新辅助联合治疗在低位直肠癌的应用及存在的问题

Neoadjuvant Combination Therapy in the Treatment for Locally Low Rectal Cancer and the Existing Problems

目的探讨新辅助联合治疗（术前放化疗）、全直肠系膜切除（total mesorectal excision,TME）在局部进展期低位直肠癌的治疗效果。方法2003年1月至2007年12月,将49例T3、T4期的低位直肠癌给予放疗总剂量44~50Gy,每次2Gy,每周5次,共5周 同时常规给予5-FU＋MMC持续静脉滴注,放疗结束后休息6周进行手术。手术均按TME操作规范进行。结果全部病例均按计划完成新辅助联合治疗,放化疗的副反应发生率为26.5%（3/49）,3例肿瘤完全消失,未行手术。46例施行了根治性切除术,40例为保肛手术,6例为腹会阴切除术,故全组保肛率为87.8%（43/49）。已切除的标本病理结果显示8例肿瘤消失（T0）,总肿瘤消失为11例。辅助治疗后TNM分期：T0N0M011例,T2N0M022例,T3N0M04例,T2N1M07例,T3N1M04例,T4N1M11例,共40例（81.6%）达到降期。全组均获随访,中位随访时间24（6~38）个月。1例（2.0%）局部复发,1例（2.0%）肝转移,无死亡,3例未行手术的患者随访8~26个月至今,仍未发现肿瘤复发。结论新辅助联合治疗与TME相结合能有效地提高肿瘤的切除率和保肛率,降低局部复发率,达到肿瘤降期的目的,进一步降低了术后复发的风险,其远期疗效尚待进一步观察。

Objective To explore the therapeutic efficacy of neoadjuvaat combination therapy （ preoperative radiotherapy and chemotherapy） in the treatment of locally low reetal cancer （LLRC）. Method 49 pa- tients with T3 and T4 LLRC were treated by preoperative radiotherapy and chemotherapy, 2 Gy daily up to 44 50Gy in 5 weeks concomitantly with continuous infusion of 5-FU ＋ MMC. In all patienls, the surgery was carried out under the rule of TME technique. Results Neoadjuvant combination therapy had been completed in all pa- tients uneventfully, among them, 3 patients were resulted in complete response （CR）, so surgery was given up and the remaining 46 patients were carried out with curative resection, 40 patients with SSR and 6 with APR. The overall sphincter presevvation was achieved in 87.8%. In pathological findings, there were ToNoM0 （CR） in 11, T2N0M0 in 22, T3N0M0 in 4, T2N1M0 in 7, T3N1 M0 in 4 and 1 case of T4. All patients were followed up for 6 38 months with median of 24 months, no death, 1 local recurrence occurred and 1 suffered from liver metastasis but still alive with an overall recurrence rate of 2.0%. Conclusion Neoadjuvant combination therapy com- bined with TME have showed its high efficacy in increase of the resectability and sphincter preservation, tumor down-staging, and lower local recurrence rate to achieve the objective of further reducing the risk of recurrence. But its long-term survival improvement is still in observation.