一例低位直肠癌的循证治疗

Evidence-Based Treatment of a Patient with Lower Rectal Cancer

目的为一例确诊的低位直肠癌患者制定循证治疗方案。方法针对低位直肠癌的治疗问题,提出问题,检索Cochrane Library(2009年第2期)、PubMed(1966～2009.5)、TRIP Database、SUM search、中国生物医学文献数据库(1989～2009.5)、中国科技期刊数据库(1989～2009.5)、中国期刊全文数据库(1994～2009.5),收集相关证据,对所获证据进行评价,并结合医生的经验及患者的愿望制定治疗方案。结果共纳入24篇系统评价/Meta分析和1个临床指南。结果显示:术前化放疗能降低直肠癌术后的局部复发率和病死率。与单纯术前放疗相比,术前化放疗联合可提高II和III期直肠癌疾病病理学反应和局部病变的控制,减低局部复发的风险;与术后放化疗相比,术前化放疗能降低局部复发的风险;与单纯手术相比,术后放疗并不能提高II和III期直肠癌患者的生存率,而术后化疗或术后放化疗却能提高患者术后的生存率;与传统的直肠癌外科根治术相比,全直肠系膜切除术(TME)能降低直肠癌术后局部复发率,从而提高患者的生存率和生活质量;经腹腔镜全直肠系膜切除术和开腹全直肠系膜切除术治疗直肠癌在病死率和复发率方面无差异。根据以上证据结合患者意愿,对该例患者术前采用5-Fu+LV方案化疗并联合放疗1月,后行开腹直肠癌根治术。术后半月患者恢复良好出院,出院后继续采用5-Fu+LV方案化疗6次。术后2年至今未见复发。结论术前化放疗、术后化疗和术后放化疗能使直肠癌患者受益,TME是直肠癌的标准手术方式,但远期预后尚需要更长时间的随访观察。

Objective To find individualized evidence-based treatments for a patient with lower rectal cancer. Methods Based on the clinical questions raised, evidence was collected and critically assessed. Patient preferences and physician clinical experience were also taken into consideration in the decision-making treatment. Results Twenty- four systematic reviews or meta analyses and 1 clinical guideline were included. The evidence showed that preoperative chemoradio- therapy reduces risk of local recurrence and death from rectal cancer compared to preoperative radiotherapy alone. Preoperative combined chemoradiotherapy, enhanced pathological response and improved local control in the resectable stage II and III rectal cancer. Preoperative chemoradiotherapy reduced the risk of local recurrence as compared with postoperative chemoradiotherapy. Postoperative radiotherapy alone did not improve survival for the patients with resected stage II and stage III rectal cancer, whereas either chemotherapy alone or combined chemotherapy and radiotherapy improved survival in comparison with observation. As compared with conventional radical surgery, total mesorectum excision （TME） resulted in lower postoperative local recurrence rate and higher survival rate. No significant differences in terms of disease-free survival rate, local recurrence rate, mortality, and morbidity were found between laparoscopic and open total mesorectal excision. Conclusion The patients with lower rectal cancer might benefit from preoperative chemoradiotherapy, postoperative chemotherapy, and chemoradiotherapy. TME is the standard rectal cancer surgery. However, long-term prognostic benefits need to be confirmed by further follow-up.