全直肠系膜切除术联合侧方淋巴结清扫术治疗中低位直肠癌侧方淋巴结转移的疗效  

The efficacy of total mesorectal excision combined with lateral lymph node dissection in the treatment of lateral lymph node metastasis in middle and low rectal cancer

作　　者：韩晓东 李衎 武亚超 姜玉娟 刘春明 黄天臣[1] HAN Xiaodong;LI Kan;WU Yachao;JIANG Yujuan;LIU Chunming;HUANG Tianchen(Department of General Surgery,Anyang Cancer Hospital,Henan Anyang 455000,China;Department of Colorectal Surgery,National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing100021,China)

机构地区：[1]安阳市肿瘤医院普通外科,河南安阳455000 [2]国家癌症中心/国家肿瘤临床医学研究中心/中国医学科学院北京协和医学院肿瘤医院结直肠外科,北京100021

出　　处：《现代肿瘤医学》2023年第24期4576-4581,共6页Journal of Modern Oncology

基　　金：中国癌症基金会北京希望马拉松专项基金(编号:LC2017A19);国家重点研发计划“重大慢性非传染性疾病防控研究”重点专项(编号:2019YFC1315705)。

摘　　要：目的:探讨侧方淋巴结清扫术(lateral lymph node dissection,LLND)对侧方淋巴结(lateral lymph node,LLN)转移直肠癌患者的治疗价值和LLN转移位置对生存预后的影响。方法:自2015年01月至2020年01月,回顾性收集分析在中国医学科学院肿瘤医院行全直肠系膜切除术(total mesorectal excision,TME)+LLND的临床怀疑LLN转移的中低位直肠癌患者与同时期行TME根治性切除的直肠癌患者的资料。根据手术方式,分为TME+LLND组(n=129)与TME组(n=362)。倾向得分匹配后,两组各有125例患者成功匹配。本研究的长期随访终点是3年局部复发率(local recurrence,LR)和3年无复发生存率(recurrence-free survival,RFS)。结果:TME+LLND组手术时间明显长于TME组(356.1 vs 244.8 min,P<0.001),而术后并发症并无明显增加(16.0 vs 12.0,P=0.362)。预后方面,TME+LLND与TME两组间3年LR率无明显差异(10.7%vs 8.8%,P=0.817),然而,TME+LLND组患者术后远处转移明显较高(15.2%vs 7.2%,P=0.044)。根据淋巴结状态与分期对患者进行亚组分析,髂内与闭孔转移患者3年RFS与N2期患者相似(57.1%vs 55.3%,P=0.613)。髂外与髂总转移患者预后与IV期患者3年RFS相似(49.1%vs 22.5%,P=0.302),且显著劣于N2期患者(49.1%vs 55.3%,P=0.044)。结论:LLN转移直肠癌患者可以通过LLND获得令人满意的局部控制效果。局限于髂内和闭孔淋巴结转移的患者可以通过LLND取得生存获益,可视作局部淋巴结转移进行管理与治疗。髂外和髂总转移患者通过LLND治疗效果不理想,预后劣于N2期,略优于IV期患者,此类患者应谨慎选择LLND。Objective:To evaluate the efficacy of lateral lymph node dissection(LLND)for rectal cancer patients with LLN metastasis and investigate the impact of LLN metastasis on prognosis.Methods:From January 2015 to January 2020,the data of middle-low rectal cancer patients with clinical evidence of LLN metastasis who underwent total mesorectal excision(TME)+LLND and rectal cancer patients who underwent radical resection of TME at the same time were retrospectively collected and analyzed.According to the surgical method,all patients were divided into TME+LLND group(n=129)and TME group(n=362).125 matched pairs were selected and divided into the TME group and TME+LLND group for evaluation after propensity matching.Long-term endpoint of this study was 3-year local recurrence rate(LR)and 3-year recurrence-free survival(RFS).Results:The operation time was significantly longer in the TME+LLND group than in the TME group(356.1 vs 244.8 min,P<0.001),and there was no significant increase in postoperative complications(16.0 vs 12.0,P=0.362).No significant difference was observed in the 3-year LR rate between the TME group and the TME+LLND group(10.7%vs 8.8%,P=0.817),however,the rate of distant metastasis after TME+LLND was significantly higher(15.2%vs 7.2%,P=0.044).Subgroup analysis was performed according to lymph node status and stage,3-year RFS in patients with internal iliac and obturator metastases was similar to those in patients with N2stage(57.1%vs 55.3%,P=0.613).3-year RFS of patients with external iliac and common iliac metastasis was similar to those of patients with stage IV(49.1%vs22.5%,P=0.302)and significantly worse than those with N2stage(49.1%vs 55.3%,P=0.044).Conclusion:Patients with LLN metastasis can achieve satisfactory local control after LLND.Patients limited to internal iliac and obturator lymph node metastasis appear to achieve a survival benefit from LLND and can be regarded as regional lymph node metastasis.Patients with external and common iliac lymph node metastasis have a poor prognosis that is signifi

关 键 词：直肠癌 侧方淋巴结 侧方淋巴结清扫术 预后 

分 类 号：R735.37[医药卫生—肿瘤]