MRI在直肠癌新辅助放化疗前后肿瘤浸润深度评估中的应用

术前新辅助放化疗已经成为局部进展期中低位直肠癌的主要治疗模式。然而,术前放化疗可导致肿瘤退缩、局部水肿、炎性改变、纤维化和坏死,影响新辅助治疗的影像学评价。     

直肠癌术前新辅助放化疗的相关问题

近年研究结果显示,借助术前新辅助放化疗提高局部进展期中低位直肠癌的局部控制率和保肛率,是直肠癌辅助治疗的新趋势。术前新辅助放疗或放化疗对直肠癌的局部治疗效果要优于单纯手术或手术后的放化疗。随着多中心大样本研究的长期随访结果报道的发表,新辅助治疗的疗效进一步得到了认可,逐渐成为直肠癌综合治疗的标准方案。其优点有：（1）放疗使癌细胞退变、凋亡,     

直肠癌新辅助放化疗后病理完全缓解相关因素分析及评分系统构建

目的:探讨局部进展期中低位直肠癌新辅助放化疗（nCRT）后病理完全缓解（pCR）的相关因素并建立评分系统。方法:回顾性分析2016年1月至2020年1月华中科技大学同济医学院附属协和医院收治的159例行nCRT联合手术治疗的局部进展期中低位直肠癌患者的临床资料。结果:本组159例患者中33例（20.8%）患者达到pCR...     

直肠癌新辅助化疗后行腹腔镜辅助直肠癌超低位吻合术

近年来,对局部进展期的中低位直肠癌进行新辅助治疗已受到广泛的重视和认可。直肠癌的新辅助治疗不仅可以降低肿瘤的临床分期、控制局部复发率,而且还可以提高中低位直肠癌的保肛率。本病例特点:(1)采用XELOX新辅助化疗两周期,原发灶显著缩小,具有周期短的特点;(2)不同于同步放化疗导致的系膜水肿纤维化,手术遵循TME的间隙尚存,降低了手术难度及并发症的发生;(3)腹腔镜辅助下TME游离,在齿状线水平闭合-切断-吻合,手术流畅。     

直肠癌新辅助治疗

目的论述近年来术前放化疗即新辅助治疗在中低位直肠癌综合治疗模式中的作用。方法结合近期文献及笔者单位的经验,从外科治疗角度,就新辅助治疗的重点关注问题进行阐述。结果新辅助治疗经过20余年的发展,总剂量50Gy的长程放疗显示出较多优势。新辅助治疗在肿瘤降期、术后局部控制率方面取得明显优势;但对提高保肛手术几率目前还有不同看法;同时大量的研究结果没有发现该治疗方式能提高患者的远期存活率;目前还没有手段预测其治疗敏感性。结论对于进展期中低位直肠癌,新辅助治疗仍是提高手术R0切除率、降低术后局部复发的有效治疗方式。     

局部进展期中低位直肠癌新辅助放化疗疗效预测分子标志物的研究进展

新辅助放化疗作为局部进展期直肠癌推荐的术前标准治疗方案,在降低局部复发率、增加保肛率等方面具有明显优势。但因个体差异,不同病人对新辅助放化疗反应不同,部分病人不能从新辅助放化疗中获益甚至出现病情进展。目前用于预测局部进展期直肠癌新辅助放化疗疗效的分子标志物较多,但尚无分子标志物获得临床共识。随着生物组学技术发展,分子标志物的研究已从单个基因或蛋白向全基因组或蛋白组转变,为指导个体化新辅助放化疗提供更多依据。此文将探讨局部进展期中低位直肠癌新辅助分层治疗现状,综述新辅助疗效标志物。     

直肠癌侧方淋巴结清扫的个性化治疗策略

随着全直肠系膜切除术和新辅助放化疗的广泛应用,中低位直肠癌患者的预后明显改善。近年来随着腹腔镜和机器人手术系统等微创技术应用于直肠癌根治性手术,以及肿瘤分子标志物和基因测序技术的发展,直肠癌治疗已进入个体化精准医疗时代。在这样的时代背景下,关于中低位直肠癌侧方淋巴结清扫必要性的争议愈发引人注目,其包括与新辅助治疗的关系,侧方淋巴结清扫的手术指征、范围及神经保护等多个方面。作为进展期中低位直肠癌重要治疗手段,直面争议,增加侧方淋巴结清扫相关循证医学证据是当务之急。     

结直肠癌的新辅助治疗

结直肠癌（colorectal cancer。CRC）的新辅助治疗（neoadjuvant therapy）是提高CRC根治性切除率、减少局部复发和增加保肛机会的主要途径和方法。新辅助治疗包括新辅助化疗（neoadjuvant chemotherapy，NC）、新辅助放疗（neoadjuvant radiotherapy，NR）和新辅助放化疗（neoadjuvant chemoradiotherapy，NCR）。在CRC肝转移和中低位局部进展期直肠癌的治疗中。新辅助治疗尤为重要。现就CRC肝转移和中低位直肠癌新辅助治疗的进展情况简述管见。     

腹腔镜与传统手术联合新辅助放化疗治疗中低位直肠癌短期疗效对比

进展期中低位直肠癌手术后局部复发率高[1],预后差.在根治性切除手术的基础上辅以放化疗,特别是随着新辅助放化疗(neoadjuvant radiochemotherapy,NRT)的引入,直肠癌治疗在降低肿瘤局部复发率、提高保肛率、延长患者生存时间等方面均取得了明显进步.本研究通过对比对腹腔镜联合NRT与传统手术联合NRT治疗中低位直肠癌的疗效,探讨两种手术的安全性和可行性.     

分子标记物预测直肠癌新辅助放化疗效果初步评价

目的：寻找预测直肠癌新辅助治疗效果的分子标志物。方法：对26例行新辅助治疗的进展期中低位直肠癌的治疗前活检标本的K-ras基因进行测序,同时通过免疫组织化学方法对分子标志物增殖细胞核抗体（Ki-67）、核转录因子（NF-KB）、细胞周期蛋白依赖性激酶1（CDK1）进行检测。对手术标本行病理分析和肿瘤消退分级评估。结果：本组病例新辅助治疗后获得病理完全缓解（pCR）的患者7例（26．9％）均为K-ras基因野生型,治疗后降期患者17例（65．4％）。K-ras基因是否突变同新辅助放化疗（CRT）能否达到pCR密切相关（P=0．048）。K-ras基因野生型患者的降期率和肿瘤消退率均为77．8％（14／18）,同突变型的降期率和肿瘤消退率比较P=0．063。结论：中低位直肠癌患者新辅助治疗前K-ras基因野生型可能预示着较好的新辅助治疗效果。     

直肠癌新辅助放化疗后病理完全缓解的相关研究进展

局部晚期直肠癌标准的治疗方案为术前新辅助放化疗加手术的综合治疗。研究显示,直肠癌患者术前放化疗后达病理完全缓解者预后较好。尽管对这些患者的后续治疗方案有较大分歧,但已倾向于保守治疗而非根治性手术治疗。本文就局部晚期直肠癌术前新辅助放化疗后病理完全缓解的预后及预测等相关研究进展作一简要综述。     

三联新辅助治疗对局部进展期低位直肠癌细胞免疫功能的影响

目的探讨三联新辅助治疗对局部进展期低位直肠癌患者细胞免疫功能的影响及其可行性。方法综合应用放疗、热疗及化疗作为低位直肠癌术前新辅助治疗的干预措施,治疗37例不同临床分期的低位直肠癌患者,观察辅助治疗前后及术后的细胞免疫功能,包括T细胞亚群百分率（总T细胞、CD4＋、CD8＋、CD4/CD8）和NK细胞活性以及C-反应蛋白（CRP）、各免疫球蛋白和补体的变化。结果全部病例均施行根治性切除术。所有病例治疗前、治疗后及术后T细胞亚群的百分率、NK细胞活性、C-反应蛋白（CRP）、各免疫球蛋白和补体等各项指标无明显变化,差异无统计学意义（P〉0.05）。结论三联新辅助治疗对局部进展期低位直肠癌患者机体免疫功能无明显影响,是一种安全合理可行的新辅助治疗配伍。     

局部晚期乳腺癌保乳治疗的研究进展

新辅助化疗用于局部晚期乳腺癌(LABC)的治疗使得LABC患者采取保乳治疗(BCT)成为可能。笔者就近年来对LABC患者行BCT的可行性、适应证及禁忌证、影像学评估、面临的问题及解决策略、术后放疗及总体疗效等有关研究进展进行综述。     

Therapie beim lokal fortgeschrittenen Rektumkarzinom

Based on results of the German Rectal Cancer Study Group CAO/ARO/AIO-94 trial, long-term chemoradiotherapy (RT/CTx) is recommended as standard treatment for locally advanced rectal cancer (UICC stages II/III) in the lower two thirds of the rectum (0–12 cm from the anocutaneous verge). Tumor response to neoadjuvant therapy is very heterogeneous, ranging from complete remission to total resistance to RT/CTx. To fulfill the clinical requirement of individual and risk-adapted multimodal treatment, distinct progress in translational research has been achieved (e.g. gene profiling). However, in clinical reality “individualization” of the therapy of rectal cancer patients has not actually been realized. This can be achieved only on the basis of successful randomized clinical trials (e.g. the CAO/ARO/AIO-04 and GAST-05 trials) translationally combined with basic scientific approaches. One simple first step toward individualizing rectal cancer therapy is being made with the ongoing GAST-05 trial. This investigator initiated phase II trial funded by the German Research Foundation (Deutsche Forschungsgemeinschaft) excludes preoperative RT/CTx for patients with rectal cancer localized in the upper third of the rectum, using only quality controlled principles of radical surgery (partial vs total mesorectal excision) followed by adjuvant chemotherapy.     

History of neoadjuvant therapy for rectal cancer

Management of rectal cancer has evolved extensively over the last 30 years. Treatment of locally advanced rectal cancer currently incorporates surgery, chemotherapy, and radiation. Radiation was initially utilized as a salvage method as historic surgical practices were associated with high morbidity rates. In present day, multiple studies have demonstrated that the use of radiation as an adjunct to surgery decreases local recurrence rates. The now routine practice of total mesorectal excision during rectal cancer surgery has further improved outcomes. Numerous studies have evaluated the chemotherapeutic regimens as adjuncts to radiation therapy. Currently, fluorouracil-based regimens are commonly incorporated into neoadjuvant therapy for locally advanced rectal cancer, whereas oxaliplatin has not been incorporated due to more recent studies demonstrating increased toxicity and no clear oncologic benefit. Presently, trials are underway that aim to tailor therapies to specific patterns of disease, in hopes of allowing clinicians to selectively omit components of therapy to limit toxicity and morbidity while maintaining or improving oncologic outcomes. Thus, rectal cancer treatment continues to evolve, and decision-making surround treatment remains highly individualized and nuanced.     

术中放疗在直肠癌治疗中的应用

放疗与手术、化疗是治疗肿瘤的主要手段,术中放疗在直肠癌中的应用仍处于起步阶段。直肠癌患者接受术中放疗有术前或者术后放疗无法超越的优势,术中放疗可提高局部进展期直肠癌的局部控制率,可提高局部复发性直肠癌的总体生存率。总体而言,术中放疗是安全可行的,在直肠癌中的应用前景光明。     

Local-regional prostate cancer

Historically, locally advanced prostate cancer was defined clinically with the digital rectal exam (DRE). With the introduction of screening prostate specific antigen (PSA), further pretreatment stratification of locally advanced prostate cancer was possible. Tables and nomograms have been developed to predict pathologic staging prior to therapy. By combining DRE, PSA, Gleason score, and clinical staging, a patient's probability of treatment failure is estimated, thereby stratifying the risk of locally advanced disease. Pretreatment PSA velocity (PSAV) and PSA doubling time (PSADT) will likely continue to play a role in defining locally advanced prostate cancer. Imaging studies, especially high-field strength pelvic MRI, may provide additional information regarding the presence of locally advanced prostate cancer. In the future, molecular or genetic testing may permit further stratification of patients with locally advanced disease, who are at variable risk for recurrence and death after treatment. Future trials will need to assess the utility of multimodality treatments for patients in the diverse classification of locally advanced prostate cancer.     

Surgery and pre-operative irradiation for locally advanced or recurrent rectal cancer in patients over 75 years of age

OBJECTIVE: Reports of multimodal treatment regimens especially focusing on locally advanced or recurrent rectal cancer in the elderly, aged>75 years, are unavailable. We have tried to identify and evaluate pre- and peri-operative risk factors for morbidity and mortality and outcome after irradiation/surgery regimens in such patients. PATIENTS AND METHODS: Prospective registration of 86 consecutive patients aged>75 years undergoing elective surgery after irradiation 46-50 Gy for either primary locally advanced rectal cancer (n=51) or recurrent rectal cancer (n=35) from January 1991 to August 2003, 51 men and 35 women, median age 78 years (range 75-85 years) in a national cancer hospital. RESULTS: Multivisceral resections were needed in 63% of patients and 70% R0 resections were obtained in locally advanced cases and 46% in recurrent ones. Both in-hospital- and 30-day-mortality was 3.5%. Sixty-two postoperative complications occurred in 38 patients, three of them fatal. Both operation times over 5 h and transfusion of more than 3 SAG were prognostic factors regarding infections. Estimated five-year survival in R0 patients was 46%. Estimated five-year survival for patients with nonmetastatic tumours with locally advanced primary cancer was 29% and for locally recurrent rectal cancer 32%. Old males had a higher mortality rate the first year after surgery than females with only 65% relative survival compared to a matched normal population. The estimated five-year local recurrence rates were 24% for R0 resections and 54% for R1 resections (P=0.434 ns) and 24% and 45% for locally advanced and recurrent rectal cancer (P=0.248 ns), respectively. CONCLUSION: Thorough pre-operative evaluation and preparation and judicious surgery are important for achieving potentially curative treatment with acceptable morbidity in locally advanced and recurrent rectal cancer in patients over 75 years of age. We suggest that these patients should be evaluated and considered for treatment by multidisciplinary teams as younger patients.