切换至 "中华医学电子期刊资源库"

中华结直肠疾病电子杂志 ›› 2023, Vol. 12 ›› Issue (02) : 167 -171. doi: 10.3877/cma.j.issn.2095-3224.2023.02.013

所属专题: 经典病例

侧方淋巴结清扫专栏

侧方淋巴结清扫术在低位直肠癌根治术中的可行性探讨(附20例报道)
邵鹏1, 司呈帅1, 曹月鹏1, 周欣1, 章旭1, 李东正1,()   
  1. 1. 210000 南京医科大学附属肿瘤医院 江苏省肿瘤医院 江苏省肿瘤防治研究所 普通外科
  • 收稿日期:2022-07-20 出版日期:2023-04-25
  • 通信作者: 李东正

Re-evaluation the feasibility of lateral lymph node dissection in radical resection of low rectal cancer: report of 20 cases

Peng Shao1, Chengshuai Si1, Yuepeng Cao1, Xin Zhou1, Xu Zhang1, Dongzheng Li1,()   

  1. 1. Department of General Surgery, the Affiliated Cancer Hospital of Nanjing Medical University & Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research, Nanjing 210000, China
  • Received:2022-07-20 Published:2023-04-25
  • Corresponding author: Dongzheng Li
引用本文:

邵鹏, 司呈帅, 曹月鹏, 周欣, 章旭, 李东正. 侧方淋巴结清扫术在低位直肠癌根治术中的可行性探讨(附20例报道)[J]. 中华结直肠疾病电子杂志, 2023, 12(02): 167-171.

Peng Shao, Chengshuai Si, Yuepeng Cao, Xin Zhou, Xu Zhang, Dongzheng Li. Re-evaluation the feasibility of lateral lymph node dissection in radical resection of low rectal cancer: report of 20 cases[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2023, 12(02): 167-171.

目的

探讨侧方淋巴结清扫在低位直肠癌手术中的意义以及结合本中心实际探究术前影像学数据用于评估侧方淋巴结是否转移的准确性。

方法

对南京医科大学附属肿瘤医院术前影像学检查高度怀疑侧方淋巴结有转移的患者行侧方淋巴结清扫术,并对术后病理为阴性可能的原因进行分析。

结果

侧方淋巴结无转移,瘤旁及系膜淋巴结转移率为70%,其中高分化腺癌淋巴结转移率为30%,中低分化腺癌淋巴结转移率为85.7%。

结论

术前仅凭影像学评估淋巴结的大小及形态来诊断侧方淋巴结是否转移进而指导手术清扫相对困难,其准确性有待商榷;侧方淋巴结转移的发生率很低,低位直肠癌患者实施侧方淋巴结清扫术应当慎之又慎,术前除对患者进行全面的影像学评估外,还应充分了解患者的既往病史等情况,必要时需进行多学科会诊(MDT)决定手术方案。

Objective

To study the significance of lateral lymph node dissection in low rectal cancer surgery and explore the accuracy of preoperative imaging data used to evaluate whether lateral lymph node metastasis combined with the practice of Jiangsu Cancer Hospital.

Methods

The possible reasons for the negative pathology after lateral lymph node dissection were analyzed for the patients with lateral lymph node metastasis highly suspected by preoperative imaging examination in our hospital.

Results

There was no metastasis in lateral lymph nodes, and the metastasis rate in mesenteric lymph nodes was 70%. The metastasis rate of well-differentiated adenocarcinoma was 30%, and the metastasis rate of moderately poorly differentiated was 85.7%.

Conclusion

It is difficult to diagnose lateral lymph node metastasis and guide surgical dissection only by imaging evaluation of lymph node size and morphology before surgery, and its accuracy is questionable. The incidence of lateral lymph node metastasis is very low, lateral lymph node dissection should be performed with great caution in patients with low rectal cancer. In addition to a comprehensive imaging evaluation, previous medical history and other conditions of patients should be full considered before surgery. MDT could be conducted to aid surgical decision-making if necessary.

图1 术前影像学评估肿大淋巴结。1A:CT评估侧方淋巴结肿大;1B:MRI评估侧方淋巴结肿大
图2 术后标本。2A:肿瘤大体标本;2B:侧方淋巴结标本
表1 20例行侧方淋巴结清扫的直肠癌患者基本资料
病例 性别 年龄(岁) 病理分化类型 术后分期 肿瘤切缘 脉管及神经侵犯 淋巴结转移位置 肿瘤下缘距肛门距离(cm) 手术方式
1 42 中-低分化腺癌 T3N0M0 阴性 无转移 8 直肠前切除术
2 55 高分化腺癌 T2N0M0 阴性 无转移 5 直肠前切除术+预防性回肠造口术
3 60 高分化腺癌 T2N0M0 阴性 无转移 1 腹会阴联合直肠切除术
4 58 高分化腺癌 T2N0M0 阴性 无转移 4 直肠前切除术+预防性回肠造口术
5 54 高分化腺癌 T2N0M0 阴性 无转移 2 腹会阴联合直肠切除术
6 61 高分化腺癌 T2N0M0 阴性 无转移 7 直肠前切除术
7 60 高分化腺癌 T2N0M0 阴性 无转移 4 直肠前切除术+预防性回肠造口术
8 56 高分化腺癌 T2N2M0 阴性 肠上+肠旁淋巴结(瘤旁) 2 腹会阴联合直肠切除术
9 43 高分化腺癌 T3N0M0 阴性 无转移 1 腹会阴联合直肠切除术
10 48 高分化腺癌 T3N0M0 阴性 无转移 6 直肠前切除术
11 57 高分化腺癌 T3N0M0 阴性 无转移 4 直肠前切除术+预防性回肠造口术
12 62 高分化腺癌 T4aN2M0 阴性 肠上+肠旁淋巴结(瘤旁) 2 腹会阴联合直肠切除术
13 67 低分化腺癌 T4aN2M0 阴性 肠上+肠旁淋巴结(瘤旁) 1 腹会阴联合直肠切除术
14 66 中-低分化腺癌 T2N2M0 阴性 肠系膜下血管根部 8 直肠前切除术
15 44 低分化腺癌 T4aN2M0 阴性 肠上+肠旁淋巴结(瘤旁) 5 直肠前切除术+预防性回肠造口术
16 68 低分化腺癌 T3N1M0 阴性 肠上+肠旁淋巴结(瘤旁) 2 腹会阴联合直肠切除术
17 46 低分化腺癌 T4aN2M0 阴性 肠上+肠旁淋巴结(瘤旁) 1 腹会阴联合直肠切除术
18 43 高分化腺癌 T3N2M0 阴性 肠上+肠旁淋巴结(瘤旁) 3 直肠前切除术+预防性回肠造口术
19 65 高分化腺癌 T2N1M0 阴性 肠上+肠旁淋巴结(瘤旁) 4 直肠前切除术+预防性回肠造口术
20 68 低分化腺癌 T3N2M0 阴性 肠上+肠旁淋巴结(瘤旁) 6 直肠前切除术
[1]
Sammour T, Chang GJ. Lateral pelvic lymph node dissection and radiation treatment for rectal cancer: Mutually exclusive or mutually beneficial?[J]. Ann Gastroenterol Surg, 2018, 2(5): 348-350.
[2]
Fujita S, Mizusawa J, Kanemitsu Y, et al. Mesorectal excision with or without lateral lymph node dissection for clinical stage II/III lower rectal cancer (JCOG0212): A multicenter, randomized controlled,noninferiority trial[J]. Ann Surg, 2017, 266(2): 201-207.
[3]
Sugihara K, Kobayashi H, Kato T, et al. Indication and benefit of pelvic sidewall dissection for rectal cancer[J]. Dis Colon Rectum, 2006, 49(11): 1663-1672.
[4]
中国医师协会内镜医师分会腹腔镜外科专业委员会, 中国医师协会结直肠肿瘤专业委员会腹腔镜专业委员会, 中华医学会外科学分会结直肠外科学组. 中国直肠癌侧方淋巴结转移诊疗专家共识(2019版)[J]. 中华胃肠外科杂志, 2019, 22(10): 901-912.
[5]
Watanabe T, Itabashi M, Shimada Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines 2014 for treatment of colorectal cancer[J]. Int J Clin Oncol, 2015, 20(2): 207-239.
[6]
Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012[J]. Int J Cancer, 2015, 136(5): E359-386.
[7]
Baik SH, Kim NK, Lee YC, et al. Prognostic significance of circumferential resection margin following total mesorectal excision and adjuvant chemoradiotherapy in patients with rectal cancer[J]. Ann Surg Oncol, 2007, 14(2): 462-469.
[8]
Kim TH, Jeong SY, Choi DH, et al. Lateral lymph node metastasis is a major cause of locoregional recurrence in rectal cancer treated with preoperative chemoradiotherapy and curative resection[J]. Ann Surg Oncol, 2008, 15(3): 729-737.
[9]
Kusters M, Slater A, Muirhead R, et al. What to do with lateral nodal disease in low locally advanced rectal cancer? A call for further reflection and research[J]. Dis Colon Rectum, 2017, 60(6): 577-585.
[10]
Sugihara K, Kobayashi H, Kato T, et al. Indication and benefit of pelvic sidewall dissection for rectal cancer[J]. Dis Colon Rectum, 2006, 49(11): 1663-1672.
[11]
Akiyoshi T, Watanabe T, Miyata S, et al. Results of a japanese nationwide multi-institutional study on lateral pelvic lymph node metastasis in low rectal cancer: is it regional or distant disease?[J]. Annals of Surgery, 2012, 255(6): 1129-1134.
[12]
Swedish rectal Cancer Trial, Gedermark B, Dahlberg M, et al. Improved survival with preoperative radiotherapy in resectable rectal cancer[J]. N Engl J Med, 1997, 336(14): 980-987.
[13]
Georgiou P, Tan E, Gouvas N, et al. Extended lymphadenectomy versus conventional surgery for rectal cancer: A meta-analysis[J]. Lancet Oncol, 2009, 10(11): 1053-1062.
[14]
Kusters M, Beets GL, van de Velde CJH, et al. A comparison between the treatment of low rectal cancer in Japan and the Netherlands, focusing on the patterns of local recurrence[J]. Ann Surg, 2009, 249(2): 229-235.
[15]
LeBlanc JK. Imaging and management of rectal cancer[J]. Nat Clin Pract Gastroenterol Hepatol, 2007, 4(12): 665-676.
[16]
Kim TH, Jeong SY, Choi DH, et al. Lateral lymph node metastasis is a major cause of locoregional recurrence in rectal cancer treated with preoperative chemoradiotherapy and curative resection[J]. Ann Surg Oncol, 2008, 15(3): 729-737.
[17]
Brown G, Richards CJ, Bourne MW, et al. Morphologic predictors of lymph node status in rectal cancer with use of high-spatial-resolution MR imaging with histopathologic comparison[J]. Radiology, 2003, 227(2): 371-377.
[18]
Nagayoshi K, Ueki T, Manabe T, et al. Laparoscopic lateral pelvic lymph node dissection is achievable and offers advantages as a minimally invasive surgery over the open approach [J]. Surg Endosc, 2016, 30(5): 1938-1947.
[19]
Hasegawa S, Takahashi R, Hida K, et al. Revisiting the treatment strategy for rectal cancer through the pattern of local recurrence[J]. Eur J Surg Oncol, 2016, 42(11): 1674-1679.
[20]
Oh HK, Kang SB, Lee SM, et al. Neoadjuvant chemoradiotherapy affects the indications for lateral pelvic node dissection in mid/low rectal cancer with clinically suspected lateral node involvement: a multicenter retrospective cohort study[J]. Ann Surg Oncol, 2014, 21(7): 2280-2287.
[1] 代莉, 邓恢伟, 郭华静, 黄芙蓉. 术中持续输注艾司氯胺酮对腹腔镜结直肠癌手术患者术后睡眠质量的影响[J]. 中华普通外科学文献(电子版), 2023, 17(06): 408-412.
[2] 王得晨, 杨康, 杨自杰, 归明彬, 屈莲平, 张小凤, 高峰. 结直肠癌微卫星稳定状态和程序性死亡、吲哚胺2,3-双加氧酶关系的研究进展[J]. 中华普通外科学文献(电子版), 2023, 17(06): 462-465.
[3] 唐旭, 韩冰, 刘威, 陈茹星. 结直肠癌根治术后隐匿性肝转移危险因素分析及预测模型构建[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 16-20.
[4] 张生军, 赵阿静, 李守博, 郝祥宏, 刘敏丽. 高糖通过HGF/c-met通路促进结直肠癌侵袭和迁移的实验研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 21-24.
[5] 张焱辉, 张蛟, 朱志贤. 留置肛管在中低位直肠癌新辅助放化疗后腹腔镜TME术中的临床研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 25-28.
[6] 李婷, 张琳. 血清脂肪酸代谢物及维生素D水平与结直肠癌发生的关系研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 661-665.
[7] 付振保, 曹万龙, 刘富红. 腹腔镜直肠癌低位前切除术中不同缝合方法的回肠双腔造口术临床效果研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 684-687.
[8] 贺亮, 王松林, 周业江. 两种预防性回肠造口在腹腔镜ISR术治疗超低位直肠癌的效果对比研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 697-700.
[9] 倪文凯, 齐翀, 许小丹, 周燮程, 殷庆章, 蔡元坤. 结直肠癌患者术后发生延迟性肠麻痹的影响因素分析[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 484-489.
[10] 范小彧, 孙司正, 鄂一民, 喻春钊. 梗阻性左半结肠癌不同手术治疗方案的选择应用[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 500-504.
[11] 杨红杰, 张智春, 孙轶. 直肠癌淋巴结转移诊断研究进展[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 512-518.
[12] 马慧颖, 凡新苓, 覃仕瑞, 陈佳赟, 曹莹, 徐源, 金晶, 唐源. 磁共振加速器治疗局部晚期直肠癌的初步经验[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 519-523.
[13] 关旭, 王锡山. 基于外科与免疫视角思考结直肠癌区域淋巴结处理的功与过[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 448-452.
[14] 顾睿祈, 方洪生, 蔡国响. 循环肿瘤DNA检测在结直肠癌诊治中的应用与进展[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 453-459.
[15] 卢艳军, 马健, 白鹏宇, 郭凌宏, 刘海义, 江波, 白文启, 张毅勋. 纳米碳在腹腔镜直肠癌根治术中253组淋巴结清扫的临床效果[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 473-477.
阅读次数
全文


摘要