早期直肠癌的微创治疗

单纯放疗和局部切除联合放疗已经成为早期直肠癌根治性切除术可接受的替代治疗方式。与根治性手术相比,单纯放疗和局部切除联合放疗都可取得满意的疗效,并且避免了根治性手术所带来的多种并发症和不良反应,能够提高直肠癌患者的生活质量,是值得推广的治疗方式。     

早期直肠癌局部治疗方法的选择

随着饮食结构的西化,大肠癌的发病率及死亡率逐年增加。同时由于诊疗水平的提高使包括早期直肠癌在内的早期大肠癌病例不断增加。直肠癌治疗原则同其他实体肿瘤一样,即彻底切除原发灶及淋巴结。由于直肠癌特殊的解剖学位置,根治性切除术后容易引起排尿、排便及性功能障碍,严重影响患者的生存质量,尤其是距肛门缘2～8cm的低位直肠癌病例常常施行经腹会阴直肠切除术（Miles手术）,并同时设置结肠永久造口,这对低度恶性的肿瘤治疗实属过度（over treatment）。因此在不影响治疗结果的前提下施行保留功能的手术日益受人关注。近年来早期直肠癌的临床病理生物学行为表明一部分直肠癌不施行标准的开腹根治术就可以达到治愈的目的。本文就早期直肠癌的保留排尿、排便及性功能的治疗方法进行综述。     

影响低位直肠癌局部切除选择的因素分析

目的探讨低位直肠癌局部切除选择的影响因素。方法回顾性分析101例局部切除治疗低位直肠癌患者的临床资料。Kaplan-Meier法计算生存率,并对预后进行单因素及多因素分析。结果经肛门切除91例,经骶骨切除9例,经阴道切除1例,并发症发生率为5.9%,全组无手术死亡病例。术前放疗5例,术后放疗34例。5年生存率为91.0%,Tis、T1、T2及T3或T4病变的5年生存率分别为100%、92.6%、77.1%和83.3%;局部复发率为15.8%。单因素分析显示,肿瘤的侵袭深度、直径>3 cm、有脉管瘤栓、溃疡型癌、放射治疗和局部复发与预后有关(P<0.05)。多因素分析显示,肿瘤直径>3 cm、局部复发是影响预后最重要的因素(P<0.05)。结论低位直肠癌病理为高中分化、直径≤3 cm、无脉管瘤栓的T1病变及原位癌,是局部切除术的合理适应证。     

直肠癌的辅助治疗

直肠癌辅助治疗观念的提出是基于手术后局部失败率较高。通过术前、术后的放疗或加化疗来提高保肛率、减少复发、提高生存率是近年研究的焦点，对T3期的病人建议采用术前联合治疗、手术加术后以5-Fu为基础的化疗。术前放疗建议按照常规剂量，放疗后4-8周行手术治疗。术后是否行辅助治疗应取决于病理分期，术后辅助治疗方案的选择建议以5-Fu为基础。加用LV、或Capecitabine、或Oxaliplatin、或CPT-11伴随放疗的临床研究正在进行中。     

早期中低位直肠癌经肛门切除的疗效分析

目的:探讨早期中低位直肠癌经肛门局部切除术的临床应用价值。方法:回顾性分析2012年至2015年期间我院收治的112例早期中低位直肠癌患者,分为经肛门局部切除组（n=52）和根治性切除组（n=60）。术后标本行常规免疫组化病理检测,同时对比两组患者的各种临床病理特征。结果:两组患者肿瘤大小、肿瘤距肛缘距离比较差异无统计学意义（P＞0.05）;术后住院天数、术中出血量、术后并发症发生率及手术时间比较差异有统计学意义（P＜0.05）。结论:早期中低位直肠癌经肛门切除与根治性手术比较治疗效果相当,但操作更简便易行,创伤小,恢复快、并发症少、术后生活质量高,具有一定优势,特别是内镜切割吻合器的联合应用,使得该术式更简便易行,在具有适应征患者中可以推广。     

放化疗结合相控阵聚焦热疗治疗直肠癌术后局部区域复发的临床观察

目的:探讨放化疗与相控阵聚焦热疗同步治疗直肠癌术后复发的疗效及安全性,并与单纯放化疗进行比较.方法:将直肠癌术后复发患者随机分为热放化组(治疗组)及单纯放化组(对照组),其中冶疗组患者采用三维适形放疗,2.5～4 Gy/(次·d),5次/周.总剂量DT 48～65 Gy,并口服卡培他滨2 500 mg/(m2·d),连用14 d.同时配合应用相控阵聚焦热疗系统,2次/周,时间为45～60 min/次,直到治疗结束.对照组放化疗方法同治疗组.结果: 治疗组中完全缓解(CR)占20.5%,部分缓解(PR)占64.7%,有效率为85.3%,对照组完全缓解(CR)占16.1%,部分缓解(PR)占41.9%,有效率为58.1%;疼痛症状缓解率治疗组为92%,对照组为72.7%,两组比较差异有统计学意义,P<0.05;毒副反应发生率两组比较差异均无统计学意义,P<0.05.结论:放化疗与相控阵聚焦热疗同步治疗直肠癌术后复发疗效及症状改善方面明显提高,且毒副反应无明显增加.     

直肠癌新辅助治疗研究进展

新辅助放化疗已经成为Ⅱ／Ⅲ期直肠癌的标准治疗模式。全文就生存率、无病生存率及局部控制率等方面,阐述新辅助放化疗的优势,并对新辅助治疗的术前放疗剂量及对保肛手术的影响作初步探讨。     

直肠癌术后复发的三维适形放射治疗

目的 探讨直肠癌术后复发三维适形放射治疗的治疗计划设计及治疗方法.方法 收治22例直肠癌术后局部复发患者,采用俯卧位固定于立体定位体架内的真空垫内,带定位体架作CT增强扫描,勾画靶区后进行三维治疗计划设计.处方剂量DT35～50 Gy,分5～9次,9～18 d完成;等效生物剂量43～70 Gy.结果 22例患者治疗后17例临床症状缓解,总有效率为77.3%.结论 三维立体定向适形放射治疗可以使处方剂量线和肿瘤靶区相适形,剂量分布比常规放疗更合理;使肿瘤局部控制率提高.有疗程短、分次剂量高、放疗反应低和提高生存质量等.     

Local excision and postoperative radiotherapy for distal rectal cancer

To assess the outcome following local excision and postoperative radiotherapy (RT) for distal rectal carcinoma.

Seventy-three patients received postoperative radiotherapy following local surgery for primary rectal carcinoma at Princess Margaret Hospital from 1983 to 1998. Selection factors for postoperative RT were patient preference, poor operative risks, and “elective” where conservative therapy was regarded as optimal therapy. Median distance of the primary lesion from the anal verge was 4 cm (range, 1–8 cm). There were 24 T1, 36 T2, and 8 T3 lesions. The T category could not be determined in 5. Of 55 tumor specimens in which margins could be adequately assessed, they were positive in 18. RT was delivered using multiple fields by 6- to 25-MV photons. Median tumor dose was 50 Gy (range, 38–60 Gy), and 62 patients received 50 Gy in 2.5-Gy daily fractions. The tumor volume included the primary with 3–5 cm margins. No patients received adjuvant chemotherapy. Median follow-up was 48 months (range, 10–165 months).

Overall 5-year survival and disease-free survival were 67% and 55%, respectively. Tumor recurrence was observed in 23 patients. There were 14 isolated local relapses; 6 patients developed local and distant disease; and 3 relapsed distantly only. For patients with T1, T2, and T3 lesions, 5-year local relapse-free rates were 61%, 75%, and 78%, respectively, and 5-year survival rates were 76%, 58%, and 33%, respectively. The 5-year local relapse-free rate was lower in the presence of lymphovascular invasion (LVI) compared to no LVI, 52% vs. 89%, p = 0.03, or where tumor fragmentation occurred during local excision compared to no fragmentation, 51% vs. 76%, p = 0.02. Eleven of 14 patients with local relapse only underwent abdominoperineal resection, 8 achieved local control, and 4 remained cancer free. The ultimate local control, including salvage surgery, was 86% at 5 and 10 years. The 5-year colostomy-free rate was 82%. There were 2 patients who experienced RTOG Grade 3 late complications, and 1 with Grade 4 complication (bowel obstruction requiring surgery).

The local relapse rate for patients with T1 disease was high compared to other series of local excision and postoperative RT. Patients with LVI or tumor fragmentation during excision have high local relapse rates and may not be good candidates for conservative surgery and postoperative RT.     

直肠癌新辅助化放疗

近年来的前瞻性研究已证实新辅助化放疗即术前化放疗可以明显提高直肠癌患者的局部控制率和保肛率,但直肠癌新辅助化放疗的理论基础、适应证、治疗方案、治疗时间等尚未明确.     

Outcomes following completion and salvage surgery for early rectal cancer: A systematic review

Objectives

To establish outcomes after completion and salvage surgery following local excision in literature published since 2005, to inform decision-making when offering local excision.

低位直肠癌术前加速放疗的临床意义

 目的　观察低位直肠癌术前放疗的临床病理变化及意义。方法　对30例已行术前30 Gy（3 Gy／次,2次／d,前后野交替,间隔6 h）生物效应等同于常规放疗40 Gy的低位直肠癌患者进行术后病理变化分析;直肠镜观察放疗前后直肠肿块的肉眼变化、放疗后手术标本的病理形态学特征。结果　放疗后直肠镜仅见小的病灶、肿块缩小和无明显变化者分别为7例（23.3 %）、16例（53.3 %）和7例（23.3 %）。放疗患者按直肠癌组织学退变的分级标准（RCRG）分为Ⅰ级8例（26.7 %）、Ⅱ级15例（50.0 %）、Ⅲ级6例（20.0 %）。结论　术前30 Gy加速放疗可使大多数直肠癌瘤体缩小,使癌组织坏死,癌组织和间质产生纤维变性,降低肿瘤分期,有利于肿瘤的切除;对低位直肠癌保肛手术具有积极的作用。     

早期低位直肠癌局部切除23例疗效分析

背景与目的:目前,早期低位直肠癌经肛门局部切除术越来越受到重视,因为它可以达到与开腹根治术类似的疗效。本研究目的是探讨早期低位直肠癌局部切除的疗效。方法:回顾性分析1989年2月～1999年4月间我院局部切除早期低位直肠癌23例的临床资料。结果:(1)12例为直肠腺癌,11例为腺瘤恶变;(2)23例中T0期17例,T1期6例;(3)有3例局部复发,其中2例再次经肛门局部扩大切除治愈,另外1例经腹会阴联合切除术;(4)本组病例术后随访均超过5年,5年生存率为95.65%。结论:只要严格掌握手术适应证,局部切除治疗早期直肠癌可取得较好的疗效,是一种切实可行的方法。     

直肠癌新辅助治疗后病理降期相关研究进展

术前同步放化疗已成为局部晚期直肠癌的标准治疗模式.新辅助治疗后病理降期与直肠癌预后关系密切,找到能预测直肠癌新辅助治疗病理降期标记,有着重要的临床意义.不同放化疗方案、靶向药物在新辅助治疗中的应用、新辅助治疗后至手术间隔时间与病理降期相关.     

Survival and treatment trends of rectal cancer patients in a population with suboptimal local control

Aim

To explore trends in rectal cancer survival in Manitoba, particularly in patients where local control was an issue.

Method

Patients diagnosed with rectal or rectosigmoid adenocarcinoma from 1985 to 1999 were included. Demographic, treatment and mortality information were abstracted from the registry. Relative survival was examined for all patients for the periods 1985–1989, 1990–1994 and 1995–1999, and subsequently limited to those who underwent major surgery (Hartmann's, anterior, and abdominal perineal resection).

Results

Of the 2925 patients identified, 2163 (74%) had undergone a major surgery. Five-year relative survival was 46%, 54% and 53% for all patients for the three periods, respectively; major surgery results were 53%, 59% and 60%. Radiotherapy was used in 32% of cases in 1985–1989 and in 40% of cases in 1995–1999. Chemotherapy was used in 13% of cases in 1985–1989 and in 37% of cases in 1995–1999.

Conclusion

Consistent with other studies, overall rectal cancer survival in Manitoba has improved since 1985. Better local control, as suggested in other studies, does not appear to be a major factor in that improvement. Future work should include review of the local control strategy in Manitoba and factors to explain the improved survival.     

三维适形放射治疗局部晚期和术后复发性直肠癌

目的：探讨局部晚期和术后复发性直肠癌三维适形放射治疗（three dimensional conformal radiation therapy,3D-CRT）的临床疗效。方法：60例局部晚期和术后复发性直肠癌均在外照射40Gy后随机分为后程适形放疗组（适形组）30例,常规放疗组（对照组）30例。结果：适形组及对照组有效率分别为86.7%和70.0%,2组差异无统计学意义（P〉0.05）;适形组及对照组1、2、3年生存率分别为80.0%、53.3%、36.7%和56.7%、40.0%、13.3%,P=0.02;1、2、3年局部控制率分别为86.7%、80.0%、50.0%和73.3%、53.3%、30.0%,2组差异均有统计学意义（P=0.0438）;在副反应方面2组差异无统计学意义（P〉0.05）。结论：局部晚期和术后复发性直肠癌常规外照射加三维适形放疗有较好疗效。