直肠癌骶前复发的流行病学研究与外科治疗现状

Epidemiological research status and surgical treatment strategy of presacral recurrent rectal cancer

直肠癌骶前复发是直肠癌术后局部复发的一种特殊类型,指复发肿瘤累及骶骨前方软组织和(或)骶骨骨性结构。骶前复发是直肠癌局部复发的常见形式,占局部复发类型比例的15.63%~41.67%。根据文献报道,骶前局部复发率在2.8%~4.8%之间。直肠癌骶前复发与肿瘤临床分期、病理学类型、手术方式、(新)辅助放化疗、肿瘤距肛门距离、环周切缘阳性、淋巴结转移以及单侧侧方淋巴结清扫等临床因素有关。术后定期复查是早期发现直肠癌骶前复发的重要措施。CT和MRI的诊断是骶前复发的重要检查方法。骶前复发往往合并其他部位局部复发和远隔脏器转移,我们将骶前复发分为以下3种情况:(1)骶前复发合并远处转移;(2)骶前复发合并盆侧壁或侧方淋巴结转移、或其他脏器及吻合口复发;(3)单纯骶前复发。根据多学科团队讨论评估,针对不同类型,治疗方案和手术方式各异。如肿瘤未侵犯到骶(S)2~3以上关节面,复发灶联合骶尾骨的切除应作为首选;如骶前复发合并前向型复发,可以联合盆腔脏器切除;如合并盆侧壁复发,可以行髂内动静脉切除以及侧方淋巴结、腹主动脉周围淋巴结清扫。R0切除可以提高患者术后5年生存率。

Presacral recurrence,a special recurrence type in rectal cancer after surgical treatment,refers to recurrent cancer invading the presacral soft tissue or the bony structure of sacrum.It is also a major constituent of recurrent rectal cancer(15.63%to 41.67%).Reports show that presacral recurrence rate is about 2.8%to 4.8%,and it is associated with clinic staging,pathological type,surgical approach,(neo)adjuvant radiochemotherapy,tumor distance from the anus,positive circumferential margin,lymph node metastasis,and unilateral lateral lymph node dissection.CT and MRI are important for the detection of presacral recurrence.Presacral recurrence is always combined with local recurrence in other parts and distant organ metastasis.Therefore,we divide that into the following 3 types:1)presacral recurrence with distant metastasis;2)presacral recurrence with pelvic wall or lateral lymph node metastasis,or with recurrence of pelvic organs or anastomosis;and 3)simple presacral relapse.According to MDT evaluation.We adopt corresponding treatment scheme and surgical approach depending on the types mentioned above.When tumor recurred in the sacrum and located lower than S2/3 articular surface,then resection of recurrent tumor combined with sacrococcygeal should be the treatment of choice.For presacral recurrence with anterior invasion,combined total pelvic exenteration were available.For presacral recurrence with lateral pelvic wall invasion,internal iliac arteriovenous resection and lateral lymph node dissection and para-aortic lymph node dissection should be carried out.R0 resection may improve the 5-year overall survival rate of these patients.