直肠癌术中放疗.ppt

Long termoutcomesafterNaturalOrificeSpecimenExtractionversusconventionallaparoscopy assistedsurgeryforrectalcancer amatchedcase controlstudy Introduction 01 MaterialsandMethods 02 IndicationsandPreoperativeEvaluation 03 Conclusion 04 目录 Abstract 摘要 Thetreatmentofrectalcancerhasevolvedfrombeingsolelyasurgicalendeavortoamultidisciplinarypractice Despitetheimprovementinoutcomesconferredbytheadditionofchemoradiationtherapytorectalcancertreatment advancesinsurgicaltechniquehavesignificantlyincreasedratesofsphincterpreservationandtheavoidanceofapermanentstoma Inrecentyears intersphinctericresectionforlowrectalcancerhasbeenofferedandperformedinpatientsasanalternativetoabdominoperinealresection Anoverviewofthisprocedure includingindications oncologicalandfunctionalresultsbasedoncurrentliterature ispresentedherein 直肠癌的治疗已从单纯的外科手术演变为多学科的实践 尽管通过在直肠癌治疗中增加放化疗所带来的结果有所改善 但手术技术的进步显着增加了括约肌保留率和避免了永久性造口 近年来 低位直肠癌的括约肌间切除术已作为腹腔镜会阴切除术的替代方法提供给患者 本文介绍了该程序的概述 包括适应症 基于当前文献的肿瘤学和功能结果 Researchbackground statusandsignificance 研究背景 现状及意义 1 Therehasbeenanevolutioninthetreatmentofrectalcancerinrecenttimes Afewdecadesago rectalcancertreatmentwassolelyasurgicalendeavour Nowadays ithasevolvedintotherapyinvolvingseveraldisciplines Nevertheless surgeryremainsthecornerstoneofcurativetreatment Theincorporationandwidespreaduseoftotalmesorectalexcision TME asthestandardmodeofsurgicalresectionofadenocarcinomaoftherectumhasbeenthemostimportantsurgicaldevelopmentinoutcomesimprovementforthisdisease SupervisedteachingofTME aswellasthedetailedpathologicalauditofresectedspecimens hasalsoledtobetteroncologicalresults Advancesinsurgicaltechniquewiththeuseofeitheradvancedstaplingormanualcoloanalanastomoseshaveallowedforachievingcontinuityofthegastrointestinaltractatlevelsclosertotheanalvergethanthoseachievedhistorically Theadventofadjuvantandneoadjuvantchemoradiotherapyhasalsoincreasedlocalcontrolofdiseaseandinsomeinstanceshasledtoincreasedsurvival 近来在治疗直肠癌方面有了进展 几十年前 直肠癌治疗只是外科手术 现在 它已经演变成涉及多个学科的治疗 尽管如此 手术仍然是治愈性治疗的基石 全直肠系膜切除术 TME 作为直肠腺癌手术切除标准模式的纳入和广泛应用一直是该疾病预后改善最重要的手术方式 TME的监督教学以及对切除标本的详细病理学检查 也导致了更好的肿瘤学结果 采用先进的吻合器或手动结肠吻合术的手术技术的进步已经实现了胃肠道的连续性 其接近肛门边缘的水平比那些历史上的水平要高 辅助和新辅助化放疗的出现也增加了对疾病的局部控制 并且在某些情况下导致了生存率的增加 1 Researchbackground statusandsignificance 研究背景 现状及意义 Surgeryforrectalcancerinrecentyearshasfocusedonanatomicandfunctionalpreservationofthesphincterwithoutcompromisingoncologicaloutcomes Radicalsurgicaltreatmentofcancersinlowerthirdoftherectumhastraditionallyincludedlowanteriorresection LAR andcoloanalanastomosis andabdominoperinealresection APR Historically thedecision makingforsphinctersavingprocedureshasbeenrelatedtothedistancebetweenthetumorandtheanalsphinctercomplex Inthe1980s adistalmarginof5cmwasrequired Intheensuingdecades the 2 cm rule wasacceptedandadopted Thisrulehasbeenchallenged however andcurrentlyadistalmarginof1cmisacceptedasbeingappropriateforoptimaloncologicoutcome Thisprovidesagreaterproportionofrectalcancerpatientswiththepossibilityofsphincterpreservation Recently adequacyofthecircumferentialresectionmarginisbeingconsideredofequal ifnotgreater importanceintheriskoflocalrecurrenceofrectalcancer Inrecentyears intersphinctericresection ISR hasbeenproposedtooffersphincterpreservationinpatientswithverylowrectallesions asanalternativetoAPR Ofnote APRhasconsistentlyhadhigherratesoflocalrecurrencerates upto22 comparedwithLAR 近年来对直肠癌的手术主要集中在括约肌的解剖和功能保存而不影响肿瘤学结果 传统上 直肠下三分之一癌症的根治性手术治疗包括低位前切除术 LAR 和结肠吻合术以及腹会阴联合切除术 APR 从历史上看 括约肌手术的决策与肿瘤与肛门括约肌复合体之间的距离有关 在20世纪80年代 需要5厘米的远端边缘 在随后的几十年中 2厘米规则 被接受并通过 然而 这一规则已受到挑战 目前1厘米远端边缘被认为适合最佳肿瘤学结果 这为直肠癌患者提供了更大比例的保留括约肌的可能性 最近 圆周切除范围的充分性被认为与直肠癌局部复发风险的重要性相同 如果不是更大的话 近年来 作为APR的一种替代方法 已提出括约肌间切除术 ISR 为直肠病变非常低的患者提供括约肌保护 值得注意的是 与LAR相比 APR一直具有较高的局部复发率 高达22 2 MaterialsandMethods 方式方法 AliteraturesearchforrelevantarticlesintheEnglishlanguageassociatedwithintersphinctericresection ISR between2000and2012wasundertaken Allarticlesregardingintersphinctericresectionwerecaseseriesfromsingleinstitutionsorsystematicreviews Casereportswereexcludedfromthisoverview Medlinewasthesearchengineutilized 2 1 ISR Definition SchiesselandcolleaguesinitiallydescribedthetechniqueofISR DuringISR atransanaldivisionoftherectum withremovalofpartortheentireinternalanalsphincter IAS afterTME isperformed thusobtaininganadequatedistalmargin Restorationofbowelcontinuityisachievedbyperformingahand sewncoloanalanastomosis 在2000年至2012年期间进行了与英语间关节切除术 ISR 相关的英文文献的文献检索 所有关于括约肌切除术的文章都是来自单一机构或系统评论的病例系列 病例报告被排除在本概述之外 Medline是利用的搜索引擎 2 1 ISR 定义 Schiessel及其同事最初描述了ISR的技术 在ISR期间 进行直肠的经肛门分割 并在TME后切除部分或全部肛门内括约肌 IAS 从而获得足够的远端边缘 恢复肠道连续性是通过手工缝合的结肠吻合术来实现的 3 IndicationsandPreoperativeEvaluation 适应症和术前评估 WhenplanningforproctectomywithISRforrectalcancer carefulpatientselectionisparamount Tumorheight itsrelationshiptoeachcomponentofthesphinctercomplex andthepresenceornotofregionallymphnodeordistalmetastasesneedstobeevaluated Forthisreason acombinationofacarefulphysicalexamandimagingmodalitiesisutilized Preoperativeevaluationbythesurgeonbymeansofdigitalrectalexamandrigidproctoscopyprovidesinformationregardingthelevelofthedistaledgeoftumourrelativetothe analanatomiccomponentofinterest whichvariesamongexpertsintheliterature 13 14 Analanatomiccomponentsofinterestincludetheanalverge thedentatelineandtheanorectalring SpecializedimagingisrequiredtostudytherelationshipoftheIASandexternalanalsphincter EAS withthetumour Invasionofthesestructuresbythelesioncanalsobedepicted Endorectal endoanalultrasoundandmagneticresonanceimaging MRI areperformedforthisreason Inaddition high resolutionMRIisaccurateatestimatingthecircumferentialmargin withanoverallaccuracyof88 15 Additionalcross sectionalimagingevaluatesthepresenceofdistalmetastases 当计划采用ISR进行直肠癌切除术时 慎重选择患者是非常重要的 需要评估肿瘤高度 与括约肌综合征各组分的关系 是否存在区域淋巴结或远端转移灶 出于这个原因 利用了仔细的体格检查和成像模式的组合 外科医生通过数字直肠检查和硬性直肠镜检查进行术前评估 提供了关于肿瘤远端边缘相对于 感兴趣的肛门解剖部位 的水平的信息 这在文献 13 14 中各专家之间有所不同 感兴趣的肛门解剖部件包括肛门边缘 齿状线和肛门直肠环 需要专门的成像来研究IAS和肛门外括约肌 EAS 与肿瘤的关系 也可以描绘病变侵入这些结构 由于这个原因 进行了直肠 肛门内超声和磁共振成像 MRI 另外 高分辨率MRI在估计圆周边缘时是准确的 总体准确率为88 15 额外的横断面影像评估远端转移灶的存在 3 IndicationsandPreoperativeEvaluation 适应症和术前评估 ESPRIT PM Capon MUSIC InclusioncriteriaforperformanceofISRincludethefollowing i tumourslocated30mmfromanalverge ii tumourslocated15mmfromdentateline iii tumourslocated1cmfromanorectalring iv localspreadrestrictedtotherectalwallortheIAS v adequatepreoperativesphincterfunctionandcontinence vi absenceofdistantmetastases ContraindicationstotheperformanceofISRarethepresenceoffecalincontinence T4lesions undifferentiatedtumors aswellastumorsinvadingthepuborectalisandtheexternalanalsphincter EAS 执行情监侦的纳入标准包括以下内容 i 距离肛门边缘30mm处的肿瘤 ii 位于齿状线15毫米处的肿瘤 iii 距肛门直肠环1厘米处的肿瘤 iv 限于直肠壁或IAS的局部涂抹 v 足够的术前括约肌功能和节制 vi 没有远处转移 ISR表现的禁忌症包括大便失禁 T4病变 未分化肿瘤以及侵犯耻骨直肠肌和肛门外括约肌 EAS 的肿瘤 3 IndicationsandPreoperativeEvaluation 适应症和术前评估 ESPRIT PM Capon MUSIC Asignificantnumberofpatientsmayrequireneoadjuvantchemoradiationtherapy InasystematicreviewofISRinvolving14studiesand1289patientswhounderwentISRbyMartinandcolleagues 44 ofpatientshadstageIIIdiseaseand38 underwentpreoperativechemoradiationoverall Ofnote incertainstudiesincludedinthereview preoperativeradiationwasacontraindicationtoperformingISRduetopossibleadversefunctionaleffects ThisisincontrasttoarecentstudybyDenostandcolleaguesinwhich93 ofpatientsundergoingISRreceivedpreoperativeradiotherapy 相当数量的患者可能需要新辅助放化疗 在一项涉及14项研究的ISR和1289例接受ISR的患者的系统评价中 44 的患者患有III期疾病 38 患者接受术前放化疗 值得注意的是 在该评价纳入的某些研究中 术前放疗是由于可能的不良功能影响而进行ISR的禁忌证 这与最近由Denost及其同事进行的一项研究相反 其中接受ISR的患者中有93 接受了术前放疗 3 IndicationsandPreoperativeEvaluation 适应症和术前评估 ESPRIT PM Capon MUSIC 3 1 SurgicalTechnique TheprincipleoftheISRtechniqueisbasedonananatomicdissectionplanebetweentheIASandEAS Thetechniqueincorporatesacombinedabdominalandperinealapproach Initially highligationoftheinferiormesentericvesselsisdone ThisisfollowedbyTMEdowntothelevelofthepelvicfloor TMEcanbeperformedthroughalaparotomyorlaparoscopically Subsequently aperanalresectionoftheIASisundertaken Thedistalresectionlinemaybeattheintersphinctericgroove totalISR betweenthedentatelineandtheintersphinctericgroove subtotalISR oratthedentateline partialISR Additionalmaneuverstoreducetheriskoflocaltumorcellimplantationincludeclosureoftherectalstump cytocidalwashout andpathologicalevaluationofthedistalmarginwithfrozensectionanalysis Thespecimenisusuallydeliveredperanum AhandsewncoloanalanastomosiswithconstructionofacolonJ pouch transversecoloplasty orstraightanastomosisisperformed Certaingroups especiallyinJapan performlateralpelviclymphnodedissectionforTNMstageIIItumors Adefunctioningtemporarystomaisfashioned whichisclosed6weeksto12monthsfromtheprimaryoperation 3 1 外科技术 ISR技术的原理是基于IAS和EAS之间的解剖解剖平面 该技术采用了腹部和会阴联合的方法 最初 完成肠系膜下血管的高位结扎 接下来是TME 直至盆底 TME可以通过剖腹手术或腹腔镜进行 随后 进行IAS的每次肛门切除术 远端切除线可能位于括约肌间沟 总ISR 齿状线与括约肌间沟 次级总体ISR 之间 或齿状线 部分ISR 进一步的操作来降低局部肿瘤细胞植入的风险包括闭合直肠残端 杀细胞的冲刷 并通过冰冻切片分析对远端边缘进行病理评估 标本通常按照每个肛门递送 一个手工缝合的结肠吻合术 结肠结肠J形袋 横形成形术或直肠吻合术 某些组织 特别是在日本 对TNMIII期肿瘤进行侧盆腔淋巴结清扫 这是关闭从主要操作6周到12个月 3 IndicationsandPreoperativeEvaluation 适应症和术前评估 ESPRIT PM Capon MUSIC 3 2 Short TermAdverseEvents TheoveralloperativemortalityassociatedwithISRis0 8 Thecumulativemorbidityrateisreportedtobe25 8 Anastomoticleakwasexperiencedafterameanof9 1 andtherateofpelvicsepsiswas2 4 Therateofclinicallyapparentanastomoticleakagefollowingstapledanastomosisfollowinganteriorresectionisintherangeof3 15 Ratesofleakagerisesignificantlyformoredistallysitedanastomoses Anastomoticleakageisassociatedwithpostoperativeanastomoticstricture cancerrecurrence poorpostoperativefunction aswellasincreasedoperativemortality Inconclusion ISRcanbeperformedwithacceptableratesofanastomoticleakageandlowoperativemortality 短期不良事件 与ISR相关的总体手术死亡率为0 8 据报道 累计发病率为25 8 平均9 1 发生吻合口瘘 盆腔脓毒症发生率为2 4 吻合术后临床表现吻合口瘘的发生率在3 15 之间 对于更远端的吻合口 漏率显着增加 吻合口瘘发生与术后吻合口狭窄 癌症复发 术后功能差以及手术死亡率增加有关 最后 ISR的吻合口漏率和手术死亡率均可接受 3 IndicationsandPreoperativeEvaluation 适应症和术前评估 ESPRIT PM Capon MUSIC 3 3 OncologicOutcomes Radicalsurgicalremovalofthetumoristheonlychanceforpermanentcureofrectalcancer despiteallprogressinthedevelopmentofoncologictherapy Rullierandcolleaguesreportedalocalrecurrencerateof2 inaseriesof92patientsundergoingISR Mostpatients 78 hadT3lesions and88 underwentlongcourseneoadjuvantradiochemotherapy Theoverall5 yearsurvivalratewas81 witha5 yeardisease freesurvivalof70 Yamadaetal reportedasimilarlylow2 5 cumulative5 yearlocalrecurrencerate a5 yeardisease freesurvivalrateof83 5 forstageIIpatientsand72 forstageIIIpatients 肿瘤结局 尽管肿瘤治疗的发展取得了一些进展 但根治性手术切除肿瘤是直肠癌永久治愈的唯一机会 Rullier等报道92例接受ISR的患者局部复发率为2 大多数患者 78 有T3病变 88 接受长程新辅助放化疗 5年总生存率为81 5年无病生存率为70 Yamada等人报道5年局部复发率为2 5 5年无病生存率为83 5 而III期患者为72 3 IndicationsandPreoperativeEvaluation 适应症和术前评估 ESPRIT PM Capon MUSIC TilneyandTekkisperformedaliteraturesearchtoidentifystudiesreportingoutcomesfollowingISR Twenty onestudiesaccumulatingatotalof612patientswereidentified Thepooledrateoflocalrecurrencewas9 5 withanaverage5 yearsurvivalof81 5 Distantmetastasesoccurredin9 3 InMartin ssystematicreview themeandistalmarginfreefromtumourwas17 1mm CRM negativemarginswereachievedin96 ofpatients andtheoveralllocalrecurrenceratewas6 7 range 0 23 The5yearoverallanddisease freesurvivalratewas86 3 and78 6 respectively Ratesoflocalrecurrencefollowinglowanteriorresectionforthetreatmentofrectalcancerarecommonlyreportedintherangeof2 6 32 followingsurgeryalone Preoperativechemoradiationtherapyhasledtolocalrecurrenceratesinthe6 range Tilney和Tekkis进行了文献检索 以确定研究报告ISR后的结果 共有612名患者进行了21项研究 局部复发率汇总为9 5 平均5年生存率为81 5 远处转移发生率为9 3 在Martin的系统评价中 无肿瘤的平均远端边缘为17 1mm 96 的患者达到了CRM阴性边缘 总体局部复发率为6 7 范围 0 23 5年总体无病生存率分别为86 3 和78 6 低位前切除术后局部复发率在直肠癌治疗中的报道通常在手术后的2 6 32 范围内 术前放化疗导致局部复发率在6 的范围内 3 IndicationsandPreoperativeEvaluation 适应症和术前评估 ESPRIT PM Capon MUSIC 3 4 AnorectalPhysiology Animportantgoalofsphincterpreservingsurgeryistoreachacceptablequalityoflifelevelsbypreservingfecalcontinence ThemainconcernoftheISRtechniqueisfunctionaloutcome PhysiologicstudieshaveshownthatanalrestingpressureisduetotheIASfor55 thehemorrhoidalplexusfor15 andtotheEASfor30 TotalorpartialexcisionoftheIASisboundtoaffectcontinence Furthermore preoperativeradiationtherapymaycauseadditionallossofsphincterfunction Kohleretal reporteda29 reductioninrestinganalpressurefollowingISR Squeezepressurerecoveredtopreoperativelevelsafter12months RparedoutcomesinpatientsundergoingpartialorsubtotalIASresection SubtotalexcisionofthesphincterwasassociatedwithsignificantreductioninrestingbutnotsqueezepressureafterISR Ofnote therehavebeennostudiesassessinganorectalphysiologyandcontinenceafterneoadjuvantradiationandpriortoISR 肛肠生理学 保留括约肌的手术的一个重要目标是通过保持粪便控制达到可接受的生活质量水平 ISR技术的主要关注点是功能性结果 生理研究表明 肛门静息压是由于55 的IAS 15 的痔疮丛和30 的EAS 全面或部分切除IAS必然会影响控尿 此外 术前放射治疗可能会导致括约肌功能的额外损失 科勒等人 报告ISR后静息肛门压力减少29 术后12个月挤压恢复到术前水平 Rullier等人比较IAS部分切除或次全切除患者的结局 ISR后小切除括约肌切断与静息压力显着降低但不是挤压压力相关 值得注意的是 尚未有研究评估新辅助放疗后以及ISR之前的肛门直肠生理和控制情况 3 IndicationsandPreoperativeEvaluation 适应症和术前评估 ESPRIT PM Capon MUSIC 3 5 FunctionalOutcomesandQualityofLife AsanantithesistoanaphorismbythefamedarchitectLouisSullivan inrectalcancersurgery functionfollowsform thetypeofoperationperformed Lossofapartofthesphinctercomplex lossoftherectalreservoir andradiationisboundtohaveadverseeffectoncontinenceanddefractoryfunction BretagnolandcolleaguesreportedthatfecalcontinencemeasuredbyboththeKirwanandWexnerscoreswassignificantlyworseafterISR Inaddition theneedforantidiarrhealmedicationwashigherinpatientsundergoingISRcomparedwithpatientsthathadundergoneconventionalcoloanalanastomosis Frequency urgency theWexnerscore andtheFecalIncontinenceSeverityIndex FISI weresignificantlyimprovedfollowingcolonicJ pouchreconstructioncomparedwithstraightcoloanalanastomosis Regardingqualityoflife QOL Bretagnoletal usedboththeSF 36andfecalincontinencequalityoflife FIQL tocompareQOLbetweenpatientsundergoingISRandconventionalcoloanalanastomosis TherewasnodifferenceintheQOLscoresbetweenISRpatientsandconventionalcoloanalanastomosispatientsinthephysicalandmentalsubscalesoftheSF 36 功能成果和生活质量 作为着名建筑师LouisSullivan在直肠癌手术中与格言的对比 功能遵循形式 所执行的操作类型 丧失括约肌复合体的一部分 丧失直肠的储库和辐射必然会对控制和防止功能产生不利影响 Bretagnol及其同事报道 在ISR后 Kirwan和Wexner评分测量的大便失禁明显恶化 此外 接受ISR的患者与接受常规结肠吻合术的患者相比 对止泻药物的需求更高 结肠J后 频率 尿急 Wexner评分和粪便失禁严重程度指数 FISI 显着改善与直结肠吻合相比 囊重建 关于生活质量 QOL Bretagnol等人使用SF 36和大便失禁生活质量 FIQL 来比较接受ISR和常规结肠吻合术的患者的生活质量 ISR患者与传统结肠吻合术患者在SF 36的身体和心理分量表上的生活质量评分没有差异 3 IndicationsandPreoperativeEvaluation 适应症和术前评估 ESPRIT PM Capon MUSIC InMartin ssystematicreview themeannumberofbowelmovementsperdaywas2 7 Nearlyhalf 51 2 ofpatientsreported perfectcontinence aboutathird 29 1 reportedexperiencedfecalsoiling 23 8 hadflatusincontinence had18 6 hadurgency InalargestudyassessingfunctionaloutcomesafterISR Denostreportedthathalfofthepatientshada goodfunctionalresult 39 hadminorfecalincontinence and11 hadmajorincontinence Inthesamestudy theonlyindependentpredictorsof good continencewereadistanceoftumourgreaterthan1cmfromtheanorectalringandanastomosishigherthan2cmfromtheanalverge PossibletechnicalmodificationswhenperformingISRmayimprovefunctionaloutcome