆腔复发率及5年生存率上优于传统根治术组。结论：对Ⅲ期低位直肠癌行择区扩大淋巴结清扫对降低盆腔复发、提高生存率有临床意义。     

Rectal cancer with jumping metastasis to the obturator lymph node only

In May, 1993, we operated upon a 40-year-old woman with lower rectal cancer with jumping metastasis to a solitary right obturator lymph node only. For the rectal cancer with submucosal invasion, we performed low anterior resection with regional lymph node dissection as far as the second group, based on theGeneral rules for clinical and pathological studies on cancer of colon, rectum and anus, 4th edition, of the Japanese Society for Cancer of the Colon and Rectum, including the obturator lymph nodes. Well differentiated adenocarcinoma and mucinous carcinoma were seen in the submucosal invasive front. The risk of obturator metastasis must be considered during operation for rectal cancer.     

淋巴结切除术对子宫内膜癌的临床意义

手术治疗是子宫内膜癌的主要治疗方式,通过手术治疗可以明确诊断、病理分级、临床分期,并为术后的辅助治疗提供充分的临床资料。对于子宫内膜癌患者是否常规进行淋巴结切除仍存在较大争议,特别是对于低危的子宫内膜癌患者而言,因为低危患者淋巴结转移发生率非常低,且不影响患者的预后,但目前没有全面的划分淋巴结转移危险因素及其危险程度的统一标准。本文就子宫内膜癌的淋巴结转移特点,影响淋巴结转移的因素,淋巴结切除的并发症,淋巴结切除术对预后的影响,淋巴结切除的临床意义及淋巴结切除的发展方向等方面加以综述,我们认为对于内膜癌患者应选择个体化的治疗方案,注重术前的全面评估,对于G3,透明细胞,浸润肌层≥1/2,病灶>2cm,宫颈受累等应进行包括腹主动脉旁淋巴结在内的系统淋巴结切除术。