Lokal ileri ve/veya lenf düğümü tutulumu olan rektum kanserinde neoadjuvan kemoradyoterapiye yanit ve sfinkter koruyucu cerrahinin araştırılması

Amaç: Lokal ileri ve/ veya lenf düğümü tutulumu olan rektum kanseri tanısıyla uzun dönem neoadjuvan kemoradyoterapi uygulanan olgularda tümör ve nodal evrede gerileme ve patolojik yanıt oranlarının belirlenmesi amaçlanmıştır. Yöntem: Mersin Şehir Eğitim ve Araştırma Hastanesi Radyasyon Onkolojisi Bölümünde 2017 yılı içerisinde neoadjuvan kemoradyoterapi uygulanmış olan lokal ileri ya da lenf düğümü metastazı olan rektum kanserli 23 olgunun verileri retrospektif olarak değerlendirildi. Tüm olgulara kemoterapi, radyoterapi ile eşzamanlı olarak uygulanmıştır. Yirmi bir olguya neoadjuvan kemoradyoterapi bitiminden 4- 8 hafta sonra küratif cerrahi yapılmıştır. Neoadjuvan kemoradyoterapiye yanıtın değerlendirmesi ameliyat öncesi evreleme ile patolojik evrenin karşılaştırılması ile yapıldı. Rezeksiyon materyalinde herhangi bir kanser hücresi gözlenmemesi patolojik tam yanıt olarak değerlendirildi. Tümör ve nodal evredeki gerileme kısmi yanıt olarak değerlendirildi. Bulgular: Olguların ortalama yaşı 57.3± 9.8 idi. Tedavi öncesi yapılan radyolojik incelemelerde olguların 9’unda (%39.1) T3, 14’ünde (%60.9) T4 tümör saptandı. Olguların 14’ünde (%60.9) lenf düğümü metastazı izlenmezken, 9 olguda (%39.1) lenf düğümü metastazı saptandı. Tümörün yerleşim yeri; 8 (%34.8) alt rektum, 7 (%30.4) orta rektum, 8 (%34.8) üst rektum idi. Sfinkter koruyucu cerrahi olguların %71.4’üne uygulanabildi. Neoadjuvan kemoradyoterapi sonrası olguların 7’sinde (%30.4) patolojik tam yanıt, 13’ünde (%56.5) ise kısmi yanıt izlendi. Neoadjuvan tedaviye yanıt ile tümör yerleşimi ve sfinkter koruyucu cerrahi uygulanabilirliği arasında yapılan istatistiksel analizde anlamlı farklılık izlenmemiştir Sonuç: Neoadjuvan kemoradyoterapi uygulanan olguların büyük bir kısmında tümörde boyut ve/ veya evre gerilemesi sağlanabilmektedir. Evre gerilemesi, sfinkter koruyucu cerrahi uygulanabilirliğini arttırmamaktadır.

Anahtar Kelimeler:

Lokal ileri rektum kanseri, neoadjuvan kemoradyoterapi, sfinkter koruyucu cerrahi

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1. Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R; German Rectal Cancer Study Group. Preoperative versus postoperative chemoradiotherapy for rectal cancer.N Engl J Med. 2004 Oct 21; 351(17): 1731-1740.
2. Rahbari NN, Elbers H, Askoxylakis V, Motschall E, Bork U, Büchler MW, Weitz J, Koch M. Neoadjuvant radiotherapy for rectal cancer: meta-analysis of randomized controlled trials. Ann Surg Oncol 2013 Dec;20(13): 4169-4182.
3. Wagman R, Minsky BD, Cohen AM, Guillem JG, Paty PP.Sphincter preservation in rectal cancer with preoperative radiation therapy and coloanal anastomosis: long term follow-up. Int J Radiat Oncol Biol Phys. 1998 Aug 1; 42(1): 51-57.
4. Das P, Skibber JM, Rodriguez-Bigas MA, Feig BW, Chang GJ, Wolff RA, Eng C, Krishnan S, Janjan NA, Crane CH. Predictors of tumor response and downstaging in patients who receive preoperative chemoradiation for rectal cancer. Cancer 2007; 109: 1750-1755.
5. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. AJCC cancer staging manual (7th ed). New York, NY: Springer; 20106. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet 1986; 2: 996-999.
7.Biondo S, Navarro M, Marti-Rague J, Arriola E, Pares D, Del Rio C, Cambray M, Novell V.Response to neoadjuvant therapy for rectal cancer: influence on long-term results. Colorectal Dis 2005; 7: 472-479.
8. Devine RM, Dozois RR. Surgical management of locally advanced adenocarcinoma of the rectum. World J Surg 1992; 16: 486-489.9. Halefoglu AM, Yildirim S, Avlanmis O, Sakiz D, Baykan A. Endorectal ultrasonography versus phased-array magnetic resonance imaging for preoperative staging of rectal cancer. World J Gastroenterol 2008; 14: 3504-3510.
10. Collette L, Bosset J-F, den Dulk M, Nguyen F, Mineur L, Maingon P, Radosevic-Jelic L, Piérart M, Calaiset G. Patients with curative resection of cT3-4 rectal cancer after preoperative radiotherapy or radiochemotherapy: does anybody benefit from adjuvant fluorouracil- based chemotherapy? A trial of the European Organisation for Research and Treatment of Cancer Radiation Oncology Group. J Clin Oncol 2007;25:4379-4386.
11. Das P, Skibber JM, Rodriguez-Bigas MA;. Feig BW; Chang GJ; Hoff PM; Eng C;. Wolff RA;. JanJan NA; Delclos ME; Krishnan S;. Levy LB; Ellis LM; Craneet CH Clinical and pathologic predictors of locoregional recurrence, distant metastasis, andoverall survival in patients treated with chemoradiation and mesorectal excision for rectal cancer. Am J Clin Oncol 2006; 29: 219-224.
12. Fietkau R, Barten M, Klautke G, Klar E, Ludwig K, Thomas H, Brinckmann W, Friedrich A, Prall F, Hartung G. Postoperative chemotherapy may not be necessary for patients with ypN0-category after neoadjuvant chemoradiotherapy of rectal cancer. Dis Colon Rectum. 2006; 49: 1284–1292. 13. Park IJ, You YN, Agarwal A, Skibber JM, Rodriguez-Bigas MA, Eng C, Feig BW, Das P, Krishnan S, Crane CH, Hu CY, George J. Changet GJ. Neoadjuvant treatment response as an early response indicator for patients with rectal cancer. J Clin Oncol 2012; 30: 1770-1776.
14. Silberfein EJ, Kattepogu KM, Hu CY, Skibber JM, Rodriguez-Bigas MA, Feig B, Das P, Krishnan S, Crane C, , Kopetz S, Eng C, Chang GJ. Long-term survival and recurrence outcomes following surgery for distal rectal cancer. Ann Surg Oncol 2010;17:2863-2869.
15. Smith KD, Tan D, Das P, Chang GJ, Kattepogu K, Feig BW, Skibber JM, Rodriguez-Bigas MA. Clinical significance of acellular mucin in rectal adenocarcinoma patients with a pathologic complete response to preoperative chemoradiation. Ann Surg 2010; 251: 261-264.
16. Wong RK, Tandan V, De Silva S, Figueredo A. Preoperative radiotherapy and curative surgery for the management of localized rectal carcinoma. Cochrane Database Syst Rev 2007:CD002102.
17. Bujko K, Kepka L, Michalski W, Nowacki MP. Does rectal cancer shrinkage induced by preoperative radio(chemo)therapy increase the likelihood of anterior resection? A systematic review of randomised trials. Radiother Oncol 2006; 80: 4-12.
18. Bozzetti F, Baratti D, Andreola S, Zucali R, Schiavo M, P Spinelli , Gronchi A, Bertario L, Mariani L, Gennari L. Preoperative radiation therapy for patients with T2-T3 carcinoma of the middle-to-lower rectum. Cancer 1999; 86: 398-404.
19. Habr-Gama A, Perez RO, Nadalin W, Sabbaga J, Ribeiro U Jr, Silva e Sousa AH Jr, Campos FG, Kiss DR, Gama-Rodrigues J. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 2004; 240: 711-717.
20. Schell SR, Zlotecki RA, Mendenhall WM, Marsh RW, Vauthey JN, Copeland EM 3rd. Transanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapy. J Am Coll Surg 2002; 194: 584-590.
21. Kim CJ, Yeatman TJ, Coppola D, Trotti A, Williams B, Barthel JS, Dinwoodie W, Karl RC, Marcet J Local excision of T2 and T3 rectal cancers after down- staging chemoradiation. Ann Surg 2001; 234: 352-358.
22. Habr-Gama A, de Souza PM, Ribeiro U Jr, Nadalin W, Gansl R, Sousa AH Jr, Campos FG, Gama-Rodrigues J. Low rectal cancer: impact of radiation and chemotherapy on surgical treatment. Dis Colon Rectum 1998; 41: 1087-1096.
23. Guillem JG, Chessin DB, Shia J, Moore HG, Mazumdar M, Bernard B, Paty PB, Saltz L, Minsky BD, Weiser MR, Temple LKF, Cohen AM,Wong WD. Clinical examination following preoperative chemoradiation for rectal cancer is not a reliable surrogate end point. J Clin Oncol 2005; 23: 3475- 3479.
24. Chen CC, Lee RC, Lin JK, Wang LW, Yang SH. How accurate is magnetic resonance imaging in restaging rectal cancer in patients receiving preoperative combined chemoradiotherapy? Dis Colon Rectum 2005; 48: 722-7228.
25. Capirci C, Rubello D, Chierichetti F, Crepaldi G, Carpi A, Nicolini A, Mandoliti G, Polico C. Re- staging after neoadjuvant chemoradiotherapy for rectal adenocarcinoma: role of F18-FDG PET. Biomed Pharmacother 2004; 58: 451-457.
26. Meterissian S, Skibber J, Rich T, Roubein L, Ajani J, Cleary K, Ota DM. Patterns of residual disease after preoperative chemoradiation in ultrasound T3 rectal carcinoma. Ann Surg Oncol 1994; 1: 111-116.
27. Zmora O, Dasilva GM, Gurland B, Raphael Pfeffer; Moshe Koller; Juan J. Nogueras; Steven D. Wexner. Does rectal wall tumor eradication with preoperative chemoradiation permit a change in the operative strategy? Dis Colon Rectum 2004; 47: 1607- 1612.
28. Stipa F, Zernecke A, Moore HG, Minsky BD, Wong WD, Weiser M, Paty PB, Shia J, Guillem JG.Residual mesorectal lymph node involvement following neoadjuvant combined-modality therapy: rationale for radical resection? Ann Surg Oncol 2004; 11: 187-191.
29. Nakagawa WT, Rossi BM, de O Ferreira F, Ferrigno R, David Filho WJ, Nishimoto IN, Vieira RA, Lopes A. Chemoradiation instead of surgery to treat mid and low rectal tumors: is it safe? Ann Surg On- col 2002; 9: 568-573.
30. Bo Young Oh, Jung Wook Huh, Woo Yong Lee, Yoon Ah Park, Yong Beom Cho, Seong Hyeon Yun, Hee Cheol Kim, Ho-Kyung Chun. Are We Predicting Disease Progress of the Rectal Cancer Patients without Surgery after Neoadjuvant Chemoradiotherapy? Cancer Res Treat. 2017 Jul 3.