Ⅰ期低位直肠癌单纯局部切除术与术后放疗的临床研究

The effect of local excision and adjuvant radiotherapy for patients with stage I rectal cancer

目的探讨Ⅰ期低位直肠癌局部切除术后加与不加放疗的疗效及失败模式。方法回顾分析2000-2008年间进行了局部切除术的77例I期低位直肠腺癌患者资料，其中41例为术后放疗。54例病理T1期，23例病理T2期。Kaplan-Meier法计算生存率并Logrank法检验，并行单因素预后分析。结果随访时间满5年者为40例。低危组患者单纯局部切除术与术后放疗5年无局部或区域复发生存率和总生存率均相似（86％：83％，X^2=0．29，P=0．588和100％：100％，×^2=1．50，P=0．221），高危组患者的5年无局部或区域复发生存率相似（80％：82％，X^2=0．27，P=0．600），但总生存率不同（92％：66％，X^2=4．64，P=0．031）。全组5年总生存率、无局部或区域复发生存率分别为83％、82％。单因素分析示病变大小、切缘状态、分化程度、肿瘤距肛缘距离及病理T分期影响5年总生存率。全组总复发率为29％，局部或区域失败占70％，若行挽救性根治性手术5年总生存率可达69％。结论I期低位直肠癌低危患者单纯局部切除术疗效可能较佳，高危者术后放疗价值待商榷；术后失败以局部复发多见，复发后行挽救性手术者有望长期生存。

Objective To evaluate the long-term survival and treatment failure patterns for patients with stage I adenocarcinoma in the lower rectum after local excision with or without adjuvant radiotherapy. Methods From Jan. 2000 to Dec. 2008, Seventy-seven patients with rectal cancer received local excision. Among them, 41 received adjuvant radiotherapy. Fifty-four patients were pathologically proven as T1, the other 23 as T2. Patients were classified into low-and high-risk groups according to tumor grade, the length of tumor, surgical margin, circumference ratio of tumor/rectum and T stage. Surival rates and prognostic factors were estimated by Kaplan - Meier method , and comparisons were made by the Logrank test. Results Fourty patients were followed up more than 5 years. The 5-year ]ocoregional recurrence-free survival （LRFS） and overall survival （OS） rates were 83% and 82% for the whole group. There were no significant differences in 5-year LRFS and OS rates in low-risk patients between local excision alone and local excision followed by adjuvant radiotherapy （ 86% ： 83% , X^2 = 0. 29, P = 0. 588 and 100% ： 100%, X^2 = 1.50, P = O. 221 ）. In high-risk patients, the 5-year LRFS were similar （ 80% ： 82% , X^2 = O. 27, P = 0. 600） , but the OS were significantly different （92%：66% ,X^2 = 4. 64,P = O. 031 ） between local excision alone and local excision followed by adjuvant radiotherapy. By univariate analysis, large tumor size, positive margin, poor differentiation, tumor located less than 5 cm from anal verge and pTz stage were poor prognostic factors for OS. The overall relapse rate for the whole group was 29% , and 70% of them were loeoregional relapse. The 5-year OS for patients treated with radical salvage surgery after local relapse was 69%. Conclusions For stage I lower-sited rectal cancer, low-risk patients can achieve good result after local excision alone. The role of adjuvant radiotherapy in high-risk patients needs further evaluation. Local relapse is the main cause of failure, and salvage surgery after local relapse can provide long-term survival.