客观评价和正确开展结直肠癌的新辅助治疗

结直肠癌的新辅助治疗应遵循以下原则：（1）对于II期,III期的直肠癌病人应进行术前新辅助治疗。具体方案可采用放疗或放化疗联合。但不推荐单纯化疗。（2）对于不伴有远处转移的结肠癌病人不推荐术前新辅助治疗。仅对于可切除结肠癌肝转移病人可行新辅助化疗,以达缩小病灶,杀灭潜在转移灶之目的。     

胰腺神经内分泌肿瘤初治治疗策略

20％ ～ 30％胰腺神经内分泌肿瘤(pNENs)在初诊时可切除,70％ ～ 80％的pNENs是局部晚期或转移性肿瘤.对手术可切除的pNENs,建议积极手术切除原发肿瘤和转移肿瘤.对功能性的局部晚期或转移性pNENs,积极的减瘤术有助于控制症状,改善患者的生命质量;无功能性肿瘤不推荐减瘤术,除非发生出血、梗阻等危及生命的并发症.对Ⅰ型肝转移,应积极联合原发肿瘤切除;Ⅱ型肝转移,可探索全身综合治疗联合肝脏的局部治疗,如RFA、动脉栓塞和栓塞化疗;Ⅲ型肝转移可给予舒尼替尼、依维莫斯联合长效生长抑素的治疗.pNENs获得根治性切除后无需辅助治疗,但若是转移性病灶获得根治性切除,建议给予后续治疗,预防复发.     

不同类型胰腺癌的治疗策略

目的探讨不同类型胰腺癌的治疗策略。方法通过阅读近几年国内外胰腺癌治疗的相关文献,对胰腺癌的分类及其治疗措施的进展进行归纳总结。结果依据术前影像学评估将胰腺癌分为可切除胰腺癌、交界可切除胰腺癌、局部进展期胰腺癌和合并远处转移的胰腺癌。可切除胰腺癌应行根治性切除,术后辅以化疗。交界可切除胰腺癌患者中,静脉受侵若能够切除重建,主张行手术治疗,术后行辅助化疗;对于静脉受侵不可切除重建及动脉受侵的患者,应行新辅助治疗,然后对肿瘤的可切除性进行重新评估,明确是否可行手术治疗。局部进展期或合并转移的胰腺癌患者多已失去手术时机,多主张行新辅助放化疗或二线联合靶向治疗。结论大多数胰腺癌患者就诊时肿瘤已进入进展期,熟悉掌握胰腺癌的类型,采取针对性的治疗措施,可改善患者的生存时间。     

结直肠癌肝转移外科治疗的争议

肝脏是结直肠癌最常见的转移部位,肝转移是结直肠癌治疗失败的主要原因。外科切除在结直肠癌肝转移综合治疗模式中占据主导地位．也是患者获得治愈机会的重要手段。尽管如此,在结直肠癌肝转移外科治疗领域目前还存在很多困惑和争议．包括结直肠癌肝转移分期系统尚不完善、潜在可切除标准尚未统一、可切除肝转移灶是否需要新辅助化疗、根治切除后辅助化疗方案的选择以及不可切除肝转移灶患者无症状原发灶的处理等。本文依据近年来发表的研究资料,结合自身临床实践,剖析肝转移外科研究领域中不同的观点和依据。     

临界可切除胰腺癌的诊疗策略

胰腺癌早期诊断困难,80%的患者就诊时已发生局部进展或远处转移。目前,手术切除仍是胰腺癌患者获得长期生存的唯一方法。近年来,胰腺癌综合治疗水平较前有所提高。针对临界可切除胰腺癌进行新辅助治疗,可以达到降期,甄别人群,筛选潜在获益人群进行手术的目的。合理选择有效化疗方案,恰当选择手术时机,能进一步提高胰腺癌的切除率,从而延长该类高危人群的生存期。     

结直肠癌同时性肝转移手术时机的选择

目的 探讨可切除性结直肠癌同时性肝转移的手术时机.方法 回顾性分析2009年10月至2011年11月上海交通大学医学院附属仁济医院收治的5例结直肠癌伴同时性肝转移患者的临床资料,根据患者的情况分别行手术治疗+辅助化疗、新辅助化疗或靶向治疗.结果5例患者均行手术+术后辅助治疗.3例原发灶和肝转移灶可切除者,1例先行新辅助化疗,肝转移灶明显缩小后一期手术切除原发灶和肝转移灶,术后6个月MRI检查发现肝内复发;1例未行新辅助化疗,术后9个月CT检查发现肺内多发转移灶;1例因原发灶穿孔腹腔感染,先切除原发灶,术后化疗+靶向治疗,二期切除肝内转移灶,术后12个月CT检查发现肺内单发转移灶.其余2例因肝内多发性转移灶无法手术切除,仅切除原发灶,1例术后13个月死于骨转移;另1例行辅助化疗+靶向治疗,CT检查示肝内转移灶曾一度进行性缩小,但术后11个月开始肝内转移灶渐增多、增大.5例患者术后均行k-ras基因检测,除病例2的Condon 12位点为野生型、Condon 13位点为突变型外,其余患者均为野生型.结论新辅助化疗或新辅助化疗+靶向治疗的效果个体差异大,消灭体内微转移灶作用有限,首选一期手术切除原发灶和同时性肝转移灶有可能使患者获益最大.     

结直肠癌肝转移临床治疗现状

目前,结直肠癌发病率呈上升趋势,肝脏是结直肠癌最易发生转移的靶器官之一,手术是惟一有效的治愈手段。结直肠癌肝转移（CLM）的治疗正在由＂手术切除-术后化疗＂向＂新辅助治疗-手术切除-靶器官局部治疗-术后化疗＂等多学科综合治疗（MST）模式转变。该模式的核心问题是如何创造条件进行根治性手术切除及预防术后复发。切缘阴性的病理性根治（R0）切除联合提高肿瘤局控率的肝脏靶器官局部治疗,是控制肿瘤复发的重要方法。     

晚期结直肠癌术前评估及治疗策略

晚期结直肠癌主要分为局部晚期、术后局部复发及远处转移,远处转移主要包括腹膜转移及肝、肺等全身脏器的转移.手术切除是可能治愈晚期结直肠癌的惟一手段.术前以影像学评估为主,特别是对结直肠癌肝转移患者转移病灶可切除性的评估是外科治疗中尤其值得关注的问题.新辅助治疗及辅助治疗增加了晚期结直肠癌患者原发及转移病灶的手术切除率.近10年来,随着肿瘤外科的发展,多学科团队治疗模式的提出和实施,不仅使患者最大限度的受益,延长患者的生存时间,同时最大限度提高了患者的生命质量.     

进展期结直肠癌的新辅助治疗

结直肠癌的发病率全世界范围内逐年上升．手术治疗是结直肠癌治疗的最佳选择，术后辅助治疗包括化疗、放疗、介入、靶向治疗等可使相当多的患者受益，但手术后的复发和转移以及初诊即无法手术的患者依然是临床医生面临的一大困扰。新辅助治疗的实施可使进展期结直肠癌的预后有进一步的提高。新辅助治疗指手术治疗前通过全身或介入化疗、放疗和靶向治疗等使肿瘤减负的一种治疗手段。新辅助治疗目的：（1）降低肿瘤局部负荷，使不可切除的肿瘤获得切除机会或更大的切除成功率；（2）使肿瘤缩小从而减少切除范围，保留更多正常组织；（3）通过新辅助治疗的疗效指导手术以后的治疗；（4）提高术后长期生存率，减少术后复发，预防术后远处转移。     

伴有同时性不可切除肝转移的结直肠癌患者治疗的思考

对于肝转移灶不可切除的结直肠癌患者,需要经过多学科刚队讨论,采用全身化疗、介入化疗和肝转移灶消融毁损术等多种方法改善患者预后．应结合患各和肿瘤的特征将患者分为不同组刖,制定各自的治疗同标和治疗策略。其中部分患者,如果化疗后可能转化为潜在可切除,建议给予强化的三药联合方案,尽髓缩短疗程,从而获得肿瘤的最佳反应率．继而行手术切除。KRAS野乍型的患并推荐西妥子单抗联合FOLFOX或FOLFIRI方案,而且旦转移灶转化为可切除,就应该积极手术切除。埘十肝转移灶不可切除且原发灶尤症状的患者,手术切除原发灶似乎可以获得生存收益。关于非手术治疗的选择,目前临床上还存在争议。     

Surgical management of locally advanced lung cancer

Majority of cases of lung cancer are detected at an advanced stage; such patients are usually treated with chemotherapy and radiotherapy, and the prognosis is frequently poor. Surgical resection remains the only reliable curative method for the treatment of lung cancer, and combined resection of the primary tumor and involved neighboring structures is performed when possible in patients with locally advanced disease. In the TNM classification, tumors with direct extrapulmonary extension are subdivided based on the anatomic extent of disease and its potential for surgical treatment: T3 lesions with limited, circumscribed extension are thought to be potentially surgically resectable, whereas T4 tumors with extensive extension are considered unresectable. Although surgical treatment for T3 lesions is generally accepted, the outcome is frequently not satisfactory. On the other hand, advanced surgical techniques are now being applied for T4 lesions due to improvements in surgery and anesthesiology and progress in combined treatment modalities. In the present staging, T4N0–1M0 lesions are categorized as stage IIIA disease, and T4 tumors without mediastinal nodal metastasis are now considered to be potentially curable if complete resection is possible. This article reviews the modern surgical management of patients with lung cancer invading neighboring structures, including the chest wall, superior sulcus, diaphragm, tracheal carina, left atrium, superior vena cava, aorta and vertebrae. Furthermore, the surgical treatment of carcinomatous pleuritis, which was categorized as T4 disease in the previous TNM classification, is also assessed, and the role of surgical resection in cases of locally advanced lung cancer is discussed.     

个体化治疗直肠癌同时性肝转移

肝转移是影响结直肠癌预后的重要因素之一。一般认为手术切除是唯一可能治愈结直肠癌肝转移的治疗手段。而近年随着新辅助化疗与肿瘤物理消融技术以及微创技术的进展,尤其在生物一心理一社会的现代医学模式背景下,对可以手术切除的结直肠癌同时性肝转移患者如何选择更为合理的手术方式尚存在较多争议。中国医科大学附属盛京医院收治1例直肠癌同时性肝转移患者经新辅助化疗后腹腔镜下肝转移癌微波消融＋开腹结直肠癌根治性切除术的联合序贯治疗,为同类患者治疗方式的个体化选择提供参考。     

复发转移性结肠癌1例MDT讨论

目的总结1例右半结肠癌肝肺转移并腹膜后转移患者的诊治经过及经验。方法回顾性分析昆明医科大学第一附属医院于2016年8月收治的1例行MDT讨论的右半结肠癌肝肺转移并腹膜后转移患者的临床资料,对其诊治经验进行总结分析,以期为国内学者诊治晚期结直肠癌提供参考意见。结果该患者于MDT前接受了数周期化疗和3次手术切除原发灶及转移灶后,再次发现腹膜后占位,经影像科、肿瘤内科、放疗科和胃肠与疝外科多学科MDT讨论后,认为目前患者的治疗方案主要是手术,术后继续口服化疗药物。患者接受了腹膜后肿瘤切除术+腹腔粘连松解术。术后已获访3个月,未发现复发转移灶,继续随访。结论右半结肠癌合并肝肺转移及腹膜后转移的治疗上主要以术前新辅助治疗,手术切除原发病灶、转移灶和复发病灶为基础,术后结合放化疗和分子靶向治疗在内的综合治疗,同时需定期监测CEA值变化。     

Intraoperative radiotherapy for pancreatic adenocarcinoma

Intraoperative radiotherapy (IORT) is an innovative treatment approach for cancer of the pancreas. The common causes of treatment failure in pancreatic cancer are regional recurrence and distant metastasis. While at present the benefit of IORT in unresectable pancreatic cancer is still controversial and awaits further prospective trials for its clarification, the experience gathered over a period of 30 years with IORT for pancreatic cancer does suggest that IORT should be part of the adjuvant therapy of surgical resection. A combination with pre- or postoperative external beam radiotherapy and chemotherapy may be beneficial for both resectable and unresectable patients. IORT was shown to be a relatively safe intervention and it notably improved the quality of life of patients with locally advanced pancreatic carcinomas by alleviating their pain. Here, we summarize and discuss the experience reported to date and present our historical analysis of IORT for pancreatic cancer. Received for publication or Sept. 18, 1997; accepted on March 25, 1998     

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??Interpretation of surgical treatment part of updated NCCN clinical practice guideline for rectal cancer SHEN Zhan-long, YE Ying-jiang, ZHOU Jing, et al. Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing100044, China
Corresponding author: YE Ying-jiang, E-mail:yeyingjiang@
pkuph.edu.cn
Abstract NCCN??National Comprehensive Cancer Network) clinical practice guideline updated in many areas of diagnosis, treatment and follow-up in 2017. Main content include tumor budding is added to an adverse histological feature with adverse outcome after operation of malignant polyps; options of "watch and wait" after chemoradiation and chemotherapy is recommended to cT1N0M0 rectal cancer patients who underwent transanal local resection with unfavorable histopathological features; postoperative treatment of pT3-4N0M0 rectal cancer patients whose preoperative stage is cT1-2N0M0 could be "watch and wait" or chemotherapy; the patients underwent preoperative therapy is not necessary to get postoperative treatment; perioperative target therapy is deleted from the strategy of resectable synchronous liver metastasis of rectal cancer??short course radiotherapy is permitted in the treatment of primary tumor of resectable liver metastasis of rectal cancer; the effect of cytoreductive surgery combined with intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis of colorectal cancer is affirmed cautiously.     

The mayo clinic experience with multimodality treatment of locally advanced or recurrent colon cancer

Background Patients with incompletely resected locally advanced and recurrent colon cancers have a dismal prognosis. Since 1981, 100 colon cancer patients have been treated with combination therapy including surgical resection, chemotherapy, and external plus intraoperative radiotherapy. Methods A prospective computerized intraoperative radiation database identified patients for this retrospective review. Data collection included patient demographics, tumor and treatment variables, and morbidity, recurrence, and survival statistics. Results The mean age was 55.2 years. Follow-up was available for all patients. Fifty-nine patients have died. Median follow-up of survivors was 70.5 months. Twenty-five patients with locally advanced colon cancer had a median survival of 38.2 months and a 5-year survival of 49%. Eleven of these patients are still free of disease. Seventy-three patients treated for recurrent colon carcinoma had a median survival of 33.3 months from the time of recurrence, with a 5-year survival of 24.7%. Twenty-one are alive without evidence of recurrence. The 38 patients with recurrent disease whose disease was completely resected had a 37.4% 5-year survival. Conclusions A multimodality approach using en-bloc surgical resection with radiotherapy and chemotherapy affords some patients with locally advanced and recurrent colon cancer a chance for long-term survival. Presented at the 54th Annual Cancer Symposium of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.     

胸段食管鳞癌的多学科综合治疗

食管癌患者就诊时大多已为中晚期,第七版UICC食管癌新分期Ⅲ期以上肿瘤单纯手术切除往往疗效不满意,系统性的多学科治疗至关重要.越来越多的证据表明术前同期放化疗是最为有效的诱导治疗方式,可使肿瘤降期并提高根治性切除率;针对食管鳞癌中常见的多组、多野淋巴结转移患者,术前诱导化疗不失为可行的选择.对于已根治性手术切除的局部进展期肿瘤,术后辅助放疗或有助于弥补手术清扫范围的不足以加强局控;术后辅助化疗的作用亦有待进一步深入研究.胸段食管鳞癌与西方国家常见的食管下段腺癌有本质的不同,需要积累更多的前瞻性临床研究,以形成适合我国食管癌患者的综合治疗模式.     

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.     

Management of potentially resectable colorectal cancer liver metastases

Colorectal cancer is a very common malignancy worldwide and development of liver metastases,both synchronous or metachronous,is a common event.Of all patients with metastatic colorectal cancer,up to 77% have a liver-only disease and approximately 10%-20% of patients with colorectal liver metastases are considered resectable at the time of diagnosis.Surgical resection of liver metastases remains the best treatment option and it is associated with a survival plateau and a 20%-25% of long-term survivors.Perioperative chemotherapy for resectable liver metastases may improve resecability of liver metastases and disease free survival,but its impact on overall survival is still unclear and more studies are needed.Moreover,preoperative chemotherapy can increase postoperative complications.Further studies are needed to define the role of adjuvant chemotherapy after a R0 resection of liver metastases and to define the criteria for a better selection of patients candidate to hepatectomy.New strategies such as targeted therapies are emerging with promising results.Optimal management requires a multidisciplinary approach,local and systemic,but it is a still pending question.Colorectal liver metastases represent a major challenge for oncologists and surgeons.In this review will be analyzed available data about assessment and management of the patients with potentially resectable colorectal liver metastases.