cT3N0 rectal cancer: Potential overtreatment with Preoperative chemoradiotherapy is warranted
cT3N0 rectal cancer: Potential overtreatment with Preoperative chemoradiotherapy is warranted
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DOI：
10.1200/jco.2007.13.5434
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发表时间：
2008-01-20
影响因子：
45.3
通讯作者：
Pucciarelli, Salvatore
中科院分区：
文献类型：
--
作者：
Guillem, Jose G.;Diaz-Gonzalez, Juan A.;Pucciarelli, Salvatore
目的 虽然联合治疗 (CMT) 是 T3 和/或淋巴结 (LN) 阳性直肠癌的首选治疗方法，但 2004 年发表的德国直肠癌研究表明，18% 经直肠内超声 (ERUS) 认为适合术前 CMT 的患者可能被过度分期。由于数据还表明，全直肠系膜切除后的 LN 阴性直肠癌可能不需要放疗，因此考虑对 cT3N0 子集省略放疗是合理的。因此，我们确定了 CMT 前 ERUS 或磁共振成像 (MRI) 分期的准确性，以探讨非术前 CMT 方法治疗 cT3N0 疾病的有效性。 患者和方法 188 名 ERUS-/MRI 分期 T3N0 直肠癌患者接受了术前 CMT（基于氟尿嘧啶和 45-50.4 Gy），随后进行根治性切除。确定病理完全缓解率 (pCR) 和直肠系膜淋巴结受累率。结果 肿瘤位于距离肛缘中位数 5 厘米处。 143 名患者（76%）接受了保留括约肌手术。总体 pCR 为 20%，41 名患者 (22%) 直肠系膜淋巴结病理呈阳性。 LN 阳性发生率随 T 分期显着增加：ypT0，3%； ypT1，7%； ypT2，20%； ypT3-4, 36% ( P =.001)。 结论 术前 ERUS/MRI 对中远端 cT3N0 直肠癌分期的准确性有限，因为尽管进行了 CMT，仍有 22% 的患者未检测到直肠系膜淋巴结受累。因此，ERUS/MRI分期T3N0直肠癌患者应继续接受术前CMT。尽管 18% 的患者可能被过度分期并因此过度治疗，但我们的数据表明，更多的人可能被低估并需要术后 CMT，这与显着较差的局部控制、更高的毒性和更差的功能结果相关。
Purpose Although combined-modality therapy (CMT) is the preferred treatment for T3 and/or lymph node (LN)-positive rectal cancer, the German rectal cancer study published in 2004 demonstrated that 18% of patients deemed suitable for preoperative CMT by endorectal ultrasound (ERUS) may be overstaged. Because data also suggest that LN-negative rectal cancer after total mesorectal excision may not require radiotherapy, it is reasonable to consider omitting radiotherapy for the cT3N0 subset. We therefore determined the accuracy of pre-CMT ERUS or magnetic resonance imaging (MRI) staging, to explore the validity of a nonpreoperative CMT approach for cT3N0 disease.Patients and Methods One hundred eighty-eight ERUS-/MRI-staged T3N0 rectal cancer patients received preoperative CMT ( fluorouracil based and 45-50.4 Gy) followed by radical resection. Rates of pathologic complete response (pCR) and mesorectal LN involvement were determined.Results Tumors were located a median of 5 cm from the anal verge. Sphincter-preserving surgery was performed in 143 patients ( 76%). Overall pCR was 20%, and 41 patients (22%) had pathologically positive mesorectal LNs. The incidence of positive LNs significantly increased with T stage: ypT0, 3%; ypT1, 7%; ypT2, 20%; ypT3-4, 36% ( P =.001).Conclusion The accuracy of preoperative ERUS/MRI for staging mid to distal cT3N0 rectal cancer is limited because 22% of patients have undetected mesorectal LN involvement despite CMT. Therefore, ERUS-/MRI-staged T3N0 rectal cancer patients should continue to receive preoperative CMT. Although 18% may be overstaged and therefore overtreated, our data suggest that an even larger number would be understaged and require postoperative CMT, which is associated with significantly inferior local control, higher toxicity, and worse functional outcome.