Determining the Need for Radical Surgery in Patients With T1 Rectal Cancer
Determining the Need for Radical Surgery in Patients With T1 Rectal Cancer
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DOI：
10.1001/archsurg.2011.76
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发表时间：
2011-05-01
影响因子：
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通讯作者：
Bordeianou, Liliana
中科院分区：
文献类型：
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作者：
Salinas, Harry M.;Dursun, Abdulmetin;Bordeianou, Liliana
假设：在直肠癌患者的现代术前分期时代，通过肿瘤的组织学特征和术前影像学可以可靠地预测淋巴结转移。局部切除可以安全地提供给恶性淋巴结风险较低的患者。设计：我们回顾了109例连续的术前影像学结果提示T1N0或T2N0疾病的患者，他们接受了全肠系膜切除术。所有患者术前均行直肠内超声检查或磁共振成像和计算机断层扫描，伴或不伴正电子发射断层扫描。最终病理检查确定27例患者为T3病变。对其余82例患者的病史、体格检查结果、放射学和病理学资料进行评估，以确定淋巴结阳性的预测因素。环境：三级保健转诊中心。患者：术前影像学提示T1N0或T2N0直肠癌患者。主要观察指标：评价不同临床和病理肿瘤特征对T1和T2直肠癌伴阴性淋巴结的预测作用。背景：与根治性切除相比，局部切除T1和T2直肠癌的发病率较低。然而，局部切除后的复发率较高，可能是由于未切除的淋巴结转移。关于淋巴结转移预测因子的报道在文献中仍然不一致。虽然局部切除可能适用于某些直肠癌，但选择标准尚不清楚。结果：35例T1患者中有4例（11%）淋巴结呈阴性，47例T2患者中有13例（28%）淋巴结呈阳性。在单因素分析中，唯一有意义的预测因素是浸润深度：65例淋巴结阴性患者中有24例（37%），17例淋巴结阳性患者中有13例（76%）肿瘤浸润粘膜下层的下三分之一及以上（P= 0.02）。在考虑浸润深度（粘膜下三分之一及以上）、大小、与肛门边缘的距离、分化、淋巴血管和小血管浸润的逻辑回归分析中，只有浸润深度仍然是一个显著的预测因子。结论：总的来说，89%的T1患者（35例中的31例）和72%的T2患者（47例中的34例）接受了不必要的根治性切除术。直肠内超声或磁共振成像和计算机断层扫描，无论有无正电子发射断层扫描，术前分期都不能可靠地识别这些患者。此外，侵袭性疾病的组织学标记也没有帮助。因此，局部切除T2直肠癌是不合理的。局部切除应该只提供给浅表T1肿瘤患者，他们将坚持积极的术后监测。
Hypothesis: In the era of modern preoperative staging of patients with rectal cancer, lymph node metastases can be reliably predicted by the histological features of the tumor and preoperative imaging. Local resection can then be safely offered to the patients who are at low risk of having malignant lymph nodes.Design: We reviewed the records of 109 consecutive patients with preoperative imaging results suggestive of T1N0 or T2N0 disease who underwent total mesorectal excision. All patients underwent preoperative endorectal ultrasonography or magnetic resonance imaging and computed tomography, with or without positron emission tomography. Final pathologic investigation identified T3 disease in 27 patients. History, physical examination results, and radiologic and pathologic data were evaluated for predictors of positive nodes in the remaining 82 patients.Setting: Tertiary care referral center.Patients: Patients with preoperative imaging suggestive of T1N0 or T2N0 rectal cancer.Main Outcome Measures: To evaluate different clinical and pathologic tumor features as predictors of positive lymph nodes in T1 and T2 rectal cancers with negative radiographic nodes.Background: Local resection of T1 and T2 rectal cancer results in lower morbidity compared with radical resection. However, recurrence rates after local resection are higher, likely owing to unresected nodal metastasis. Reports on predictors of lymph node metastasis remain inconsistent in the literature. Although local resection may be appropriate for some rectal cancers, selection criteria remain unclear.Results: Despite indications of negative nodes on radiographic examination, 4 of 35 patients with T1 disease (11%) and 13 of 47 with T2 disease (28%) had positive nodes. On univariate analysis, the only significant predictor was depth of invasion: 24 of 65 patients with negative nodes (37%) vs 13 of 17 patients with positive nodes (76%) had tumors invading the lower third of the submucosa and beyond (P=.02). On logistic regression analysis accounting for depth of invasion (lower third of the submucosa and beyond), size, distance from anal verge, differentiation, and lymphovascular and small-vessel invasion, only depth of invasion remained a significant predictor.Conclusions: In all, 89% of patients with T1 disease (31 of 35) and 72% of those with T2 disease (34 of 47) underwent unnecessary radical resection. Endorectal ultrasonography or magnetic resonance imaging and computed tomography, with or without positron emission tomography, for preoperative staging could not identify these patients reliably. In addition, histologic markers of aggressive disease were not helpful. Thus, local resection for T2 rectal cancer is not justified. Local resection should be offered only to patients with superficial T1 tumors who will adhere to aggressive postoperative surveillance.