摘要：局部进展期直肠癌侧方淋巴结（LLN）转移与患者预后相关。但是对侧方淋巴结清扫（LLND）的临床意义，学术界始终存在争议。在此，我们特邀莫斯科 Chechenov国立医科大学的Petrv Tsarkov教授为我们分享结直肠癌淋巴结清扫术方面的临床争议与思考。
编者按：局部进展期直肠癌侧方淋巴结（LLN）转移与患者预后相关。但是对侧方淋巴结清扫（LLND）的临床意义，学术界始终存在争议。在此，我们特邀莫斯科 Chechenov国立医科大学的Petrv Tsarkov教授为我们分享结直肠癌淋巴结清扫术方面的临床争议与思考。
肿瘤瞭望消化时讯：临床应该如何定义结直肠癌淋巴结清扫的程度？
Tsarkov 医生：广泛淋巴结清扫术的临床适应证仍然是一个很有争议的问题，因为我们的诊断工具仍存在局限性。例如，经CT 或 MRI 检查评估的阳性淋巴结在结直肠癌中的阳性预后价值非常低 （10%~30%）。现在我们尝试使用人工智能来改善这种情况，但这些诊断工具的诊断价值仍然相当低，因此我们需要在手术开始前和手术期间决定是否扩展淋巴结清扫术。俄罗斯外科医生的观点是，对于T2-T4期结肠癌和直肠癌患者，应进行预防性淋巴结清扫术，因为这样做有一定的获益，这些肿瘤中约有 30% 会发生淋巴结转移。
Dr Tsarkov: Clinical indications for extensive lymph node dissection is still a controversial question, because it is limited by possibilities of our diagnostic tools. For example, the positive prognostic value of CT or MRI investigation of positive lymph nodes in colon and rectal cancer is very low - from 10-30%. Now we try to use artificial intelligence to improve this situation, but there is still quite a low diagnostic value of these diagnostic tools. That is why we need to decide about the extension of lymph node dissection before we start surgery and during surgery. The position of Russian surgeons is to do prophylactic extension of lymph node dissection for patients who have T2-T4 tumors of colon and rectal carcinomas, because there is some benefit from this, as around 30% of these tumors will have metastases to the lymph nodes.
肿瘤瞭望消化时讯：鉴于局部晚期直肠癌向外侧淋巴结 （LLN） 的转移与患者预后相关，我们如何定义外侧淋巴结清扫术 （LLND）？
Tsarkov 医生：如果患者的侧方淋巴结阳性，当然会降低该患者的预后。但是，如果我们对这些阳性淋巴结采取一些治疗，即使我们不能从根本上治疗这些患者，也可以提高患者的存活率并延长总生存期。在我们机构，自 2000 年以来，我们一直使用外侧淋巴结清扫术。我们可能拥有接受侧方淋巴结清扫手术的白种人患者数量最多的群体，这与日本、中国或韩国等亚洲国家的情况不同，在那些国家，这种手术类型被非常频繁且广泛地采用。在西方世界，这种情况并不常见。我们可以看到，对于仅累及髂内淋巴结的患者，该手术的预后非常好——约 60% 的患者能够存活。但是，如果患者存在阳性淋巴结的髂外扩散，那么他们的存活率就较差，这类患者的存活率约为30%~35%。
Dr Tsarkov: If a patient has a positive lateral lymph nodes, of course this decreases the prognosis for this patient. But if we do some treatment for these positive lymph nodes, we can improve survival rates and prolong overall survival, even if we cannot treat these patients radically. In our institution, we have used lateral lymph node dissections since the year 2000. We have perhaps the largest population of patients that have had lateral lymph node dissection for Caucasian patients, not from an Asian population like Japan, China or Korea, where this type of procedure is used very often and intensively. In the Western parts of the world, it is not a common situation. We can see that for patients who just have internal iliac lymph node involvement, the prognosis is very high - around 60% of patients will survive. But if we have an external iliac extension of positive lymph nodes, unfortunately, this group of patients have poorer survival rates, but it is still a 30-35% survival rate for these types of patients.
肿瘤瞭望消化时讯：目前关于局部晚期中低位直肠癌的治疗策略有哪些争议？
Tsarkov 医生：在我看来，主要争议是我们应该如何治疗低位直肠癌。对于中位直肠癌，我们都知道大多患者将使用标准的全直肠系膜切除术进行治疗。即使仅通过手术而没有任何辅助治疗，或许90%以上的患者也不会出现局部复发。然而对于低位直肠癌，我们还存在一些争议：第一个争议点是生存率及其影响因素。我认为关键因素在于侧方淋巴结清扫，因为约 30% 的低位直肠癌患者具有髂外侧淋巴结阳性，这也是我们需要关注这种情况的原因；第二个争议点是功能结局。对于局部直肠癌，我们通常需要使用腹会阴联合切除术，这意味着患者需要永久性造口。目前，全球范围内，我们采用了一种“观察等待”策略来治疗这种情况，以避免手术，即所谓的器官保留策略。如果患者在放化疗后（8周内）没有获得完全缓解，那么我们在采用这种策略时应非常谨慎，因为若未获得完全缓解，我们应更倾向于考虑手术治疗。
Dr Tsarkov: The main controversy in my opinion is how we should treat low rectal carcinoma. For mid rectal cancer, we all know that the majority of patients will be treated using standard total mesorectal excision. Maybe >90% of patients will not recur locally, even if we just use surgery without any additional treatment. However, for low rectal carcinomas, we have some controversies. The first controversy is the survival rate and the features that contribute to the survival rate. In my opinion, the main feature is lateral lymph node dissection, because around 30% of patients with low rectal carcinoma will be lateral iliac lymph node positive. That is why we need to focus on this situation. The second controversy is the functional outcome. For local rectal carcinoma we often need to use abdominoperineal resection, which means a permanent stoma. Today, all over the world, we use a watch and wait strategy for treatment of this to avoid surgery - a so-called organ preservation strategy. If we do not have a complete response immediately after chemoradiation therapy (within 8 weeks), we should be very careful using this strategy, because if we do not have a complete response, we should look at surgery more extensively.
来源：肿瘤瞭望消化时讯
