摘要
局部进展期直肠癌(LARC)患者的治疗目标包括患者的长期生存和功能的保留。其诊疗策略逐渐从"大"手术变为"小"手术,从手术治疗变为非手术治疗。"等待观察(W&W)"策略由于减少了手术的损伤,提高了括约肌解剖结构和控制排便功能的保留率,能够更好地保留性功能以及膀胱排尿功能。全程新辅助治疗(TNT)将全部或者部分的辅助化疗前移,在肿瘤退缩方面显出了明确的优势,被寄予提高患者临床完全缓解(cCR)的期待。本文将结合文献及国际指南,评述以W&W为核心的LARC诊疗策略如何由标准的术前放化疗向TNT模式的变迁。经过近十余年的发展,LARC的分组和诊疗策略更为细致,美国国立综合癌症网络(NCCN)指南和欧洲肿瘤内科学会(ESMO)指南中,都强调针对不同危险分级的患者给予不同强度的术前治疗,对分期更晚的患者推荐施行TNT模式的治疗,凸显了TNT策略对于增进肿瘤退缩的价值。cCR后W&W虽已有一定数据的积累,在盆腔肿瘤控制和器官保留方面均不劣于甚至优于标准的手术治疗,但其是否确实对长期生存没有负面影响,仍缺乏前瞻性随机对照临床研究的数据;对于W&W策略中的细节也缺乏共识,依然强调W&W策略需要在有经验的肿瘤中心、在多学科团队的框架下来探索。鉴于我国的特殊医疗环境,建议目前应以患者对肛门括约肌等器官功能需求的主观意愿为主要驱动力,积极开展前瞻性观察性研究,积累我国临床病例的数据及经验,并积极融入国际研究。
Therapeutic goal for locally advance rectal cancer (LARC) patients includes long-term survival and function preservation of pelvic organs. During the recent two decades, treatment strategy for LARC is gradually shifing to minimally invasive surgery, even avoiding a major surgery."Watch and wait (W&W)" strategy is effective in dramatically decreasing surgical trauma and significantly improving preservation of defecation, urination and sexual function. Total neoadjuvant therapy (TNT) shifts all or part of adjuvant chemotherapy to the neoadjuvant phase and has showed obvious advantage in tumor shrinkage and complete clinical response (cCR) achievement. This article will summarize the transition of treatment strategy of LARC towards W&W from standard treatment. After more than ten years of development, both NCCN and ESMO guidelines recommend stratified neoadjuvant treatment considerations based on distinct risk classifications and especially suggest TNT for LARC patients with advanced diseases, which affirms the value of TNT in tumor shrinkage. Although accumulating data show that pelvic control and organ preservation using W&W strategy after cCR is equal or non-inferior to standard surgery, impact on long-term survival still needs prospective randomized controlled study;no consensus has been achieved for the detail of the W&W strategy. Thus W&W strategy is suggested to applied in hospitals specialized in the treatment of rectal cancer within the framework of multiple disciplinary treatment. In view of special medical conditions of our country, we still need to accumulate more experience and data of W&W strategy for rectal cancer patients with appeals for sphincter preservation and actively participate in international researches.
作者
肖巍魏
陈功
Xiao Weiwei;Chen Gong(Department of Radiotherapy, Sun Yat-Sen University Cancer Center, Guangzhou 510060, China;Department of Colorectal Surgery, Sun Yat-Sen University Cancer Center, Guangzhou 510060, China)
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2019年第6期514-520,共7页
Chinese Journal of Gastrointestinal Surgery
基金
中山大学5010培育项目(5010-2018-04).
关键词
直肠肿瘤
局部进展期
“等待观察”策略
临床完全缓解
全程新辅助治疗
Rectal neoplasms, locally advanced
"Watch and Wait" strategy
Complete clinical response
Total neoadjuvant therapy
