Advances in Clinical Medicine
Vol. 13  No. 08 ( 2023 ), Article ID: 70236 , 7 pages
10.12677/ACM.2023.1381722

直肠癌MDT评估精准治疗

秘如勇1*,周逢强2#,孙强玉2,耿振2

1山东第一医科大学(山东省医学科学院)研究生部,山东 济南

2滨州市人民医院胃肠外科,山东 滨州

收稿日期:2023年7月4日;录用日期:2023年8月1日;发布日期:2023年8月8日

摘要

直肠癌在我国是一种比较常见的恶性肿瘤,直肠癌多学科治疗(Multi-disciplinary Team, MDT)在国外已经开展较长时间,已经成为国外直肠肿瘤病人进行治疗的固定模式。近几年,我国也相继在各级医院逐步开展MDT,MDT的重要性逐步得到体现。内镜下治疗、新辅助治疗、综合治疗、加速康复外科等多种治疗方式与模式的出现改变了人民以往追求手术根除恶性肿瘤的传统观念,外科医生对于恶性肿瘤治疗开始不仅仅局限于手术切除,逐步开始探索发展肿瘤的综合治疗,追求多学科诊治,进行个性化的治疗。直肠癌的治疗已经演变成各学科综合治疗,本文将对直肠恶性肿瘤的多学科综合治疗进行综述。

关键词

直肠癌,多学科治疗,综合治疗

MDT Evaluation of Precision Therapy in Rectal Cancer

Ruyong Bi1*, Fengqiang Zhou2#, Qiangyu Sun2, Zhen Geng2

1Graduate Faculty, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan Shandong

2Gastrointestinal Surgery, Binzhou People’s Hospital, Binzhou Shandong

Received: Jul. 4th, 2023; accepted: Aug. 1st, 2023; published: Aug. 8th, 2023

ABSTRACT

Rectal cancer is a relatively common malignant tumor in our country. The Multi-disciplinary Team of rectal cancer has been carried out for a long time in foreign countries, which has become a fixed pattern of the treatment of rectal tumor patients in foreign countries. In recent years, MDT has been gradually carried out in various hospitals in China. The importance of MDT has been gradually manifested. With the emergence of endoscopic therapy, neoadjuvant therapy, comprehensive therapy, accelerated rehabilitation surgery and other treatment methods and models, people’s traditional concept of pursuing surgical eradication of malignant tumors has been changed. Surgeons began to explore the development of comprehensive treatment of tumors, pursue multidisciplinary diagnosis and treatment, and carry out personalized treatment, rather than limited to surgical resection for malignant tumors. The treatment of rectal cancer has evolved into multidisciplinary comprehensive treatments. This article will review the multidisciplinary comprehensive treatment of rectal malignancies.

Keywords:Rectal Cancer, Multi-Disciplinary Team, Comprehensive Treatment

Copyright © 2023 by author(s) and Hans Publishers Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

http://creativecommons.org/licenses/by/4.0/

1. 引言

在2020年全球癌症统计分析报告中指出结直肠癌的发病人数为193.2万人,占全球癌症发病率的10%,在全球恶性肿瘤中排第三位 [1] ,直肠癌发病率在世界各个地方也有较大差异。目前,手术仍然是直肠癌的主要治疗方法,但新治疗方法的出现为病人的治疗提供了多种可能性,多学科综合治疗(MDT)的出现把这些新技术、新手段凝聚起来加以合理利用用于治疗疾病。

2. 内镜下治疗越来越重要

内镜是直肠癌检查的重要手段,通过结肠镜检查可以发现直肠粘膜的微小病变以及鉴别癌前病变,还通过内镜加以治疗 [2] ,直肠癌通常由良性的癌前息肉病变发展而来,随着时间进展,息肉内的细胞突变到一定程度后最终可能会发展为直肠癌。通过内镜可以直观的观察肿瘤位置、大小、形态等,并可以留取活检。内镜不仅可以发现早期直肠粘膜病变,也可以对直肠早癌进行内镜下治疗,但是内镜下切除病变仍具有一定的局限性,其更常常作为一种诊断方法而不是治疗方法。目前应用最广泛的内镜技术是内镜下粘膜剥离术(endoscopic submucosal dissection, ESD)与内镜下粘膜切除术(endoscopic mucosal resection, EMR),EMR是一种相对安全的手术,术后并发症发生风险较低,但有一定的局限性。ESD能对任何浅表肿瘤进行切除,包括结直肠浅表性的病变,无论肿瘤大小或在肿瘤术后复发率等方面相较于EMR都更有优势,但其发生并发症(如穿孔)的概率也相对较大 [3] [4] [5] 。一般EMR切除的最大病变不超过20 mm,超过20 mm的病变推荐使用ESD,若ESD对于较大病变难以实施时,可以采用分块EMR技术 [6] 。通过ESD对于早期肿瘤(T1期)实现完整切除,通过病理得到肿瘤的可靠分期,对于不伴有淋巴结转移的病人可以避免进行不必要的手术 [7] 。美国国家综合癌症网络(NCCN)指南建议,含有浸润性直肠癌的息肉患者,在内镜下切除无法评估的碎片状标本或边缘时,也就是说切除标本距肿瘤横切缘1~2 mm内存在肿瘤或横切边缘透热中存在肿瘤细胞时,应额外使用手术进行切除 [8] 。这强调了切除标本边缘阴性和区域内切除术的重要性。对于术后病理提示切缘阳性的病人或内镜下切除病变比较困难的病人还是需要进行根治性手术治疗。经内镜下治疗早期直肠癌(T1期)相对于传统的直肠癌根治性手术具有术后恢复快,创伤小等优点 [9] 。但对于直肠早期病变通过内镜下治疗要严格把握适应症,通过超声内镜加以评估肿瘤具体情况 [4] 。内镜对于消化道肿瘤的筛查与确诊、早期肿瘤的治疗起着越来越重要的作用。

3. 手术仍然是治疗直肠癌的主要手段

3.1. 直肠癌局部切除手术

直肠癌局部切除手术主要包括传统经肛局部切除术(transanal excision, TAE)、经肛内镜显微手术(transanal endoscopic microsurgery, TEM)、经肛微创外科手术(transanal minimally invasive surgery, TAMIS)等。传统经肛局部切除术(transanal excision, TAE)由于存在视野限制、切缘阳性、切除标本不完整、术后复发率高等缺点已被经肛腔镜手术取代 [10] 。目前,经肛腔镜切除已成为治疗早期直肠癌(T1期)的标准术式 [11] 。

3.2. 直肠癌根治性手术

全直肠系膜切除(total mesorectal excision, TME)理念的提出极大的推动了直肠癌根治理念的进步,TME的出现使术中残存肿瘤组织的可能性进一步降低,直肠癌的局部复发率也进一步降低,进一步改善了患者的生存预期,现在TME已经成为直肠癌根治的标准术式 [12] 。基于TME的理念,经肛全直肠系膜切除术(transanal total mesorectal excision, TaTME)打破了传统经腹入路切除直肠病变的方式,采用一种“自下而上”的新理念,获得了更加清晰地的直肠视野,其对于肥胖患者级骨盆狭窄的病人更有意义。TaTME能够保证充分远端切缘,较少术中的出血量,缩短患者的术后恢复时间 [13] 。现如今经典直肠癌手术均可在腹腔镜辅助操作下完成。腹腔镜下直肠癌根治历经多年发展已经有了多种手术方式,腹腔镜直肠癌根治手术与传统开放直肠癌根治手术相比,患者在预后方面并无明显差异 [14] 。近年比较热门的达芬奇机器人的应用进一步推动了直肠癌根治微创手术的进步,达芬奇机器人由于其机械臂的灵活性对于肥胖患者与骨盆条件较差的患者更有利。来自于我国的一项多中心随机试验表明,中低位直肠癌的机器人手术在肿瘤学质量方面,患者术后恢复方面以及患者术中出血、中转开腹率等方面是优于传统腹腔镜手术的 [15] 。但也有一些认为机器人手术与传统腹腔镜手术产生的围手术期结局并无明显差异 [16] 。新兴的机器人手术是否更有利于患者的手术治疗,还需要更多的临床实验来证明。机器人手术在费用方面目前仍存在较大争议,因此对于直肠癌患者的手术治疗,在进行MDT讨论应综合考虑患者家庭因素,为患者选择合适的手术方式。

4. 围手术期放疗与化疗

围手术期的治疗有多种选择,其中最常用包括化疗(CT)、放疗(RT)、放化疗(CRT)、新辅助放化疗(nCRT)。nCRT是患者通过术前放化疗使肿瘤体积缩小、降低肿瘤分期,提高肿瘤切除率和改善患者预后,提升患者保肛率的一种治疗方法。新辅助治疗的出现进步改善了直肠癌患者术后预期,提高了生存率、降低了死亡率。在新辅助治疗后,约50%~60%左右患者肿瘤达到了降级效果,并有一部分病理可达到完全缓解 [17] 。在Robert Mechera等 [18] 人的一项Mate分析中认为术前行新辅助放化疗可降低患者术后检出的阳性淋巴结数目。欧洲肿瘤内科学会(ESMO)建议 [19] ,在直肠癌局部晚期(CT3-4N0-2)以及考虑行TME不能完全切除的情况下行新辅助治疗。

5. 直肠癌的影像学处理

影像学的应用,可以依据图像中的一些数据获得直肠癌患者术前的无创性临床指标 [20] 。目前常用的影像学检查方法,包括CT、MRI、超声等。不同的影像学检查方法成像特点不同,检查的准确性也不同,医师应通过术前各种影像学检查进行综合评估。行术前胸部、腹部及颅脑CT,静脉注射造影剂等检查,可以观测有无肝、肺、骨等远处转移(M分期)情况及局部浸润情况 [21] 。MRI是目前直肠癌术前最准确的影像学分期方法之一 [22] ,能够比较准确的反应肿瘤的浸润深度及有无侵犯邻近器官(T分期)、预测肠壁外血管侵犯(EMVI)、预测神经浸润情况、环周切缘、有无淋巴结转移(N分期)等情况 [23] [24] [25] [26] 。但是MRI对于检测淋巴结转移的特异性较差,DWI与T2w成像的结合提高了淋巴结检测,但对于良恶性鉴别有一定困难 [22] [27] 。影像学检查对于患者行新辅助放化疗、以及术后复查评估患者生存分析等方面也有指导意义 [22] [24] 。影像组学的出现也在直肠癌的诊断与治疗中表现出了其独特优势 [28] 。通过术前影像学检查,可以初步获得肿瘤的分期、位置、大小以及有无独立危险因素等情况,进行准确的术前检查,是制定可靠的治疗方案的关键。

6. 病理的处理

病理是直肠恶性肿瘤诊断的金标准。直肠癌患者术前行内镜检查取活检送病理报告,诊断为直肠癌后行多学科综合治疗。一些直肠炎症表现与直肠癌在影像表现上类似,难以区分,通过病理可以鉴别。尽管术前的影像学检查为直肠癌患者的预后与治疗提供了一定的依据,但是肿瘤术后的病理情况是分期的金标准,对于预测预后及指导后续治疗更具有实际意义。术后病理切除的边缘状态影响局部和远处复发的最重要因素之一 [29] 。另一项就是淋巴结检出情况,阳性淋巴结检出数目被认为是影响预后的一个重要指标,切除的淋巴结总数与疾病复发和总体生存期明显相关 [30] 。也可以通过术后病理体现肿瘤组织对于术前放化疗的反应。通过病理可以准确的反映出手术是否遵循了TME原则。准确的评估患者术后病理情况,对于评估患者术后复发情况、生存期以及指导后续相关治疗等起着重要作用。

7. 加速康复外科促进病人术后恢复

加速康复外科(enhance recovery after surgery, REAS)是近年来的热门话题,其目的在于通过管理患者围手术期,包括外科、麻醉、营养、疼痛等情况,缩短患者住院时间及降低手术并发症,最终实现加速康复 [31] 。营养支持治疗是加速康复外科的一个重要环节,有研究认为,围术期营养不良会增加病死率、住院费用、术后并发症发生率、住院时间 [32] [33] 。所以ERAS的核心是通过多学科团队的密切合作,来优化病人的围术期管理,加快病人康复,降低并发症发生以及缩减病人住院费用。恶性肿瘤病人由于肿瘤消耗且好发于老年人,发生营养风险的概率更大,所以合理的管理与指导患者围术期管理,给予患者实施合理的ERAS很重要。目前我国常用的营养风险评定为NRS2002 [34] ,基于国内加速康复外科临床实践指南,认为NRS2002评分 ≥ 3分认为有营养风险,均应进行营养干预,制定营养诊疗计划。对于高龄患者(≥75岁),实施ERAS住院时间不会明显缩短,但会减少术后并发症发生率 [35] 。相关研究表明 [36] ,对于有营养风险的患者进行营养支持,可减少相关手术并发症发生率,缩短住院时间,减少住院费用等。ERAS方案的实施可以提高患者3年生存率、缩短住院时间和降低再入院率 [37] ,并且可以缩短患者对于固体食物的耐受时间,并且不影响术后效果 [38] 。有关我国一项回顾研究证实 [39] ,结直肠手术患者实施ERAS方案可以缩短患者术后首次排气时间、住院时间、降低术后I、II级并发症的发生率。ERAS理念可以安全的应用于结直肠手术病人,这一理念有利于病人加快术后身体机能恢复,改善患者预后。

8. MDT精准治疗

MDT应该作为直肠癌患者的管理核心,它的质量主要取决于参与的多名专家之间的协调。MDT的建立应逐步规范化,成立MDT诊治专家小组,避免人员的更换导致诊治标准的偏差。MDT的成立在于简化治疗过程中的决策与管理,通过各个科室发挥自己的专业特长,提出合理诊疗方案,减少时间和错误,这不仅使每个患者得到了高质量的治疗,还为更多的年轻医生得到了进一步提升自己的机会。

利益冲突声明

所有作者均声明不存在利益冲突。

作者贡献声明

秘如勇负责撰文及确定文章架构;孙强玉、耿振查阅文献并修改论文;周逢强确定文章架构及审校。

文章引用

秘如勇,周逢强,孙强玉,耿 振. 直肠癌MDT评估精准治疗
MDT Evaluation of Precision Therapy in Rectal Cancer[J]. 临床医学进展, 2023, 13(08): 12291-12297. https://doi.org/10.12677/ACM.2023.1381722

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  40. NOTES

    *第一作者。

    #通讯作者。

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