초록

목적 : 항문에서 5cm 이내에 위치한 하부 직장암 환자들에서 항문 괄약근 보존율, 병기 강하율 등 수술 전 화학방사선요법의 효과를 분석하고자 하였으며 수술 전 화학방사선요법 시행 후에 수술을 받지 않은 환자의 예후도 분석하고자 하였다. 대상 및 방법 : 원격전이가 없는 직장암으로 진단 받고 1995년 1월 1일부터 2004 년 9월 30일 사이에 단국대학교병원 방사선종양학과에서 수술 전 화학방사선요법을 시행 받은 환자 37 명을 대상으로 후향적 분석을 하였다. 환자들은 종양이 하부 직장에 위치하여 수술시 항문 괄약근 보존이 어려울 것으로 판단되었다. 대상 환 자들은 방사선치료 전에 병기결정을 위한 검사들을 시행하였고 50.4 Gy/28 회의 수술 전 화학방사선요법을 시행한 후 약 1 개월에 조직검사를 포함한 병기결정을 위한 검사들을 다시 시행하였다 수술은 25명의 환자에 서 수술 전 화학방사선요법 종료 후 약 6 주경에 시행하였다. 증상이 호전된 후에 수술을 거부한 12 명은 주의 갚게 경과관찰을 하였다. 결과 : 병기 재평가 검사 소견 및 수술 후 병리소견을 종합할 때 전체 37 명 중 T 병기가 강하된 경우는 21 명 (56.8%), N 병기가 강하된 경우는 12 명 (32.4%) 이었다. 방사선치료 후에 수술이 시도된 환자 25 명 중 24 명에서 병소의 근치적 절제가 이루어졌다 이 중 11 명에서는 복회음부절제술, 7 명에서는 하전방절제술, 6 명에서는 국소절제술을 시행하였다 24 명 모두에서 절제연 음성의 한전절제가 이루어졌고 절제가 이루어진 환자들의 항문 괄약근 보존율은 13/24 (54.2%) 였다 환자의 거부로 수술을 시행하지 못한 환자 12 명 중 6 명은 임상적으로 완전관해의 소견이었고 조직검사에서도 암세포가 없었던 환자들이었는데 그 중 4 명이 30 개월 이상, 1 명 이 12 개월 이상 무병상태로 경과 관찰되고 있으며 1 명만 7 개월만에 국소재발이 확인되었다 반면 부분관해의 소견을 보이고 수술을 거부한 환자 6명 전원은 추적관찰 중 사망하거나 원격전이가 확인되었다 결론: 하부 직장암 환자들에서 수술 전 화학방사선요법은 수술 시행환자에서 높은 비율의 괄약근 보존율을 보였다. 하부 직장암에서 임상적으로 완전관해의 소견을 보인 경우도 수술 시행이 원칙이지만 수술을 거부하는 경우는 주의 깊게 경과 관찰을 하여도 좋은 예후를 기대할 수 있음이 시사된다.

Abstract

Purpose: This study explored the anal sphincter-saving rate and down-staging rate after preoperative chemoradiotherapy for treating lower rectal cancer. We also explored the prognosis of the patients who refused surgery after preoperative chemoradiotherapy. Materials and Methods: Thirty seven patients with histologically proven lower rectal cancer who underwent preoperative chemoradiotherapy were retrospectively analyzed. In each case, the tumor location was 0 to 5 em from the anal verge, and curative resection of the cancer with performing a sphincter-saving procedure was not feasible before chemoradiotherapy. In each case, the staging examinations, including biopsy, were done before starting radiotherapy and this was repeated at 1 month after radiation therapy. Results: After chemoradiotherapy, among the 37 included patients, 56.8% and 32.4% were downstaged to the T stage and N stage, respectively, when comparing the postradiotherapy stage with pre-radiotherapy stage. Twenty five patients underwent complete resection of cancer at 6 weeks after radiotherapy: eleven, eight and six patients underwent abdominoperineal resection, low anterior resection and local excision, respectively. The sphincter-saving rate among the 24 completely resected cases was 54.2%. Twelve patients refused surgery after radiotherapy. Among 6 patients who refused surgery with biopsy-proven complete remission after chemoradiotherapy, 5 patients were alive without disease at a median follow up period of 31 months, and only 1 patient had local failure. Conclusion: For lower rectal cancer, a high sphincter-saving rate was accomplished with preoperative chemoradiotherapy. The prognosis of the patients who refused surgery with biopsy proven complete remission after chemoradiotherapy was good and these patients need to be kept under close surveillance.

주제어

#수술 전 화학방사선요법   #직장암   #하부 직장암   #항문 괄약근 보존  

저자의 다른 논문

참고문헌 (37)

1. Gimellius B. Gronberg H, Jarhult J. Wallgren N. Cavallin-Stahl E. A systematic overview of radiation therapy effects on rectal cancer. Acta Oncologica 2003;42:476-492 
2. Glimelius B. Isacsson U, Jung B. Pahlman L. Radiotherapy in addition to radical surgery in rectal cancer: evidence for a dose-response effect favoring preoperative treatment. Int J Radiat Oncol Biol Phys 1997;37:281-287 
3. Wheeler JMD. Warren BF. Jones AC. Mortensen NJM. Preoperative radiotherapy for rectal cancer: implications for surgeons. pathologists and radiologists. British J Surg 2001;88: 1556-1557 
4. Baxter NN. Morris AM. Rothenberger DA. Tepper JE. Impact of preoperative radiation for rectal cancer on subsequent lymph node evaluation: a population-based analysis. Int J Radiat Oncol Biol Phys 2005;61:426-431 
5. Ngan SY. Fisher R. Burmeister BH. et al. Promising results of a cooperative group phase II trial of preoperative chemoradiation for locally advanced rectal cancer (TROG 9801). Dis Colon Rectum 2005;48:1389-1396 
6. Johnson LB, Jorgensen LN. Adawi DT. et al. The effect of preoperative radiotherapy on systemic collagen deposition and postoperative infective complications in rectal cancer patients. Dis Colon Rectum 2005;48:1573-1580 
7. Rouanet P, Fabre JM, Dubois JB, et al. Conservation surgery for low rectal carcinoma and high-dose radiation. Functional and oncologic results. Ann Surg 1995;221:67-73 
8. Gerard JP, Romestaing P, Baulieux J, Benchimol. Local curative treatment of rectal cancer by radiotherapy alone. Colorectal Dis 2003;5:442-444 
9. Sardi A, Minton JP, Nieroda C, Sickle-santanello B, Young D, Martin EW Jr. Multiple reoperations in recurrent colorectal carcinoma. an analysis of morbidity, mortality, and survival. Cancer 1988;61:1913-1919 
10. Horgan AF. Finlay IG. Preoperative staging of rectal cancer allows selection of patients for preoperative radiotherapy. Br J Surg 2000;87:575-595 
11. Manfredi S. Benhamiche M. Meny B. CheyneI N. Rat P. Faivre J. Population-based study of factors influencing occurrence and prognosis of local recurrence after surgery for rectal cancer. Br J Surg 2001;88:1221-1227 
12. Shin SS. Ahn YC. Chun HK. et al. Preoperative concurrent radio-chemotherapy for rectal cancer: report of early results. J Korean Soc Ther Radiol Oncol 2003;21:125-134 
13. Heriot AG, Grundy A. Kumar D. Preoperative staging of rectal carcinoma. Br J Surg 1999;86:17-28 
14. Christoforidis E. Kanellos I. Tsachalis T. Blouhos K. Lamprou I. Betsis D. Locally recurrent rectal cancer after curative resection. Tech Coloproctol 2004;8(suppl):132-134 
15. Holm T. Johansson H. Rutqvist LE. Codermark B. Tumor location and the effects of preoperative radiotherapy in the treatment of rectal cancer. British J Surg 2001;88:839-843 
16. Folkesson J, Birgisson H, Pahlman L. Cedermark B, Glimelius B. Gunnarsson. Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol 2005;20:5644-5650 
17. Branagan G, Chave H, Fuller C, McGee S, Finnis D. Can magnetic resonance imaging predict circumferential margins and TNM stage in rectal cancer? Dis Colon Rectum 2004;47:1317-1322 
18. Vironen J, Jubola M, Kairalumoa M, Jantunen I. Kellokumpu I. Tumor regression grading in the evaluation of tumour response after different preoperative radiotherapy treatments for rectal carcinoma. Int J Colorectal Dis 2005;20:440-445 
19. Gagliardi G, Hawley PR, Hershmann MJ, Arnott SJ. Prognostic factors in surgery for local recurrence of rectal cancer. Br J Surg 1995;82:1401-1405 
20. Charbit L, Peschaud F. Penna Ch. Lymph nodes and rectal cancer. J Chir 2005;142:85-92 
21. Korean National Statistical Office. Cause of death in 2001. 2002 
22. Lezoche E, Guerrieri M, Paganini AM, et al. Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscoic microsurgical excision. World J Surg 2002;26:1170-1174 
23. Ngan SYK. Optimising treatment for rectal cancer. Drug & Aging 2001;18:79-85 
24. Aschele C. Friso M. Pucciarelli S. et al. A phase I-II study of weekly oxaliplatin, 5-fluorouracil continuous infusion and preoperative radiotherapy in locally advanced rectal cancer. Ann Oncol 2005;16:1140-1146 
25. Roman S. Cenni JC. Roy P, et al. Value of rectal ultrasound in predicting staging and outcome in patients with rectal adenocarcinoma. Dis Colon Rectum 2004;47:1323-1330 
26. Minsky BD, Cohen AM, Enker WF, Paty P. Sphincter preservation with preoperative radiation therapy and colorectal anastomosis. Int J Radiat Oncol Biol Phys 1995;31:553-559 
27. Minsky BD. Conservative treatment of rectal cancer with local excision and postoperative radiation therapy. Eur J Cancer 1995;31:1343-1346 
28. Colorectal Cancer Collaborated Group. Adjuvant radiotherapy for rectal cancer: a systematic overview of 8507 patients from 22 randomised trials. Lancet 2001;358:1291-1304 
29. Peeters KC, van de Velde CJ, Leer JW, et al. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients-a dutch colorectal cancer group study. J Clin Oncol 2005;23:6199-6206 
30. Marijnen CAM. van de Velde. Preoperative radiotherapy for rectal cancer. British J Surg 2001;88:1556-1557 
31. Kang KM. Choi BO. Jang HS. Kang NK. Chai KY. Choi lB. Effect of preoperative radiotherapy for T2, T3 distal rectal cancer. J Korean Soc Ther Radiol Oncol 2002;20:215-220 
32. Berger C, de Muret A. Garaud P. et al. Preoperative radiotherapy (RT) for rectal cancer: predictive factors of tumor downstaging and residual tumor cell density (RTCD): prognostic implications. Int J Radiat Oncol Biol Phys 1997;37:619-627 
33. Cho JH. Seong JS. Keum KC. et al. Efficacy of a preoperative concurrent chemoradiotherapy for locally advanced unresectable rectal cancer. J Korean Soc Ther Radiol Oncol 2000;18:293-299 
34. Bosset JF. Calais G, Malnson P. et al. Enhanced tumorocidal etfect of chemotherapy with preoperative radiotherapy for rectal cancer: preliminary results-EORTC 22921. J Clin Oncol 2005;23:5620-5627 
35. Luna-Perez P. Rodriguez-Ramirez S, Rodriguez C, et al. Preoperative chemoradiation therapy and sphincter preservation with locally advanced rectal adenocarcinoma. World J Surg 2001;25:1006-1011 
36. Sauer R, Becker H. Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731-1740 
37. Williamson PR, Hellinger MD. Larach SW. Ferrara A. Endorectal ultrasound of T3 and T 4 rectal cancers after preoperative chemoradiotherapy, Dis Colon Rectum 1996;39:45-49 

이 논문을 인용한 문헌 (2)

1. Choi, Sang-Gyu ; Kim, Su-Ssan ; Bae, Hoon-Sik 2007. "Results of Preoperative Concurrent Chemoradiotherapy for Locally Advanced Rectal Cancer" 대한방사선종양학회지 = The Journal of the Korean soceity for therapeutic radiology and oncology, 25(1): 34~42  원문보기 상세보기
2. Yoon, Mee-Sun ; Nam, Taek-Keun ; Kim, Hyeong-Rok ; Nah, Byung-Sik ; Chung, Woong-Ki ; Kim, Young-Jin ; Ahn, Sung-Ja ; Song, Ju-Young ; Jeong, Jae-Uk 2008. "Results of Preoperative Concurrent Chemoradiotherapy for the Treatment of Rectal Cancer" 대한방사선종양학회지 = The Journal of the Korean soceity for therapeutic radiology and oncology, 26(4): 247~256  원문보기 상세보기