术前针形腹腔镜检查评估中晚期胃肠道癌的治疗方案

目的 探讨针形腹腔镜检查对中晚期胃肠道癌治疗方案的术前评估。方法 25例老年中晚期胃肠道癌在术前局麻下接受 2 mm针形腹腔镜检查。结果 胃癌淋巴转移和腹膜转移与剖腹手术比较,符合率分别为 61. 5％（ 8/13例）和 3/5例。结直肠癌淋巴转移和腹膜转移符合率分别为 5/6例和 1/2例。结论 局麻下针形腹腔镜检查作为补充和完善影像学和临床诊断,在肿瘤的临床分期、治疗方案制定、合理术式选择等方面均具一定价值,值得进一步探讨。     

腹腔与全身性联合新辅助化疗治疗胃癌腹膜转移的初步效果

胃癌腹膜转移是晚期胃癌患者死亡的首要因素,讲者系统阐述了目前日本和我国在预防和治疗腹膜转移研究中取得的进展,详细介绍了腹腔与全身性联合的新辅助化疗(neoadjuvant intraperitoneal-systemic chemotherapy,NIPS)的优势与临床效果。指明NIPS是治疗胃癌腹膜转移的一种安全、有效的转化治疗方案,部分患者可以获得转化手术治疗,甚至达到R0切除,显著提高了转化手术率,延长了患者的生存时间和改善生活质量。但NIPS也存在一些亟待研究的临床问题,尚需多中心、大样本量的随机对照研究进一步验证和解决。     

术前针形腹腔镜检查评估中晚期胃道癌的治疗方案

目前 探讨针形腹腔镜检查对中晚期胃肠道癌治疗方案的术前评估。方法 ２５例老年中晚期胃肠道癌在术前局麻下接受２ｍｍ针形腹腔镜检查。结果 胃癌淋巴转移和腹膜转移与剖腹手术比较，符合率分别为６１．５％（８／１３例）和３／５例。结直肠癌淋巴转移和符合率分别为５／６例和１／２例。结论 局麻下针形腹腔镜检查作为补充和完善影像学和临床诊断，在肿瘤的临床分期、治疗方案制定、合理术式选择等方面均具有一定价值，值得进一步探讨。     

腹腔热灌注化疗在胃肠道恶性肿瘤腹膜转移中的应用

腹膜癌(peritoneal carcinomatosis,PC)是腹膜表面播散性生长的一类局部区域性肿瘤,常见于胃肠道恶性肿瘤腹膜转移,它被认为是一种终末期疾病,既往常采用姑息性治疗。细胞减灭术(cytoreductive surgery,CRS)加术中、术后早期腹腔热灌注化疗(hyperthermic intraperitoneal chemotherapy,HIPEC),联合围手术期系统化疗的综合治疗策略是目前治疗PC的标准方案,可降低腹膜肿瘤复发率、延长患者生存时间,并取得了一定的临床疗效。本文就腹腔热灌注化疗在胃肠道恶性肿瘤腹膜转移中的应用进行概述。     

胃肠道癌腹膜转移的核心病理机制

胃肠道癌腹膜转移是目前临床治疗的最大难题,解决该难题的根本之道在于临床医生准确把握胃肠道癌腹膜转移的核心细胞病理学机制,基本掌握分子病理学机制,并融会贯通地运用到每一例患者诊治的临床决策过程中,做到"防""治"并举,积极预防、主动治疗。与临床治疗决策密切相关的胃肠道癌腹膜转移的核心细胞病理学机制有4点:(1)腹腔游离癌细胞或微癌灶定植于腹膜,对腹膜间皮细胞造成不可逆病理性损害;(2)定植的癌细胞进一步侵袭腹膜特定结构乳斑,启动加速侵袭性生长过程;(3)腹膜间质纤维化过程加重腹膜的结构性破坏;(4)癌细胞与乳斑中免疫细胞的相互作用,形成促进腹膜转移癌生长的容受性免疫微环境。这4条核心细胞病理学机制互为因果,相互促进,构成腹膜转移发展的恶性循环。临床医生只要准确把握这4点,就有可能掌握临床诊治决策先机,将应对性被动治疗变为预防性主动治疗,改善胃肠道癌腹膜转移临床诊治现状。     

胃肠道癌术后近期复发的治疗体会

<正> 近年来,胃肠道癌的治疗效果已有明显提高,但仍有一半以上病人术后生存率低于5年。其死亡原因多是癌的术后复发和转移,术后复发的诸多因素中,癌的自身生物学特点、转移情况及治疗方案、手术方式的选择、无瘤操作技术等较为重要。我院1988年1月至1998年12月,共手术治疗胃肠道癌82例,术后近期复发再治疗的13例,约占全部手术病人的15.8％。本文就术后复发的原因、类型、诊断治疗等方面谈一下体会。     

胃癌腹膜转移诊治策略

胃癌腹膜转移是最常见的胃癌复发和转移形式,预后极差,是病人死亡的主要原因之一。由于缺乏特异临床症状,其早期诊断困难,影像学检查是胃癌腹膜转移的常用诊断方法,但其准确率较低,而腹腔镜探查或腹腔灌洗细胞学检查准确率较高。目前,对胃癌腹膜转移尚无标准的治疗方案,治疗仍以化疗为主,但常规治疗不能有效地改善胃癌腹膜转移病人的预后。近年来,积极的治疗方案如腹腔热灌注化疗、肿瘤减灭术和转化治疗等已开始应用于临床。已有研究证实,转化治疗后行肿瘤减灭术能够显著延长病人生存时间。转化治疗以其较好的疗效被越来越多地应用于临床。     

腹腔内恶性肿瘤腹膜转移的治疗进展

腹膜转移癌多由进展期胃肠道癌肿和卵巢癌等恶性肿瘤的腹腔内播散和转移所致,属于癌肿演进过程中的终末阶段。临床上这些患者往往伴有不同程度的恶性腹水和胃肠道并发症等,病情发展快,预后差,治疗相当困难。近年来对腹膜癌转移的外科治疗有了一些新的认识和发展,对于一些恶性程度低、肿瘤分化较好的患者仍可进行以减瘤性腹膜切除术为主的综合性治疗,并可取得较好的临床疗效,现就其主要有关的内容作一综合分析。     

论我国胃肠道癌腹膜转移诊治的难点和痛点

经过一个半世纪的发展, 近现代临床肿瘤学研究取得了巨大成就。作为三大常见转移途径之一, 直到20世纪末, 胃肠道癌腹膜种植转移, 才开始被重新认识, 至今日才逐渐开始形成规范性诊断治疗体系。本文回顾腹膜转移癌诊治研究的发展历史, 反思临床实践中的教训与经验, 阐述腹膜转移癌在疾病再认识、机制深入理解和临床诊治策略上的难点, 以及在理论建设、技术培训和学科建设中的痛点, 并提出了认清客观现实、夯实技术培训和推进协同研究的解决方案, 为腹膜肿瘤学稳步发展提供参考。     

结直肠癌腹膜转移的诊治策略与挑战

腹膜是结直肠癌常见的转移部位,与其他转移部位相比预后较差。早期的观点认为,腹膜转移是疾病的终末状态,全身化疗为主的姑息性治疗是其主要治疗手段。随着肿瘤细胞减灭术(CRS)+腹腔热灌注化疗(HIPEC)的治疗模式逐渐得到外科医生的认可,以及靶向治疗和免疫药物的应用,结直肠癌腹膜转移患者的预后得到了很大改善。然而,结直肠癌腹膜转移的诊治仍面临很多挑战和争议。本文从对结直肠癌腹膜转移的认识演变出发,讨论了腹膜转移可能的机制,包括"寡转移"学说和"种子-土壤"学说;进一步探讨了结直肠癌腹膜转移的诊治策略及面临的挑战,包括影像学检查的局限性、腹腔镜探查的争议、腹膜转移负荷评估困难、术后复发监测和疗效评估手段有限以及中国不同地区间诊治水平差异较大等问题。同时强调了CRS+HIPEC围手术期多学科管理的重要性,并提出应加强腹膜转移的基础与临床转化研究,推广腹膜转移的规范化诊治是提高结直肠癌腹膜转移患者预后的根本。     

胃癌腹膜转移诊治现状

腹膜种植转移是胃癌常见远处转移方式。作为胃癌终末期事件,发生腹膜转移的胃癌患者往往已经失去手术根治机会,即使行外科手术切除,远期预后仍不理想。近年来,随着腹腔镜技术、腹腔化疗、腹腔热灌注化疗等临床诊疗技术的应用与推广,在多学科诊疗模式及围手术期综合治疗策略的支持下,一部分已经发生腹膜转移的胃癌患者获得了根治性手术切除机会,提高了生活质量,延长了生存时间。考虑到近年胃癌腹膜转移治疗领域的进展,本文拟结合目前临床证据,对胃癌腹膜种植转移的临床诊疗过程中的关键问题,包括腹膜转移的影像学诊断、腹腔镜检查、腹膜转移的评估以及综合诊疗方案进行讨论。     

θ����Ĥת�����β���

??Treatment strategy for gastric cancer with peritoneal metastasis LIANG Pin??HU Xiang. Department of Gastrointestinal Surgery, the First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
Corresponding author: HU Xiang??E-mail: sunnyliangpin@163.com
Abstract Peritoneal metastasis is the most common pattern of recurrence or metastasis for gastric cancer. Associated with poor prognosis??peritoneal metastasis remains one of the main causes of gastric cancer related deaths. As is lack of specific symptom??peritoneal metastasis is hard to detect. Image examination is usually performed to detect the metastasis lesions??but the accuracy rate remains low. Laparoscopy or laparoscopic cytological examination is the reliable diagnosis method with relatively high accuracy. So far??no standard theraputic regimen has been established??chemothrapy remains the major treatment method. However??conventional treatment strategy can not improve the survival outcomes of the patients. Recently??active treatment strategy such as intraperitoneal chemotherapy??cytoreductive surgery and conversion chemotherapy have been conducted. Studies have proved that cytoreductive surgery following the conversion chemotherapy significantly prolonged the survival time of the patients. Therefore??conversion chemotherapy has been increasingly applied in the treatment of gastric cancer with peritoneal metastasis.     

θ����Ĥ������ת�����β���

??Strategies of diagnosis and treatment in recurrence and peritoneal metastasis of gastric cancer MIAO Zhi-feng, XU Hui-mian. Department of Oncological Surgery, the First Hospital of China Medical University, Shenyang 110001, China
Corresponding author: XU Hui-mian, E-mail:xuhuimian@126.com
Abstract Peritoneal metastasis is the commonest form of gastric cancer. The early diagnose and treatment have a positive significance for prognosis.The detections of imageology, tumor markers and exfoliative cytology make the early diagnosis of peritoneal metastasis more promising. Simultaneously, with the development of various kinds of chemotherapy regimen and palliative operation, patients with peritoneal metastasis of gastric cancer have more options of treatments.     

Treatment of peritoneal surface malignancy by peritonectomy and intraperitoneal chemotherapy: a novel therapy with curative potential!

Peritoneal carcinomatosis has always been regarded to have a poor prognosis. Surgery is usually limited to palliation of bowel obstruction by performing an intestinal bypass or ostomy. This severe disease has been considered as equal to distant metastasis and intravenous (i.v.) chemotherapy is commonly used in order to achieve a regression of the tumour. However, resistance to cytotoxic drugs, a poor vascular supply and high osmotic pressure might prevent the efficient uptake of i.v. chemotherapeutic agents into tumour tissues. A new concept in dissemination of gastrointestinal cancer and gynecologic cancer now require that peritoneal implants are regarded in a different way. In many patients peritoneal dissemination is a locoregional spread of disease with no manifestation of systemic disease. A locoregional therapeutic approach combining cytoreductive surgery with hyperthermic intraperitoneal intraoperative chemotherapy evolved. This new treatment option seems to be an effective therapeutic approach in carefully selected patients, and offers a chance for cure or palliation in this condition with few alternative treatment options.     

分子靶向药物在胃肠道肿瘤综合治疗中的应用

分子靶向药物在晚期胃肠道肿瘤治疗中,被证实可提高患者的客观缓解率并延长总生存期.因此,其在局部进展期胃肠道肿瘤综合治疗中的价值被逐渐重视.曲妥珠单抗用于HER-2基因阳性的局部进展期胃癌新辅助化疗中的临床研究正在进行中,结果值得期待.大量研究证明,西妥昔单抗联合化疗对于KRAS基因野生型潜在可切除的结直肠癌肝转移患者,能提高手术切除率并延长总生存期;而贝伐珠单抗在KRAS基因突变型结直肠癌肝转移术前转化治疗中的作用正在评估中.对于可切除的结直肠癌肝转移,虽现有的证据显示,分子靶向药物在新辅助治疗中未能带来长期生存益处,但最终结论仍存议甚多.对于局部进展期直肠癌患者,新辅助化疗中的西妥昔单抗在二期临床研究中未能显示治疗获益,贝伐珠单抗的作用同样需要在三期临床研究后进一步证实.与晚期肿瘤单一治疗模式不同,在肿瘤综合治疗中,需要系统评估分子靶向药物与细胞毒药物、手术以及放疗之间可能的相互影响及协同作用,制定出科学并适用于临床实践的综合治疗模式.     

胃癌腹膜复发、转移诊治策略

腹膜转移是胃癌最常见的转移形式,早期诊断和治疗对预后有积极的意义。影像学、肿瘤标记物及脱落细胞学检查使腹膜转移的早期诊断更具前景,同时,多种化疗方案及姑息性手术等综合治疗的发展,也为胃癌腹膜转移病人提供了更多的选择。     

Colorectal peritoneal metastases: pathogenesis,diagnosis and treatment options – an evidence‐based update

Peritoneal metastases confer the worst survival among all sites in patients with metastatic colorectal cancer. They develop largely through transcoelomic spread, with a sequence of events that allow cells to first detach from primary tumours, survive in the peritoneal environment, attach to the peritoneal surface of organs and migrate into the submesothelial space to create a microenvironment conducive to metastatic growth. Diagnostic challenges have previously hindered early identification of peritoneal metastases. While advances in diagnostic modalities have improved our ability to identify peritoneal metastases, lesions under 0.5 cm remain challenging to detect. The advent of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) can offer selected patients with colorectal peritoneal metastases a favourable long‐term survival. Recent trials, however, have cast doubts on the efficacy of HIPEC, with the recent PRODIGE 7 trial showing no benefit from oxaliplatin based HIPEC in addition to good quality cytoreductive surgery in resectable disease. While peritoneal recurrence can be reliably predicted from high‐risk features in primary tumours such as a perforated cancer, ovarian metastases or T4a cancers, the use of prophylactic second look surgery with HIPEC or adjuvant HIPEC failed to demonstrate any survival benefit in high‐risk cases in recent clinical trials, raising further questions about the efficacy of HIPEC. With high failure rates from systemic chemotherapy in unresectable disease, novel surgical techniques such as pressurized intraperitoneal aerolized chemotherapy are being investigated in clinical trials worldwide. Further collaborative research is needed to explore newer avenues of treatment for this poor prognostic cohort.     

Systemische Behandlungsmöglichkeiten der Peritonealkarzinose

Peritoneal metastases are common in metastatic disease of many tumour types and thus are determinant for prognosis and development of tumour-related symptoms that jeopardise quality of life. Systemic chemotherapy has proven efficacious in improving both prognosis and quality of life in numerous tumour types and should therefore be considered as part of the treatment strategy--although there is no large body of data from predefined cohorts with"only peritoneal" manifestation. In further clinical trials therefore, improvement of systemic chemotherapy by integration of novel agents should be implemented in multimodal treatment approaches combining systemic treatment, cytoreductive surgery, and intraperitoneal treatment strategies.     

进展期胃癌的腹腔缓释化疗

由于胃癌标准根治术的确立,局部淋巴结转移已非胃癌复发的主要原因,而腹膜复发转移已成为临床的最主要问题.胃癌腹膜转移的治疗主要为手术加全身治疗及腹腔内治疗.腹腔化疗分为单纯腹腔置药化疗、腹腔热灌注化疗及采取缓释剂的控释化疗.腹腔单纯置药化疗的药代动力学优势不明显;缓释化疗具有药代动力学优势,是预防和治疗胃肠肿瘤腹膜转移的有效方法.