Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial.
Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial.
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DOI：
10.1016/s0140-6736(09)60485-2
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发表时间：
2009-03-07
期刊：
影响因子：
168.9
通讯作者：
Sebag-Montefiore, David
中科院分区：
文献类型：
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作者：
Quirke, Phil;Steele, Robert;Monson, John;Grieve, Robert;Khanna, Subhash;Couture, Jean;O'Callaghan, Chris;Myint, Arthur Sun;Bessell, Eric;Thompson, Lindsay C.;Parmar, Mahesh;Stephens, Richard J.;Sebag-Montefiore, David
可手术直肠癌的局部复发率可通过放疗（联合或不联合化疗）和手术技术（如全直肠系膜切除术）来改善。然而，手术和放疗对结果的贡献尚不清楚。我们评估了环周切除边缘和手术平面的影响。在这项前瞻性研究中，由当地病理学家使用标准病理学方案对1156例来自CR 07和NCIC-CTG CO16试验的可手术直肠癌患者进行了手术平面和环形切除边缘的参与评估，该试验比较了1998年3月至8月期间的短期（5天）术前放疗和选择性术后放化疗。2005.所有的分析都是通过意向治疗进行的。该试验已注册，编号为ISRCTN 28785842。128例患者（11%）累及环周切除边缘，604例（52%）手术平面为良好（直肠系膜），398例（34%）为中等（直肠系膜内），154例（13%）为差（固有肌层平面）。我们发现环形切缘阴性和上级手术平面均与低局部复发率相关。风险比（HR）为0·32（95% CI 0·16 - 0·63，p = 0·0011），环切缘阴性和阳性患者的3年局部复发率分别为6%（5 - 8%）和17%（10 - 26%）。对于达到的手术平面，直肠系膜和直肠系膜内组与固有肌层组相比的HR分别为0.32（0.16 - 0.64）和0.48（0.25 - 0.93）。在3年时，估计的局部复发率为4%（3 - 6%），直肠系膜，7%（5 - 11%），直肠系膜内和13%（8 - 21%），固有肌层组。3个手术平面组的短期术前放疗获益无差异（趋势p = 0.30）。在短疗程术前放疗组中，在直肠系膜平面切除的患者3年局部复发率仅为1%。在直肠癌中，手术平面是局部复发的重要预后因素。短期术前放疗降低了所有三个平面手术组的局部复发率，几乎消除了在直肠系膜平面切除的短期术前放疗患者的局部复发。因此，应定期评估和报告手术平面。医学研究理事会（英国）和加拿大国家癌症研究所。
Local recurrence rates in operable rectal cancer are improved by radiotherapy (with or without chemotherapy) and surgical techniques such as total mesorectal excision. However, the contributions of surgery and radiotherapy to outcomes are unclear. We assessed the effect of the involvement of the circumferential resection margin and the plane of surgery achieved. In this prospective study, the plane of surgery achieved and the involvement of the circumferential resection margin were assessed by local pathologists, using a standard pathological protocol in 1156 patients with operable rectal cancer from the CR07 and NCIC-CTG CO16 trial, which compared short-course (5 days) preoperative radiotherapy and selective postoperative chemoradiotherapy, between March, 1998, and August, 2005. All analyses were by intention to treat. This trial is registered, number ISRCTN 28785842. 128 patients (11%) had involvement of the circumferential resection margin, and the plane of surgery achieved was classified as good (mesorectal) in 604 (52%), intermediate (intramesorectal) in 398 (34%), and poor (muscularis propria plane) in 154 (13%). We found that both a negative circumferential resection margin and a superior plane of surgery achieved were associated with low local recurrence rates. Hazard ratio (HR) was 0·32 (95% CI 0·16–0·63, p=0·0011) with 3-year local recurrence rates of 6% (5–8%) and 17% (10–26%) for patients who were negative and positive for circumferential resection margin, respectively. For plane of surgery achieved, HRs for mesorectal and intramesorectal groups compared with the muscularis propria group were 0·32 (0·16–0·64) and 0·48 (0·25–0·93), respectively. At 3 years, the estimated local recurrence rates were 4% (3–6%) for mesorectal, 7% (5–11%) for intramesorectal, and 13% (8–21%) for muscularis propria groups. The benefit of short-course preoperative radiotherapy did not differ in the three plane of surgery groups (p=0·30 for trend). Patients in the short-course preoperative radiotherapy group who had a resection in the mesorectal plane had a 3-year local recurrence rate of only 1%. In rectal cancer, the plane of surgery achieved is an important prognostic factor for local recurrence. Short-course preoperative radiotherapy reduced the rate of local recurrence for all three plane of surgery groups, almost abolishing local recurrence in short-course preoperative radiotherapy patients who had a resection in the mesorectal plane. The plane of surgery achieved should therefore be assessed and reported routinely. Medical Research Council (UK) and the National Cancer Institute of Canada.