Ⅱ、Ⅲ期上段直肠癌根治术后放疗意义探讨

Significance of postoperative radiotherapy for stage Ⅱ / Ⅲ upper rectal cancer

目的 探讨Ⅱ、Ⅲ期上段直肠癌根治术后辅助放化疗的价值.方法 2000-2010年本院共收治3 995例直肠癌患者,从中筛选出符合下述条件者进行回顾分析：（1）根治性手术;（2）术前结肠镜检查显示肿瘤下界距肛缘10-16 cm;（3）术后病理为T3-T4或N1-2 M0期（AJCC 7版分期）;（4）病理类型为腺癌.结果 共入组547例患者.5年样本数为249例.全组5年OS、DFS、LRFS、DMFS分别为79.0％、76.8％、94.0％、80.1％.采用倾向评分配比法按1∶1平衡基线特征后,术后同期放化疗与未放化疗各155例.将pT4b期、有癌旁结节、淋巴结转移较多（N2期）者列为高危组,术后同期放化疗5年LRFS和OS均高于未放疗者（96.3％、82.0％,P=0.0.044;81.6％、59.1％,P=0.019）.结论 Ⅱ、Ⅲ期上段直肠癌患者根治术后总体预后较好,术后同期放化疗仍可进一步降低LRR;尤其对伴有高危因素者,术后放化疗可显著提高局部和长期疗效.

Objective To investigate the value of postoperative adjuvant chemoradiotherapy （CRT） in the treatment of stage Ⅱ/Ⅲ upper rectal cancer.Methods A total of 3995 patients with rectal cancer were admitted to our hospital from 2000 to 2010.Among them,patients who were pathologically diagnosed with adenocarcinoma and underwent radical surgery were enrolled as subjects for retrospective analyses.Moreover,all selected patients had the lower margin of the tumor located within 10-16 cm from the anal verge,as determined by a colonofiberscope before surgery,and were pathologically staged as T34 or N0-2 M0 after surgery,according to the 7th edition of American Joint Committee on Cancer tumor-node-metastasis staging system.Results A total of 547 patients were enrolled as subjects.The 5-year sample size was 249.In all patients,the 5-year overall survival （OS）,disease-free survival,local recurrence-free survival （LRFS）,and distant metastasis-free survival rates were 79.0%,76.8%,94.0%,and 80.1%,respectively.One hundred and fifty-five patients were enrolled into either postoperative concurrent CRT group or postoperative non-CRT group,with the baseline characteristics balanced between the two groups by the propensity-score matching method （1 ∶ 1）.Patients who were staged as pT4b and had paracancerous nodules and lymph node metastases （stage N2） were enrolled into high-risk group.In the high-risk group,patients treated with postoperative CRT had significantly higher LRFS and OS rates than those treated with only surgery （96.3% vs.82.0%,P=0.044;81.6% vs.59.1%,P=0.019）.Conclusions Radical surgery achieves a good prognosis in patients with stage Ⅱ/Ⅲ upper rectal cancer,and postoperative CRT can further reduce the locoregional recurrence rate.Particularly,postoperative CRT/RT can substantially improve local and long-term outcomes in patients with high-risk factors.