直腸癌側(cè)方淋巴結(jié)清掃的爭(zhēng)議與共識(shí)

ietyofCancerforColonandRectum,JSCCR)結(jié)直腸癌診療指南推薦側(cè)方淋巴結(jié)清掃手2003年日本開展的JCOG0212研究納入了701例中低位直腸癌患者資料，入組條件為腫瘤下esurvival,DFS)分別為73.3%和73.4%(HR:1.07,95%CI:0.84~1.36),HR值上限超過(guò)了預(yù)先治療方案。國(guó)家衛(wèi)生健康委員會(huì)發(fā)布的《中國(guó)結(jié)直腸癌診療規(guī)范(2023年版)》推薦cT3~4淋巴結(jié)轉(zhuǎn)移診療專家共識(shí)(2024版)》也推薦將nCRT聯(lián)合選擇性LLND作為臨床診斷側(cè)方淋度為0.72~0.88,特異度為0.80~0.85;CT的敏感度為0.62~0.95,特異度為0.90~0.94;PET-CT的敏感度為0.83,特異度為0.95[11-12]。盆腔MRI仍是診斷側(cè)方淋巴結(jié)轉(zhuǎn)移的首選，當(dāng)MRI檢查結(jié)果存疑或有檢查禁忌時(shí)PET-CT可以作為補(bǔ)充。對(duì)于大多數(shù)中低位直腸癌患者，治療前局部分期評(píng)估優(yōu)先選擇直腸MRI,包括顯示直腸腫瘤浸潤(rùn)深度、有無(wú)可疑的區(qū)域及側(cè)方淋巴結(jié)、環(huán)周切緣(Circumferentialresectionma結(jié)復(fù)發(fā)率17.9%,而初診側(cè)方淋巴結(jié)短徑小于7mm患者僅為4.1%(HR=4.6,95%CI:2.3~9.2,P<時(shí)，術(shù)前直腸MRI側(cè)方淋巴結(jié)短徑小于5mm患者淋巴結(jié)轉(zhuǎn)移率為3.5%,短徑5~10mm患者淋巴結(jié)轉(zhuǎn)移率為16.1%,短徑大于10mm患者淋巴結(jié)轉(zhuǎn)移率為34.0%[14]。日本的Jc0G0212研究結(jié)果顯示術(shù)前側(cè)方淋巴結(jié)直徑小于10mm的中低位直腸癌患者側(cè)方淋巴結(jié)轉(zhuǎn)移率為7%,直徑小于5mm患者的側(cè)方淋巴結(jié)轉(zhuǎn)移率為5.4%[15]。初診側(cè)方淋巴結(jié)直徑小于5mm的患者行LLND陽(yáng)性或假陰性結(jié)果02018年美國(guó)腹部放射學(xué)會(huì)推薦采用淋巴結(jié)邊界、信號(hào)是否均勻及形狀來(lái)可以看到除了JSccR指南推薦TME聯(lián)合LLND手術(shù)，其余各大指但TNT模式對(duì)側(cè)方淋巴結(jié)轉(zhuǎn)移的治療價(jià)值仍存在爭(zhēng)議。常規(guī)ncRT組(23.7%比30.4%,P=0.019),但兩組間局部復(fù)發(fā)率(8.3%比6.0%,P=0.12)和總生存率(83%比82%,P=0.59)差異無(wú)統(tǒng)計(jì)學(xué)意義[19],提示相對(duì)于常規(guī)ncRT,短程放療聯(lián)合鞏固化cRT后接受根治性手術(shù)，試驗(yàn)組3年DFS顯著優(yōu)于對(duì)照組(76%比69%,異無(wú)統(tǒng)計(jì)學(xué)意義(4%比6%,P=0.56)[20]。這2項(xiàng)大型隨機(jī)對(duì)照試驗(yàn)結(jié)果提示，無(wú)論是聯(lián)合長(zhǎng)新輔助免疫治療成為近年來(lái)直腸癌治療的熱點(diǎn)。在錯(cuò)配修復(fù)ficient,dMMR)或微衛(wèi)星高度不穩(wěn)定(Microsatelliteinstabilityhigh,MSI-H)的直腸針對(duì)免疫治療不敏感的微衛(wèi)星穩(wěn)定(Microsatellitestability,MSS)或錯(cuò)配修復(fù)正e,pcR)率達(dá)到37.7%,MSI-H型直腸癌JSccR結(jié)直腸癌診療指南對(duì)中低位直腸癌推薦預(yù)防性LLND策略。對(duì)于腫瘤下緣位于腹212研究對(duì)象為術(shù)前診斷無(wú)側(cè)方淋巴結(jié)轉(zhuǎn)移的中低位直腸癌標(biāo)準(zhǔn)中對(duì)術(shù)前影像評(píng)估側(cè)方淋巴結(jié)陰性的判斷標(biāo)準(zhǔn)為淋巴結(jié)短徑小于10mm,這一標(biāo)準(zhǔn)過(guò)于LLND的具體清掃范圍存在爭(zhēng)議。《日本大腸癌處理規(guī)約》(第9版)重新定義了LLND范外淋巴結(jié)(No.293)、骶外側(cè)淋巴結(jié)(No.260)、骶正中淋巴結(jié)(No.270)、腹主動(dòng)脈分叉處淋巴結(jié)(No.280)[27]。與既往版本相比，清掃范圍進(jìn)一步擴(kuò)大。既往文獻(xiàn)報(bào)道超過(guò)95%的側(cè)方淋上原因，《中國(guó)直腸癌側(cè)方淋巴結(jié)轉(zhuǎn)移診療專家共識(shí)(20[1]YanoH,MoranBJ.Theincidenceoflateralpelvicside-waentinlowrectalca08,95(1):33-49.DOI:10.1002/bjs.6061.oflong-termoncologicaloutcomesoflaterallymphnodeformetastaticnodesafterneoadjuvrJSurgOncol,2022,48(7):1475-1482.DOI:10.1016/j.ejs[3]HealdRJ,HusbandEM,RyallRD.thecluetopelvicrecurrence?[J].BrJSurg,1982,69(10):613-616.DOI:10.1002/bjs.1800691019.inColonRectalSurg,2017,30(5):346-356.DOI:10.1055/s-0037-1[5]Glynne-JonesR,WyrwiczL,TiretE,etal.Rectalcancer:ESMOClinicalPracticeGuidelinesfordiagnosis,treatmentandfollow(Suppl4):iv263.DOI:10.1093/annonc/mdy161.(2024-08-22)[2024-09-12]./professionals/phf/rectal.pdf.[7]HashiguchiY,MuroK,SaitoY,[J].IntJClinOncol,2020,25(1):1-4[8]FujitaS,MizusawaJ,KanemitsSurg,2017,266(2):201-207.DOI:10.1097/SLA.0000000000002212.441530-20231212-00211.[11]RooneyS,MeyerJ,AfzalZ,etal.Theroleedetectionoflaterallymphnodemetastasesinrectaliewanddiagnostictestmeta-analysis[J].DisColonRectum,2022,65(146.DOI:10.1097/DCR.0000000000002537.[12]HoshinoN,MurakamiK,HidaK,etal.Diagnosticaccuracyonanceimagingandcomputedtomographyforlateral(1):46-52.DOI:10.1007/s10147-018-1349-5.[13]0guraA,KonishiT,Beetsalcancerafterneoadjuvantch19,154(9):e192172.DOI:10.1001/jamas[14]UenoH,MochizukiH,HashiguchiY,etal.Plateralpelvicnodedissectionforrectalcancerlocatedbelowtheperitonealreflection[J].AnnSurg,2007,245(1):80-87.DOI:10.1097/01.sla[15]KomoriK,FujitaS,MizusawaJ,etal.Prediclateralpelviclymphnodemetastasisinpatientswithoutclinical[16]0gawaS,ItabashiM,Hi227-233.DOI:10.1002/jso2009,16(10):2787-2794.DOI:10.1245/s10434-009-0613-3. inrectalcancerpatients:societyofAbdominalRadiologydisease-focusedpanel(DFP)recommendations2017[J].AbdomRadiol(NY),2018,43(11):2893-2902.DOI:10.1007/s00261-018-1642-9.[19]BahadoerRR,Dijkstraollowedbychemotherapybeforetotalmesorectalexcisiocedrectalcancer(RAPIDO):arandomised,Oncol,2021,22(1):29-42.DOI:10.1016/s1470-2045(20)30555-6[20]CercekA,LumishM,SinopoliJ,etal.PD-1bl76.DOI:10.1056/NEJMoa2201445.[21]BandoH,TsukadaY,Inamnivolumabbeforesurgeryinpatienliteinstability-highlocallyadvanced28(6):1136-1146.DOI:10.1158/1078-0432.ccr-21-3213.owedbycamrelizumabandchemotherearlyoutcomesofamulticenterrandomizedphaseIIItrial[J].AnnOncol,2024.DOI:10.1016/j.annonc.2024.06.015.[23]0guraA,KonishiT,Cunninghrecurrenceinenlargednodes:resultsofthemulticenterlateralnodespatientswithlowcT3/4rectalcancer[J].JClininicallysuspectedlateralnodeinvolvement:amulticenterretrospectivestudy[J].AnnSurgOncol,2014,21(7):2280-2287.DOI:10.1245/s10434-014-3559-z[25]LimSB,YuCS,KimCW,elaterallymphnodeexcisioninpatientswithlocalhounderwentpreoperativechemoradiothera2):1667-1674.DOI:10.1007/s