中国恶性肿瘤整合诊治指南-肛管癌部分

目的探讨肿瘤细胞减灭术（CRS）及腹腔热灌注化疗（HIPEC）联合肝切除治疗结直肠癌腹膜转移（CRPM）合并肝转移（LM）的安全性及有效性。 方法回顾性收集中国医学科学院肿瘤医院结直肠外科自2017年6月至2019年6月采用CRS+HIPEC联合肝切除治疗的16例CRPM合并孤立LM患者的临床病理资料。 结果男性6例，女性10例，中位年龄62岁。全组患者接受CRS+HIPEC联合同步肝切除，肝脏转移瘤均获得完整切除。中位总生存期25个月，中位无病生存期9个月。1年及3年总生存率分别为75.0%及37.0%，1年及3年无病生存率分别为50.0%及9.4%。6例（37.5%）出现轻度并发症（Clavien-Dindo Ⅰ~Ⅱ），4例（25.0%）出现严重并发症（Ⅲ~Ⅳ）。 结论CRPM合并孤立的、能完整切除的LM的患者接受CRS+HIPEC联合同期肝切除是安全可行的，同时可为患者带来一定生存获益。     

肿瘤细胞减灭术加腹腔热灌注化疗治疗结直肠癌腹膜转移癌的临床研究

目的：探讨肿瘤细胞减灭术（CRS）加腹腔热灌注化疗（HIPEC）治疗结直肠癌腹膜转移癌（ CRC PC）的疗效及安全性。方法选取结直肠癌腹膜转移癌（ CRC PC）患者67例,随机分为治疗组（ CRS＋HIPEC）38例,对照组（CRS＋静脉辅助化疗）29例,比较两组的生存期、生存率、术后并发症及化疗毒副作用。结果治疗组中位生存期23.0个月,显著长于对照组的11.0个月（ P＜0.01）,治疗组1、2、3年生存率分别为70.9％、45.7％、8.2％,分别优于对照组的68.8％、21.2％、0％。术后并发症发生率两组相似（ P＞0.05）。化疗毒副作用：对照组恶心呕吐、白细胞减少、血小板减少发生率较治疗组高（P＜0.01）,而治疗组腹胀、腹泻发生率较对照组高（ P＜0.01或P＜0.05）;两组其他毒副作用相似（ P＞0.05）。结论 CRS＋HIPEC治疗CRC PC能明显延长患者生存期,并发症和化疗毒副作用并没有明显增加。     

腹膜转移的结肠癌患者MDT诊治二例

本文描述了2例异时性腹膜转移的结肠癌病例的多学科诊治过程。1例多发转移,1例单发转移。这两例患者经MDT讨论后都首先采用了肿瘤减灭术联合腹腔热灌注化疗的治疗模式（cytoreductive surgery,CRS/hyperthermic intraperitoneal peroperative chemotherapy,HIPEC）,单发转移的患者目前获得了12个月的无病生存期（disease-free survival,DFS）,而多发转移的患者也获得了12个多月的总生存期（overall survival,OS）。目前发现与结直肠癌腹膜转移患者OS相关的因素包括肿瘤减灭术（CRS）完全程度和肿瘤累及的范围（腹膜转移癌指数）等。因此,对于结直肠癌的腹膜转移患者,评估病变范围极其重要,对于较局限的腹膜转移,多学科的综合诊治和积极的治疗手段能改善这部分患者的生存时间和生存质量。     

肺癌脑转移252例综合治疗临床分析

目的　探讨肺癌脑转移综合治疗的疗效及预后影响因素。方法　回顾性分析了１９９０年１ 月～１９９６ 年１２ 月采用不同方法治疗的２５２ 例肺癌脑转移患者生存期与生存率。结果　转移灶手术切除及γ或 Ｘ刀治疗辅以放疗、化疗以及放疗与化疗联合组的中位生存期及１ 、２ 年生存率明显高于单纯放疗与化疗组（ Ｐ＜ ００１ 及 Ｐ＜ ００５） ,肺癌的病理类型对生存期与生存率无明显影响（ Ｐ＞００５） ;单发转移及无颅外转移者生存期（ 中位生存期分别为８５ 和８５ 个月） 与生存率（１ 年生存率分别为３５ ％ 和２９ ％ ,２ 年生存率分别为１１ ％ 和８ ％ ） 明显高于多发转移及伴颅外血行转移者（ Ｐ＜ ００１） ;高年龄者（ ≥５０ 岁）１ 年生存率（２９ ％ ） 明显高于低年龄组（１５ ％ , Ｐ＜ ００５） 。结论　转移灶的手术切除及γ或 Ｘ刀治疗加放疗和化疗是治疗肺癌脑转移患者的首选方法,转移的数量与部位多少及年龄是影响预后的因素。     

肿瘤细胞减灭术联合腹腔热灌注化疗（CRS/HIPEC）治疗结直肠癌腹膜转移的现状和进展

腹膜是结直肠癌转移的好发部位。结直肠癌发生腹膜转移长期以来被认为预后很差,主要采用姑息性手段治疗。尽管化疗及靶向治疗在结直肠癌治疗上有很大进展,但对于腹膜转移的结直肠癌疗效并不理想。最近越来越多的证据表明,肿瘤细胞减灭术(CRS)联合腹腔内热灌注化疗(HIPEC)的治疗方法能给这部分患者带来较大的生存获益。本文综述了结直肠癌腹膜转移的诊治现状和相关进展。目前认为CRS联合HIPEC对选择的结直肠癌腹膜转移患者是一种安全有效的治疗模式,但HIPEC能否预防进展期结直肠癌发生腹膜转移,还有待进一步的临床试验研究。     

腹膜转移癌诊疗决策中评分系统的研究进展

腹膜转移是肿瘤的晚期阶段，预后较差。肿瘤细胞减灭术联合腹腔热灌注化疗（CRS+HIPEC）可以显著改善患者预后。患者的预后往往和腹膜疾病的严重程度和CRS肿瘤细胞减灭的程度相关。在术前和术中有各种评分系统合理评估患者腹膜肿瘤负荷，本文对腹膜转移癌诊疗决策中评分系统展开综述。     

中山医院结直肠癌MDT讨论治疗策略分析

目的分析结直肠癌多学科诊疗团队（MDT）讨论后制定的治疗策略。 方法回顾性分析2010年7月至2019年2月复旦大学附属中山医院进行MDT讨论的结直肠癌患者的临床资料,对MDT讨论结果进行统计分析。 结果结直肠癌MDT总计为1 953例结直肠癌患者进行4 535人次讨论制定个体化治疗方案。其中,553例患者肝转移灶和111例患者肺转移灶被认为可切除。另有261位最初不可切除的结直肠癌肝转移患者,在接受系统化疗联合分子靶向以及介入等综合治疗后,转化为可切除,建议接受肝转移灶切除手术。实际上总计772位结直肠癌患者接受肝转移灶切除,其中同时性肝转移患者有581例,而接受结直肠癌原发灶和肝转移灶同步切除的患者有248例。肝切除手术中仅有87例患者（11.3%）实施解剖性肝切除,绝大多数实施非解剖性肝切除。肝转移灶切除手术中联合射频消融的有62例（8.0%）。术后病理提示R1切除的有18位（2.3%）。 结论复杂结直肠癌病例推荐行MDT讨论。扩展手术适应证、应用二步肝切除术、联合射频消融等局部毁损治疗可以扩大肝转移灶手术的适应人群。初始无法手术切除的患者,如状况耐受,建议给予强烈的个体化转化治疗,争取转化后手术切除。     

228例肺癌脑转移综合治疗临床分析

目的探讨肺癌脑转移综合治疗的疗效。方法回顾分析了2002年3月~2004年8月228例肺癌脑转移患者经不同方法治疗后的生存期与生存率。结果转移灶手术切除或-刀治疗辅以化疗的中位生存期及1、2年的生存率明显高于单纯-刀与化疗组(p<0.01),肺癌的病理类型对生存期与生存率无明显影响(p>0.05);单发转移及无颅外转移者生存期(中位生存期分别为9.5和9.5个月)与生存率(1年生存率分别为36%和32%,2年生存率分别为11%和9%)明显高于多发转移及伴颅外血行转移者(p<0.01)。结论转移灶的手术切除或-刀治疗辅以化疗是治疗肺癌脑转移患者理想的方法,转移的数量与部位多少是影响预后的因素。     

肝细胞癌合并食道静脉曲张破裂出血的联合手术治疗

目的探讨肝细胞癌（hepatocellular carcinoma,HCC）合并食道静脉曲张破裂出血联合手术治疗的方法、病理生理基础和治疗效果。方法选取1999年12月-2007年12月采用肝部分切除联合脾切除、门奇断流术治疗HCC合并食道静脉曲张破裂出血患者共23例（联合手术组）,观察术前、术后外周血白细胞和血小板计数的变化、食管静脉曲张缓解情况、生存率和肿瘤复发率;并与同期行单纯肝切除术的39例HCC患者（单纯肝切除组）进行比较分析。结果联合手术组手术并发症和手术死亡率与单纯肝切除组相比差异无统计学意义;联合手术组术后白细胞及血小板计数回升明显,显著高于单纯肝切除组;已随访14例患者中,13例食道静脉曲张改善;随访期间无凶险感染发生;5年生存率和3年肿瘤复发率2组间比较,差异无统计学意义。结论对于HCC合并食道静脉曲张破裂出血,采用肝部分切除联合脾切除、门奇断流术进行治疗是安全有效的,联合脾切除、门奇断流术并不增加肝切除手术的风险,不影响远期生存率和肿瘤复发率。     

腹腔镜结肠癌切除联合完整结肠系膜切除在老年结肠癌手术中的应用

目的探讨腹腔镜结肠癌切除联合完整结肠系膜切除在老年结肠癌手术中的应用。方法老年结肠癌手术患者82例,按照患者意愿进行分组,对照组41例采用开腹完整结肠系膜切除,研究组41例采用腹腔镜结肠癌切除联合完整结肠系膜切除。记录手术过程中淋巴结数量清扫状况,术前及术后指标,同时进行随访,记录生存率、局部复发及远处转移状况。结果在淋巴结清除数量上,研究组在Ⅲ期、右半结肠高于对照组(P<0.05);两组术中出血量和手术时间上无差异(P>0.05);研究组术后进食时间低于对照组(P<0.05),两组住院时间及术后并发症上无差异(P>0.05);研究组局部复发率、远处转移率、2年累积生存率(4.88%、2.44%、94.38%)与对照组(7.32%、4.88%、92.34%)相比无统计学意义(P>0.05)。结论腹腔镜结肠癌切除联合完整结肠系膜切除治疗老年结肠癌安全有效,达到淋巴组织切除最大化,获得较好的肿瘤根治效果。     

&ldquo;En bloc&rdquo; caudate lobe and inferior vena cava resection following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal and liver metastasis of colorectal cancer

There are diverse protocols to manage patients with recurrent disease after primary cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis. We describe a case of metachronous liver metastasis after CRS and HIPEC for colorectal cancer, successfully treated with a selective metastectomy and partial graft of the inferior vena cava. A 35-year-old female presented with a large tumour in the cecum and consequent colonic stenosis. After an emergency right colectomy, the patient received adjuvant chemotherapy. One year later she was diagnosed with peritoneal carcinomatosis, and it was decided to carry out a CRS/HIPEC. After 2 years of total remission, an isolated metachronous liver metastasis was detected by magnetic resonance imaging surveillance. The patient underwent a third procedure including a caudate lobe and partial inferior vena cava resection with a prosthetic graft interposition, achieving an R0 situation. The postoperative course was uneventful and the patient was discharged on postoperative day 17 after the liver resection. At 18-mo follow-up after the liver resection the patient remained free of recurrence. In selected patients, the option of re-operation due to recurrent disease should be discussed. Even liver resection of a metachronous metastasis and an extended vascular resection are acceptable after CRS/HIPEC and can be considered as a potential treatment option to remove all macroscopic lesions.     

Hepatic resection for non-colorectal, non-neuroendocrine, non-sarcoma metastasis: a single-centre experience

Background

The aim of the present study was to analyse the outcome after hepatic resection for non-colorectal, non-neuroendocrine, non-sarcomatous (NCNNNS) metastatic tumours and to identify the factors predicting survival.

Methods

All patients who underwent hepatic resection for NCNNNS metastatic tumours between September 1996 and June 2009 were included. Patients'' demographics, clinical and histopathological parameters, overall survival and the factors predicting survival were analysed.

Results

In all, 65 patients underwent hepatic resection for metastasis. The most common site of a primary tumour was the kidney (24 patients). Fifteen patients had synchronous tumours. Fifty patients had major liver resections and 22 patients had bilobar disease. The median number of liver lesions resected was 1 and the median maximum diameter of the metastasis was 6 cm. A R0 resection was performed in 51 patients. The 1-, 3- and 5-year overall survival from the time of metastasectomy was 72.9%, 47.9% and 25.6%, respectively, with a median survival of 19 months. The presence of a tumour of greater than 6 cm (P = 0.048) and a positive resection margin (P = 0.04) were associated with poor survival.

Conclusion

Hepatic resection for metastasis from NCNNNS tumours can offer acceptable long-term survival in selected patients. To offer a chance of a cure a R0 resection must be performed.     

Morbidity and survival of liver resection for colorectal adenocarcinoma

Sixty-two patients underwent hepatic resection for isolated colorectal metastases from 1963 to 1988. The numbers of hepatic resections were: lobectomy, 24 (39 percent); wedge resection, 23 (37 percent); and segmentectomy, 15 (24 percent). The median number of intraoperative blood transfusions was 3 0 units (range, 0–16 units). The median number of days in the hospital following hepatic resection was 13 (range, 4–51 days). There were 19 patients (30 percent), who developed a total of 23 complications. Surgery was required for complications in nine patients. Surgical mortality occurred in 5 of 62 (8 percent) patients. The estimated median survival in 56 patients with one to three metastases was 26 months, with a 28 percent estimated 5-year survival. The median size of the metastases was 4.0 cm (range, 0.7–13 cm). The estimated median survival in 27 patients with metastases less than 4 cm in diameter was 26 months, with a 24 percent estimated 5-year survival. The estimated median overall survival from the time of hepatic resection was 25 months.     

Preoperative main portal branch transection combined with liver locoregional transarterial neo and adjuvant immunochemotherapy for patients with hepatocellular carcinoma

BACKGROUND/AIMS: Main portal branch embolization was developed several years before in an attempt to improve prognosis and outcome for patients suffering from advanced liver malignancies. METHODOLOGY: From September 1993 to September 2000 43 patients with advanced hepatocellular carcinoma underwent main portal branch transection and neo- and adjuvant transarterial immunochemotherapy. Forty days after initial surgery, all patients underwent a phase II surgical exploration for liver resection. RESULTS: Survival ranged from 18 months to 64 months with a median of 41 months. Two- and 5-year survival was 75% and 57%, respectively. CONCLUSIONS: Main portal branch transection combined with major liver resection and neoadjuvant and adjuvant locoregional immunochemotherapy fulfilled our expectations firstly for increasing the resectability rate and secondly for increasing the overall survival and the disease-free survival.     

Comparison of serial debulking and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in pseudomyxoma peritonei of appendiceal origin

Purpose

Patients with pseudomyxoma peritonei (PMP) benefit from cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Reports on this modality usually have included only patients with successful HIPEC treatment, which can potentially cause biased results. We report the survival of a PMP population treated by CRS and HIPEC, including patients who were not eligible for HIPEC.

Methods

The outcome of the whole population of 87 patients with PMP treated by CRS and HIPEC in Helsinki University Central Hospital between 2008 and 2011 was evaluated. The results of treatment were compared with 33 patients treated by serial debulking in our unit between 1984 and 2008.

Results

Of the 87 patients in the HIPEC-era group, 56 received HIPEC, 12 were treated non-radically in an attempt at HIPEC, 9 were debulked and 10 were referred back or transferred to palliative care without surgery. The 5-year overall survival for the debulking-era group and the HIPEC-era group were 67 and 69 %, respectively. The number of patients with no evidence of disease was higher in the HIPEC-era group (47/87) than that in the debulking-era group (8/33) at the end of the follow-up. Overall survival for patients who underwent successful CRS and HIPEC at 2 and 5 years was 95 and 93 %, respectively.

Conclusions

The improved survival from using the CRS and HIPEC was not apparent after 5-year follow-up, when the whole patient population was included in the analysis. Even so, patients successfully treated by CRS and HIPEC manage well.     

Metastatic liver disease of colorectal origin: the value of locoregional immunochemotherapy combined with systemic chemotherapy following liver resection. Results of a prospective randomized study

BACKGROUND/AIMS: Liver resection for metastatic liver disease of colorectal origin, although considered as the 'gold standard' of treatment, is associated with limited long-term survival. The aim of this study was to compare overall survival, disease-free survival and the incidence of intra- or extrahepatic recurrence between patients who were randomly assigned to have locoregional chemoimmunotherapy with systemic chemotherapy group A (n = 62 patients) versus those who were treated with systemic immunochemotherapy group B (n = 60 patients). METHODOLOGY: Group A included patients who, after liver resection, received locoregional immunochemotherapy combined with systemic chemotherapy, while group B included patients who had undergone systemic immunotherapy combined with systemic chemotherapy following liver resection. The two groups were matched in terms of sex, age and stage of the disease. Prognostic factors and their impact on disease-free survival were studied in both groups. RESULTS: Two-year survival was 92% for group A versus 75% for group B, 5-year survival was 73% for group A versus 60% for group B. During the two-year period, 34% of the group A patients versus 52% of those of group B developed either intrahepatic or extrahepatic recurrence of the disease (P < 0.00212). CONCLUSIONS: From the analysis of the above results it becomes clear that regional immunochemotherapy combined with systemic chemotherapy leads to a decrease in the incidence of disease recurrence and thus to a significant prolongation of the overall survival and of disease-free survival.     

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of pseudomyxoma peritonei: A single-center experience

Background and Aims

Pseudomyxoma peritonei (PMP) results from perforated appendiceal tumors. It is usually diagnosed preoperatively by imaging. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), although aggressive long procedure with high complications rate, was considered the optimal treatment. This study is aiming to study the role of CRS and HIPEC in the management of PMP and assess the outcome.

Methods

This is a retrospective study which was conducted at King Faisal Hospital and Research Center, a tertiary care hospital during the period from November 2008 to June 2016. Approval of the Research Advisory Council was obtained. Forty-one procedures of CRS and HIPEC were performed in 38 patients. Using the open abdomen technique, CRS was performed using standard peritonectomy procedures and visceral resections directed toward the complete elimination of tumors from abdominopelvic cavity. HIPEC was performed using mitomycin C in a dose of 30 mg/m² and allowed to circulate in abdominopelvic cavity for 90 min at 41.0 to 42.2 °C.

Results

Forty-one procedures were performed in 38 patients. Three procedures were done as repeat CRS and HIPEC. No perioperative mortality. Cystoscopy and bilateral ureteric stents in 35 procedures (85.5%). Hospital stay (range 9–85 days) average is 21 days. Follow up period is 1–84 months, and median follow up is 54 months. Five-year survival rate is 92%. Median 5-year disease-free survival rate is 60%. Two patients died during the follow up period by septic shock and one patient died from disease progression.

Conclusion

CRS and HIPEC is well-tolerated and feasible management for PMP.

     

Extended Radical Resection: The Choice for Locally Recurrent Rectal Cancer

Purpose Surgery for recurrent rectal cancer is the only therapy with curative potential. This study was designed to assess factors that affect survival after surgery for locally recurrent rectal cancer. Methods Prospective databases of patients undergoing surgical resection for recurrent rectal cancer at three tertiary centers between 1990 and 2006 were combined and analyzed. Cox regression and Kaplan-Meier survival analysis were used to assess factors associated with survival. Results A total of 160 patients (96 males) underwent surgery (median age, 63 (range, 27–93) years). Ninety-five patients (59 percent) received neoadjuvant radiotherapy. Sixty-three patients (39 percent) underwent radical resection and 90 (56 percent) underwent extended radical resection. Seven patients (5 percent) were irresectable. There was one death and 27 percent had major postoperative complications, independent of extent of resection. Negative resection margins were obtained in 98 patients (R0 61 percent). Median cancer-specific and overall survival was 48 months (41.5 percent 5-year survival) and 43 months (36.6 percent 5-year survival), respectively. Margin involvement was a significant predictor of cancer-specific (P < 0.001) and overall survival (P < 0.02). Conclusions Resection for recurrent rectal cancer results in good survival with acceptable morbidity, unaffected by the extent of resection. Extended radical resection to obtain clear resection margins is the appropriate management of locally recurrent rectal cancer. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007. Reprints are not available     

Prognostic significance of early recurrence: a conditional survival analysis in patients with resected colorectal liver metastasis

Background

For patients undergoing liver resection for colorectal metastases, specific clinico-pathological variables have been shown to be prognostic at baseline. This study analyses how the prognostic capability of these variables changes in a conditional survival model.

Methods

Retrospective review of a prospectively maintained database of patients who underwent an R0 resection of colorectal liver metastases from 1994 to 2004 at a single institution.

Results

In total, 807 patients were identified, with an 87-month median follow-up for survivors. Five- and 10-year disease-specific survivals (DSS) were 68% and 55%, respectively. The probability of further survival increased as the survival time increased. For 3-year survivors (n = 504), DSS were no longer significantly different between patients with a low (0–2) or high (3–5) clinical risk score (CRS, P = 0.19). On multivariate analysis, independent predictors of DSS for 3-year survivors were recurrence within the first 3 years after a liver resection, a pre-operative carcinoembryonic antigen (CEA) >200 ng/ml and disease-free interval <12 months prior to the diagnosis of liver metastasis. However, for those patients who were recurrence free at 1 year, no clinico-pathological variables retained prognostic significance.

Discussion

After 3 years of DSS and 1 year of recurrence-free survival, baseline clinico-pathological variables have a limited ability to predict future survival. Early post-operative recurrence appears to be the most useful single clinical feature in estimating conditional DSS.