如何对直肠癌新辅助治疗后临床完全缓解患者成功实施非手术治疗:系统综述

How to successfully perform non- operative management for rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review

当前局部晚期直肠癌（LARC）标准治疗方案为新辅助放化疗（NCRT），4-8周后进行根治性手术治疗。NCRT能够导致肿瘤降期甚至导致肿瘤细胞在影像学[MRI、PET/CT以及直肠腔内超声（TU）]、临床检查[以直肠指检（DRE）为主]及肠镜±活检完全消失，即达到临床完全缓解（cCR）。对于该部分患者，目前治疗仍以根治性手术为主，但有学者提出对cCR患者可以进行非手术治疗：定期严密监测和随访，如患者能够长期维持cCR，则无需手术治疗，仅定期复查和随访即可；如果患者局部复发（LR）和（或）远处转移（DM）则根据具体情况进行补救治疗，包括根治性切除、放化疗等。非手术治疗的优势在于使部分患者避免了手术相关并发症、肛门切除及结肠造瘘，提高了患者生活质量，并且远期预后可媲美根治性手术，但局部复发风险较高，其原因在于临床对cCR的判断并不完全准确、可靠。因此，如何提高临床对于初始cCR的判断准确率以及如何监测患者是否长期维持cCR成为非手术治疗成功的关键。本文就如何提高LARC患者新辅助治疗后非手术治疗成功率进行系统综述。

The current treatment for locally advanced rectal cancer （LARC） is neoadjuvant chemoradiotherapy （NCRT） followed by radical surgery 4-8 weeks later. NCRT can lead to tumor downstaging or even to all tumor cell disappearance by imaging [MRI, PET/CT, and transrectal ultrasound （TU）], clinical examination such as digital rectal examination, and endoscopy ± biopsy, which means clinical complete response （cCR）. For those with cCR, the traditional treatment is radical surgery, but some authors have proposed a non-operative management： a wait-and-see policy with strict selection criteria, follow-up and salvage treatments achieves outcomes at least as good as radical surgery, which has dramatic priorities such as avoiding complications and colostomy. However, some study report this new method increased the risk of local recurrence （LR）. The reason for that is mainly because of poor assessment accuracy of initial cCR and the schedule of follow-up for detection of sustained cCR. We therefore review all literature related to cCR, with highlights on how to more successfully perform a non-operative management for LARC patients with a cCR after NCRT.