Intramural and Mesorectal Distal Spread Detected by Whole-Mount Sections in the Determination of Optimal Distal Resection Margin in Patients Undergoing Surgery for Rectosigmoid or Rectal Cancer Without Preoperative Therapy
Intramural and Mesorectal Distal Spread Detected by Whole-Mount Sections in the Determination of Optimal Distal Resection Margin in Patients Undergoing Surgery for Rectosigmoid or Rectal Cancer Without Preoperative Therapy
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DOI：
10.1097/dcr.0b013e318233fc4a
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发表时间：
2011-12-01
影响因子：
3.9
通讯作者：
Ohta, Tamaki
中科院分区：
文献类型：
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作者：
Shimada, Yoshifumi;Takii, Yasumasa;Ohta, Tamaki
背景：目前日本大肠癌、直肠癌和肛门癌临床和病理研究通则规定，切除远端边缘在腹膜反射上方的直肠乙状结肠癌和直肠癌需要3cm远端切除边缘，切除远端边缘在腹膜反射下方的直肠癌需要2cm远端切除边缘。这些规则的适当性尚未得到证实。目的：我们的目的是评估日本规则的适当性。设计与背景：我们回顾性分析了在日本一家三级护理癌症中心接受手术的患者的手术和病理记录。患者：该研究包括381例连续一期至IV期直肠乙状结肠或直肠癌患者，术前未进行化疗或放疗。主要结局指标：我们研究了肠壁内和肠系膜远端扩散，使用全载切片测量远端扩散的最大长度。远端扩散被定义为远端扩散比日本一般规则中规定的远端切除边缘长。评估远端扩散和长远端扩散的危险因素。结果：381例患者中，325例（85.3%）无远端扩散，56例（14.7%）有远端扩散。381例患者中有48例（12.6%）远端扩散在日本一般规则规定的范围内，8例（2.1%）超过日本限制（远端扩散）。随着TNM分期，远端扩散的患病率增加（I期2.7%，II期5.3%，III期17.4%，IV期46.2%）。在I期和II期没有观察到远端长扩散，只有1.4%的III期患者和11.5%的IV期患者发现远端扩散。远端边缘高于腹膜反射的直肠乙状结肠癌或直肠癌患者的最大远端扩散范围为38 mm；直肠癌患者远端边缘低于腹膜反射，35毫米。多变量分析显示，淋巴结累及和远处转移是肿瘤远端扩散的独立危险因素；远端转移是长远端扩散的唯一独立危险因素。结论：日本规定远端切除切缘的通则适用于大多数未经术前化疗或放疗的乙状结肠直肠和直肠癌手术患者。在推荐的远端切除边缘以外进一步增加1 ~ 2cm可能有助于改善远处转移患者的局部控制。
BACKGROUND: The current Japanese general rules for clinical and pathologic studies on cancer of the colon, rectum, and anus state that a 3-cm distal resection margin is needed in resecting rectosigmoid cancer and rectal cancer with a distal edge above the peritoneal reflection, and 2 cm is needed for rectal cancer with a distal edge below the peritoneal reflection. The appropriateness of these rules has not been proved.OBJECTIVE: Our aim was to evaluate the appropriateness of the Japanese rules.DESIGN AND SETTING: We retrospectively analyzed surgical and pathology records of patients who underwent surgery at a tertiary care cancer center in Japan.PATIENTS: The study included 381 consecutive patients with stage I to IV rectosigmoid or rectal cancer without preoperative chemotherapy or radiotherapy.MAIN OUTCOME MEASURES: We investigated both intramural and mesorectal distal spread, using whole-mount sections to measure the maximum length of distal spread. Long distal spread was defined as distal spread longer than the distal resection margin stated in the Japanese general rules. Risk factors for both distal spread and long distal spread were evaluated.RESULTS: Of 381 patients, 325 (85.3%) had no distal spread and a total of 56 (14.7%) had distal spread. Distal spread was within the limits specified by the Japanese general rules in 48 of the 381 patients (12.6%) and beyond the Japanese limits (long distal spread) in 8 patients (2.1%). The prevalence of distal spread increased with TNM stage (stage I, 2.7%; stage II, 5.3%; stage III, 17.4%; stage IV, 46.2%). Long distal spread was not observed in stage I or II, was found in only 1.4% of patients with stage III disease and in 11.5% of patients with stage IV. The maximum extent of distal spread in patients with rectosigmoid cancer or rectal cancer with the distal edge above the peritoneal reflection was 38 mm; in patients with rectal cancer with the distal edge below the peritoneal reflection, 35 mm. Multivariable analyses showed that nodal involvement and distant metastasis were independent risk factors for distal spread; distant metastasis was the only independent risk factor for long distal spread.CONCLUSIONS: The Japanese general rules specifying the distal resection margin are appropriate for most patients who undergo surgery for rectosigmoid and rectal cancer without preoperative chemotherapy or radiotherapy. A further increase of 1 to 2 cm beyond the recommended distal resection margin may contribute to improved local control for patients with distant metastasis.