结直肠癌生物学外科新理念

New concept of biology-based surgery in colorectal cancer

结直肠癌外科手术治疗原则是切除肿瘤所在的肠管及相邻肠系膜。然而,肠系膜切除的最佳面积以及淋巴结清扫的最适宜范围仍存争议。结直肠癌淋巴结转移,目前主要有2种转移学说:Halsted转移模型和Fisher转移模型。Halsted转移模型认为肿瘤转移途径是从原发灶开始转移到肠旁淋巴结,再到中间淋巴结、中央淋巴结,最后发生远处转移。而Fisher转移模型则认为肿瘤转移可能随机发生在肿瘤早期。如果Fisher转移模型成立,那么传统结直肠癌手术的淋巴结清扫只是确定肿瘤分期的一个步骤,无法改善患者预后。最新的研究数据显示:结直肠癌淋巴结转移灶和肝转移灶源自原发肿瘤不同细胞亚群,循环肿瘤细胞及循环肿瘤脱氧核糖核酸可以在早期结直肠癌中被检测到。因此,结直肠癌诊断与治疗迈向生物学外科。生物学外科,是指在精确诊断的同时依据肿瘤基因分析或分子免疫检测结果施行外科治疗,通过改变手术时机、手术适应证、手术方式,达到改善患者预后和生命质量的目的。越来越多的生物学及临床研究证据用于指导结直肠癌的手术时机及手术方式。笔者以临床实践结合文献分析认为:结直肠癌生物学外科尚处于初期,随着基因测序技术的发展和结直肠癌发病机制的揭示,生物学外科势必将发挥更重要作用。

The surgical treatment principle of colorectal cancer has always been to remove the intestine with tumor locating and the adjacent mesentery.However,the optimal area of mesen-tery resection and the optimal range of lymph node dissection are still controversial.At present,there are two main theories of lymph node metastasis of colorectal cancer,including the Halsted metastasis model and the Fisher metastasis model.The Halsted metastasis model indicates that the tumor always metastasizing from the primary focus to the paraintestinal lymph nodes,then to the intermediate lymph nodes,central lymph nodes,and finally distant metastasis.The Fisher metas-tasis model,on the other hands,suggests that tumor metastasis may occurring in the early stage of tumor and may be random events.If Fisher′s model is established,lymph node dissection in traditional colorectal cancer surgery is only a step to determine the tumor stage,which is unlikely to affect the prognosis of cancer patients.The latest research data shows that lymph node metastasis and liver metastasis of colorectal cancer originating from different cell subsets of primary tumor,and the circulating tumor cells and its DNA can be detected in early stage of colorectal cancer.Therefore,the diagnosis and treatment of colorectal cancer has moved towards to the biology-based surgery.The biology-based surgery refers to the implementation of surgical treatment according to the results of tumor gene analysis or molecular immunoassay while making accurate diagnosis,so as to improve the prognosis and quality of life of patients by changing the timing,indications and methods of surgery.More and more biological and clinical research evidences are applied to guide the surgical timing and operation mode of colorectal cancer.Based on clinical practice and literature analysis,the authors believe that the biology-based surgery of colorectal cancer is still in its infancy,and with the development of gene sequencing technology and the revelation of the pathogenesis of colorectal cancer,the biology-based surgery will play a more important role in colorectal cancer.