新辅助放化疗联合手术治疗T_3N_+/T_4N_x期直肠癌的临床研究
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摘要
目的探讨新辅助放化疗联合手术与直接手术治疗局部进展期直肠癌的临床疗效。方法回顾性分析2010年1月至2015年1月260例T_3N_+/T_4N_x期中低位直肠癌患者的临床资料,其中新辅助治疗组(新辅助放化疗+手术治疗)82例,直接手术组178例。两组患者均接受全直肠全系膜切除手术。同步化疗方案包括单药卡培他滨方案(n=36)、XELOX方案(n=32)和FOLFOX方案(n=14)。放疗采用调强放疗,DT 45～50.4 Gy,每次1.8～2.0 Gy,共25～28次。观察两组围术期情况、术后病理及随访情况。结果新辅助治疗组11例(13.4%)达病理完全缓解(pCR)。新辅助治疗组与直接手术组的胃肠道功能恢复时间、术后住院时间和30天内2次手术率的差异均无统计学意义(P>0.05);新辅助治疗组手术时间(277.5 min vs. 240.0 min)、术中出血量(100.0 ml vs. 80.0 ml)、淋巴结清扫数量(9个vs. 14个)、淋巴结阳性率(25.6%vs. 73.0%)和围术期并发症发生率(46.3%vs. 25.3%)与直接手术组比较,差异均有统计学意义(P<0.05)。新辅助治疗组3年无复发生存率(93.9%)高于直接手术组(81.3%),差异有统计学意义(P<0.05)。两组保肛率(35.9%vs. 38.9%)、3年无瘤生存率(66.2%vs. 58.0%)和3年生存率(81.1%vs. 76.5%)的差异无统计学意义(P>0.05)。结论新辅助放化疗可降低局部进展期直肠癌的局部复发率,但会增加术后并发症的发生率,而对保肛率和远期生存无明显影响。
Objective To compare the clinical efficacy of neoadjuvant chemoradiotherapy(nCRT) combined with direct surgery in the treatment of locally advanced rectal cancer. Methods A retrospective analysis was done on 260 patients with T_3N_+/T_4N_x middle and low rectal cancer from January 2010 to January 2015, including 82 patients in nCRT group and 178 patients in direct surgery group. All the patients received total mesorectal excision of rectum. In nCT group, synchronous chemotherapy regimens included single-agent capecitabine regimen(n=36), XELOX regimen(n=32) or FOLFOX regimen(n=14). Intensity-modulated radiotherapy(IMRT) was used. DT was 45-50.4 Gy, 1.8-2.0 Gy/f for 25-28 times. Peri-operative conditions, postoperative pathology and 3-year follow-up were analyzed in both groups. Results In nCRT group, 11 patients(13.4%) achieved pathologic complete response(pCR). There was no significant difference in the time of gastrointestinal function recovery, postoperative hospital stay, and unplanned reoperation rate within 30 days between the two groups(P>0.05). Operation time(277.5 min vs. 240.0 min), intraoperative blood loss(100.0 ml vs. 80.0 ml), number of lymph node dissection(9 vs. 14), rate of positive lymphnode(25.6% vs. 73.0%) and perioperative complication rate(46.3% vs. 25.3%) between nCRT group and direct surgery group had statistical significant(P<0.05). The 3-year recurrence-free survival rate of nCRT group was 93.9%, higher than 81.3% of direct surgery group with statistical significant(P<0.05), and there were no significant difference on the sphincter preservation rate(35.9% vs. 38.9%), the 3-year disease-free survival rate(66.2% vs. 58.0%) and the 3-year overall survival rate(81.1% vs. 76.5%) between the two groups(P>0.05). Conclusion Neoadjuvant chemoradiation can reduce the local recurrence rate of locally advanced rectal cancer, but it will increase the incidence of postoperative complications, but has no significant effect on sphincter preservation rate and long-term survival.
Objective To compare the clinical efficacy of neoadjuvant chemoradiotherapy(nCRT) combined with direct surgery in the treatment of locally advanced rectal cancer. Methods A retrospective analysis was done on 260 patients with T_3N_+/T_4N_x middle and low rectal cancer from January 2010 to January 2015, including 82 patients in nCRT group and 178 patients in direct surgery group. All the patients received total mesorectal excision of rectum. In nCT group, synchronous chemotherapy regimens included single-agent capecitabine regimen(n=36), XELOX regimen(n=32) or FOLFOX regimen(n=14). Intensity-modulated radiotherapy(IMRT) was used. DT was 45-50.4 Gy, 1.8-2.0 Gy/f for 25-28 times. Peri-operative conditions, postoperative pathology and 3-year follow-up were analyzed in both groups. Results In nCRT group, 11 patients(13.4%) achieved pathologic complete response(pCR). There was no significant difference in the time of gastrointestinal function recovery, postoperative hospital stay, and unplanned reoperation rate within 30 days between the two groups(P>0.05). Operation time(277.5 min vs. 240.0 min), intraoperative blood loss(100.0 ml vs. 80.0 ml), number of lymph node dissection(9 vs. 14), rate of positive lymphnode(25.6% vs. 73.0%) and perioperative complication rate(46.3% vs. 25.3%) between nCRT group and direct surgery group had statistical significant(P<0.05). The 3-year recurrence-free survival rate of nCRT group was 93.9%, higher than 81.3% of direct surgery group with statistical significant(P<0.05), and there were no significant difference on the sphincter preservation rate(35.9% vs. 38.9%), the 3-year disease-free survival rate(66.2% vs. 58.0%) and the 3-year overall survival rate(81.1% vs. 76.5%) between the two groups(P>0.05). Conclusion Neoadjuvant chemoradiation can reduce the local recurrence rate of locally advanced rectal cancer, but it will increase the incidence of postoperative complications, but has no significant effect on sphincter preservation rate and long-term survival.
引文
[1] 戴卫星,蔡国响.弊大于利[J].中华胃肠外科杂志,2016,19(6):643-646.
[2] Musters GD, Sloothaak DA, Roodbeen S, et al. Perineal wound healing after abdominoperineal resection for recter cancer:a two-centre experience in the era of intensified oncological treatment [J]. Int J Colorectal Dis,2014,29(9):1151-1157.
[3] Schiffmann L, Wedermann N, Gock M, et al. Intensifiedneoadjuvant radiochemtherapy for rectal cancer enhances surgical complications [J]. BMC Surg,2013,13:43.
[4] O'Connell MJ, Colangelo LH, Beart RW, et al. Capecitabine and oxaliplatin in the preoperative multimodality treatment of rectal cancer: surgical end points from National Surgical Adjuvant Breast and Bowel Project trial R-04 [J]. J Clin Oncol, 2013,32(18): 1927-1934.
[5] Mechera R, Schuster T, Rosenberg R, et al. Lymph node yield after rectal resection in patients treated with neoadjuvant radiation for rectal cancer: A systematic review and meta-analysis [J/OL]. Eur J Cancer, 2016[2018-04-10]. https://www.ncbi.nlm.nih.gov/pubmed/28027520.
[6] Govindarjan A, Gonen M, Weiser MR, et al. Challenging the feasibility and clinical significance of current guidelines on lymph node examination in rectal cancer in the era of neoadjuvant therapy [J]. J Clin Oncol,2011,29(34):4568-4573.
[7] 王海江, 葛磊, 雷程,等. 中低位进展期直肠癌长程新辅助放化疗后腹腔镜手术疗效分析[J].中华医学杂志, 2016,96(34): 2709-2712.
[8] Hoare D, Maw A, Gollins S, et al. Does pre-operative chemoradiotherapy cause wound complications after abdominoperineal excision for rectal cancer? An observational study[J]. Int J Surg, 2013,11(5):395-399.
[9] 王枭杰,池畔,林惠铭, 等.新辅助放化疗对不同高度低位直肠癌保肛率的影响及其预后因素分析[J].中华外科杂志,2016,54(6):419-423.
[10] Gollins S, Sebag-Montefiore D. Neoadjuvant treatment strategies for locally advanced rectal cancer [J]. Clin Oncol (R Coll Radiol),2016, 28(2):46-51.
[11] Du D, Su Z, Wang D, et al. Optimal interval to surgery after neoadjuvant chemoradiotherapy in rectal cancer: A systematic review and meta-analysis [J]. Clin Colorectal Cancer, 2017,17(1): 13-24.
[12] Franke AJ, Parekh H, Starr JS, et al. Total neoadjuvant therapy: A shifting paradigm in locally advanced rectal cancer management [J]. Clin Colorectal Cancer, 2017,17(1): 1-12.
[2] Musters GD, Sloothaak DA, Roodbeen S, et al. Perineal wound healing after abdominoperineal resection for recter cancer:a two-centre experience in the era of intensified oncological treatment [J]. Int J Colorectal Dis,2014,29(9):1151-1157.
[3] Schiffmann L, Wedermann N, Gock M, et al. Intensifiedneoadjuvant radiochemtherapy for rectal cancer enhances surgical complications [J]. BMC Surg,2013,13:43.
[4] O'Connell MJ, Colangelo LH, Beart RW, et al. Capecitabine and oxaliplatin in the preoperative multimodality treatment of rectal cancer: surgical end points from National Surgical Adjuvant Breast and Bowel Project trial R-04 [J]. J Clin Oncol, 2013,32(18): 1927-1934.
[5] Mechera R, Schuster T, Rosenberg R, et al. Lymph node yield after rectal resection in patients treated with neoadjuvant radiation for rectal cancer: A systematic review and meta-analysis [J/OL]. Eur J Cancer, 2016[2018-04-10]. https://www.ncbi.nlm.nih.gov/pubmed/28027520.
[6] Govindarjan A, Gonen M, Weiser MR, et al. Challenging the feasibility and clinical significance of current guidelines on lymph node examination in rectal cancer in the era of neoadjuvant therapy [J]. J Clin Oncol,2011,29(34):4568-4573.
[7] 王海江, 葛磊, 雷程,等. 中低位进展期直肠癌长程新辅助放化疗后腹腔镜手术疗效分析[J].中华医学杂志, 2016,96(34): 2709-2712.
[8] Hoare D, Maw A, Gollins S, et al. Does pre-operative chemoradiotherapy cause wound complications after abdominoperineal excision for rectal cancer? An observational study[J]. Int J Surg, 2013,11(5):395-399.
[9] 王枭杰,池畔,林惠铭, 等.新辅助放化疗对不同高度低位直肠癌保肛率的影响及其预后因素分析[J].中华外科杂志,2016,54(6):419-423.
[10] Gollins S, Sebag-Montefiore D. Neoadjuvant treatment strategies for locally advanced rectal cancer [J]. Clin Oncol (R Coll Radiol),2016, 28(2):46-51.
[11] Du D, Su Z, Wang D, et al. Optimal interval to surgery after neoadjuvant chemoradiotherapy in rectal cancer: A systematic review and meta-analysis [J]. Clin Colorectal Cancer, 2017,17(1): 13-24.
[12] Franke AJ, Parekh H, Starr JS, et al. Total neoadjuvant therapy: A shifting paradigm in locally advanced rectal cancer management [J]. Clin Colorectal Cancer, 2017,17(1): 1-12.