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Title: [An initial exploration of the application of transanal endoscopic microsurgery in rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy].
Author: Xue XQ, Zhou JL, Lin GL, Bai XS, Xiao Y, Wu B, Qiu HZ.
Journal: Zhonghua Wei Chang Wai Ke Za Zhi; 2019 Jun 25; 22(6):560-565. PubMed ID: 31238635.
Abstract:
Objective: To preliminarily explore the value of transanal endoscopic microsurgery (TEM) in rectal cancer patients with clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). Methods: Using descriptive case series method, Clinical data of 13 patients who met the criteria of nCRT and were considered to be cCR after MRI or CT scanning, digital rectal examination and colonoscopic biopsy, as well as no lymph node or distant metastasis were found, then underwent TEM from 2013 to 2016 at the Department of General Surgery of Peking Union Medical College Hospital were collected retrospectively. A 3-course combination of capecitabine and oxaliplatin (XELOX) was used for chemotherapy. Besides, a 6MV-X ray radiation was used as radiotherapy simultaneously. Six to eight weeks after completion of radiotherapy, a preoperative assessment was carried out with intrarectal ultrasound, MRI, or pelvic abdominal CT examination. TEM was performed afterwards with informed consent. Postoperative pathological findings and follow-up results were used to evaluate the value of diagnosis and treatment of TEM on those patients. Results: There were 8 males and 5 females with a median age of 63 (27-80) years. Preoperative examination showed that the lesions were located in the anterior wall in 3 cases, the posterior wall in 3 cases, the left side wall in 4 cases, and the right side wall in 3 cases. Before nCRT, the distance between tumor and anal margin was (4.8±1.1) (2.0-7.5) cm; after nCRT, this distance was (5.2±1.3) (3.0-7.5) cm. All the 13 patients underwent extended local resection of rectal cancer via TEM with the placement of urethral catheter. The average operative time was (52.2±3.7) (42-70) minutes, and the average intraoperative blood loss was (19.2±2.8) (5-30) ml. All the patients could engage in daily activities on postoperative day 1, and could cater themselves orally on postoperative day 2. The main discomfort was postoperative anal pain and foreign body sensation (n=5), which could be alleviated by non-steroidal anti-inflammatory drugs. One case had postoperative lung infection and was cured by antibiotic treatment. One case had urinary retention after removing urine catheter, and then a urine catheter was re-inserted. Average postoperative hospital stay was (2.8±2.4) (2-12) days. All specimens were completely resected via TEM. Histopathological examination confirmed that 7 specimens had achieved pathologic complete response (pCR) and the other 6 specimens had obtained partial tumor response of CAP grade 2. Seven patients with pCR received a median follow-up of 24 (8-48) months and no local recurrence or distant metastasis was reported during follow-up period. Among these 7 cases, one developed defecation dysfunction after discharge, mainly for defecation pain and even dare to defecate, who returned to normal defecation within 2 months after surgery; One developed severe anal pain within six months after surgery and the pain disappeared after symptomatic pain relief. The other 6 patients with CAP grade 2 refused to undergo further radical operation because of their strong desire in preserving anus, and received remedial adjuvant chemotherapy instead. Conclusion: For rectal cancer patients with cCR after nCRT, TEM does have certain application values if the patient has a strong desire to preserve anus. 目的： 初步探讨经肛门内镜显微手术（TEM）在直肠癌新辅助放化疗后临床完全缓解（cCR）患者中的应用价值。 方法： 采用描述性病例系列研究方法，回顾性收集中国医学科学院北京协和医院基本外科于2013—2016年间收治的13例适合新辅助放化疗，经影像学、直肠指检、术前结肠镜活检评估为cCR，除外淋巴结和远处转移而行TEM治疗的直肠癌患者的临床资料。所有患者在口服3程卡培他滨片的同时，静脉输注奥沙利铂（XELOX方案），与化疗同时开展使用6MV-X线照射的调强适形放疗，放疗结束后6~8周采用直肠腔内超声、MRI或盆腹部增强CT检查进行术前评估。所有患者均在获得知情同意后接受TEM。术后病理及随访结果用于评价该手术对于这类患者的诊断和治疗价值。 结果： 全组患者中男8例，女5例，中位年龄63（27~80）岁。术前检查提示病灶位于前壁3例，后壁3例，左侧壁4例，右侧壁3例。新辅助放化疗前肿瘤距肛缘距离为4.8±1.1（2.0~7.5）cm；新辅助放化疗后肿瘤距肛缘距离为5.2±1.3（3.0~7.5）cm。13例患者均通过TEM完成直肠癌的局部扩大切除，手术用时为52.2±3.7（42~70）min，术中失血量为19.2±2.8（5~30）ml。术后第1天均可以下地活动，术后第2天均可经口进食，术后的主要不适主诉为肛门疼痛、异物感（5例），非甾体类抗炎药对症处理后可缓解，术后发生1例肺部感染，予抗生素治疗，排尿困难1例，该患者既往前列腺增生史，出院后泌尿外科随诊。术后住院时间为2.8±2.4（2~12）d。术后病理提示所有标本切缘均为阴性。组织病理学检查证实7例为pCR，其余6例标本均为美国病理学会（CAP）分级标准2级的部分肿瘤反应。全部患者术后接受中位20（8~48）个月的随访，随访期间均未发生局部复发或远处转移。1例pCR患者出院后出现排粪功能障碍，主要表现为排粪疼痛以至不敢排粪，该患者在术后2个月内恢复正常排粪。另有1例患者术后半年内发生肛周疼痛，对症止痛后疼痛消失。另外6例CAP 2级的患者因保肛意愿强烈，均拒绝行进一步的根治性手术，仅接受辅助化疗。 结论： 对于新辅助放化疗后评估为cCR的直肠癌患者，在有强烈保肛意愿的前提下，TEM具有一定的诊断和治疗价值。.

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