PRE-OPERATIVE CHEMORADIOTHERAPY IN LOCALLY ADVANCED RECTAL CANCER

Background : The aim of the present study was to investigate the effectiveness and toxicity of pre-operative chemoradiation in locally advanced rectal cancer (T₃–T₄). Methods : Forty-seven patients were assessed (38 T₃ and nine T₄ tumours). Pre-operative pelvic radiotherapy was delivered in four fields, 45 Gy in 25 fractions over 5 weeks. Bolus 5-fluorouracil (5-FU) was delivered 500 mg/m ² on days 1, 2, 3 and days 22, 23, 24. Total mesorectal excision of the rectal tumour either by anterior or abdomino-perineal resection was planned at 4–6 weeks from completion of pre-operative treatment. Response to therapy was assessed by fresh macroscopic measurement of the surgical specimen. Results : All patients undergoing chemoradiation completed therapy as planned, with no treatment-related interruptions. The regimen had a low acute toxicity profile with an estimated 50% or greater response in 38 out of 47 patients (four patients had complete responses). Forty-three (97%) of 44 patients who underwent surgery were operable. Patients who were operated on between 4 and 7 weeks had a statistically better response then those who were operated on after 7 weeks (P = 0.013; Fisher’s exact test). Eight of 10 patients who were considered to be inoperable prior to the treatment underwent total mesorectal excision with negative radial margins. Anastomotic leakage occurred in four patients (9%); one required surgical intervention. Wound infection occurred in three patients (6%); one patient required re-exploration for haemorrhage. Delayed complications occurred in three patients (6%); one requiring surgery for a stomal stricture. After a median follow-up of 20 months, two patients (4%) had developed local recurrence. Conclusion : The pre-operative chemoradiation regimen employed had a low acute toxicity profile and all patients completed therapy. The majority of patients considered inoperable prior to receiving this treatment underwent successful excision. Appropriately fractionated pre-operative chemoradiotherapy is a reasonable option in this disease and deserves further evaluation.     

THE USE OF RADIOTHERAPY FOR PATIENTS WITH LOW RECTAL CANCER: AN OVERVIEW OF THE LYON EXPERIENCE

In France, the late Jean Papillon was responsible for much of the pioneering work in the radiotherapy treatment of patients with rectal cancer. This review is written in tribute to his contribution to, and vast experience in, the conservative management of this common tumour. It describes his protocols with minor modifications currently used at the Centre Hospitalier Lyon-Sud, France. In Lyon, pre-operative adjuvant irradiation is the preferred treatment for patients with T₂ and T₃ rectal cancer. Initial results suggest that this combined approach significantly improves the likelihood of successful sphincter preservation for patients with carcinoma of the lower third of the rectum. To date, the technique has given good local control with minimal postoperative morbidity and low mortality.     

RECTAL CANCER FOLLOWING COLECTOMY AND ILEORECTAL ANASTOMOSIS FOR FAMILIAL ADENOMATOUS POLYPOSIS

Background : Familial adenomatous polyposis (FAP) has historically been treated by colectomy and ileorectal anastomosis (IRA). Preservation of the rectum allows the subsequent development of cancer in the rectum. The risk of rectal cancer following ileorectal anastomosis in the Australian population has not been published to date. Methods : An audit of the Familial Adenomatous Polyposis Registry of Western Australia was undertaken to assess patients who had undergone colectomy and ileorectal anastomosis. Fifty-five patients ranging in age from 13 to 65 years were studied. Results : Seven patients (13%) developed cancer of the rectum with a median follow-up of 10 years (range: 1–31 years). Median interval to diagnosis of carcinoma of the rectum following colectomy and IRA was 10 years. All patients who developed cancer in the retained rectum had rectal polyps. Colon cancer was present in the initial colectomy specimen in 13 patients (of these, five patients developed rectal cancer). Flat polyps were noted in five patients. Four patients with flat polyps developed cancer of the rectum. Conclusions : Total colectomy and IRA should be considered as part 1 of a staged procedure in the patient with FAP. With the exception of the patient with no evidence of rectal polyps, completion proctectomy should be undertaken within 10 years of the initial colectomy.     

LOCALLY ADVANCED BREAST CANCER: IS SURGERY WARRANTED FOLLOWING CHEMOTHERAPY?

Various methods of management of locally advanced breast cancer have been proposed, including combinations of chemotherapy, surgery. radiotherapy. immunotherapy and hormone manipulation. This retrospective study evaluated the effectiveness of chemotherapy in the management of locally advanced breast cancer in pre- and perimenopausal women by examining the pathology of the mastectomy specimens. Sixteen women who on initial clinical examination had breast cancers measuring 5 cm or greater underwent chemotherapy prior to surgery. Four women were also treated with radiotherapy prior to surgery. All 16 women underwent msstectomy and axillary clearance. All specimens showed residual tumour in the mastectomy specimen or the regional lymph nodes. Chemotherapy is useful in reducing tumour burden to allow surgical resection, but does not produce centripetal shrinkage of tumour, nor sterilize the breast of cancer. In this small series. the addition of radiotherapy also failed to clear the patient of tumour. Wide surgical excision including the original tumour margins is thus required to achieve locoregional control. Until chemotherapy and radiotherapy regimens can be proved to sterilize the breast of tumour, we caution against the use of any surgery less than total mastectomy if optimal local control is to be achieved for locally advanced breast cancer in pre- and perimenopausal women.     

选择性动脉化疗灌注联合微量泵输注治疗大肠癌

目的：对选择性动脉化疗灌注联合微量泵输注治疗大肠癌的价值进行探讨。方法：用Seldinger技术对31例大肠癌病例行选择性动脉灌注化疗药物（Mitomycin,Cisplatin)，保留导管，联合微量泵连续输注药物（Cisplatin Floxuridine)。结果：治疗后，患者临床症状改善明显，完全缓解1例，部分缓解23例，无变化6例，恶化1例，有效率77.4%,1,2,3年生存率分别为74.2%,54.8%与35.5%，其中9例于治疗2次后行根治性切除。结论：选择性动脉化疗灌注联合微量泵输注治疗大肠癌是一种安全有效的治疗方法。     

PERITONECTOMY AND INTRAPERITONEAL CHEMOTHERAPY IN APPENDICEAL AND COLORECTAL CANCER

Background : Peritoneal spread of gastrointestinal malignancies has been regarded as an incurable disease, and treatment has been aimed at short-term palliation. The use of cytoreductive surgery, including peritonectomy procedures and intraperitoneal chemotherapy, has been proposed with the intention of prolonging survival, and perhaps curing patients with peritoneal carcinomatosis from appendiceal and possibly colon cancers. A series of eight patients who have undergone this procedure at St George Hospital is presented, and the results obtained by other groups are reviewed. Method : Eight patients fitted the criteria for peritoneal carcinomatosis between January 1996 and November 1998. In seven patients this was secondary to appendiceal or colon cancer, and one patient had signet ring cancer of the uterus. The surgical treatment involved removing all macroscopic evidence of disease, and this was followed by early postoperative intraperitoneal chemotherapy. Results : The eight patients (seven female, one male) ranged in age from 25 to 67 years. There were seven complications, including two patients with pelvic abscesses, and one patient who developed Tenchkoff catheter occlusion. There were three deaths, one due to pelvic sepsis after 30 days, and the other two were due to metastatic disease. Of the remaining five patients, two have developed recurrence and three remain disease-free. Conclusion : The results of peritonectomy and intraperitoneal chemotherapy for appendiceal tumours are encouraging. The role in colorectal cancer is less clear, although there are some reports that suggest a benefit.     

肝癌的内放射治疗现状

目的 了解肝癌内放射治疗的发展过程及量效关系。方法 收集近期肝癌内放射治疗的文献资料。结果 对放射微球的合理选择、放射剂量的合理掌握及给药方法的合理运用是提高疗效、降低并发症的关键。结论 联合化疗、放疗及免疫治疗以能够达到二期手术的综合治疗是今后肝癌治疗的方向。     

直肠癌保肛手术吻合口狭窄的预防和治疗

吻台口狭窄是中、低位直肠癌保肛手术的常见并发症之一。1987年5月至1995年12月，对222例直肠癌行结肠肛管吻合术。结果表明，其中16例未行术后吻合口扩张，有8例发生吻合狭窄。另202例定期扩张吻合口无1例发生吻合口狭窄。讨论了吻合口狭窄的预防，对吻合口狭窄的治疗方法作了详细描述，强调病人用扩张器定期扩张吻合口的重要性。     

大肠癌术前动脉插管化疗与一般化疗的临床病理对比分析(附20例报告)

对２０例经病理确诊为大肠癌的病人行选择性动脉插管３种抗癌药一次性灌注治疗，其中１５例手术。切除标本用光镜观察癌细胞变性坏死的程度，并与病情相似、术前仅行一般化疗的１１例病人进行比较。结果显示：经本法治疗的病人除临床症状改善外，总有效率为１００％，而对照组有效率仅为１８．１８％，两组比较有高度显著性差异（Ｐ＜０．０１）。认为术前采用选择性动脉插管化疗可使癌灶缩小，提高手术切除率，减少术中医源性扩散及术后复发，对提高大肠癌病人的５年生存率有重要的临床意义。     

低位直肠肛管癌保留肛门的外科治疗

分别用经肛门根治性局部切除、前切除、拖出术治疗70例低位直肠及肛管瘤.全组术后1年、3年、5 年生存率分别为97.1%、87.6%、84.9%,5例局部复发、2例局部复发合并远处转移、7例远处转移.结果表明,部分低位直肠肛管癌施行上述保留肛门的手术治疗,可获得根治效果.对三种术式的理论依据、手术适应证及手术注意事项进行了分析讨论.     

区域性化疗在晚期胰腺癌中的应用

本文将159例未能切除病灶的胰腺癌分为剖腹探查组、转流手术组、插管组、转流加插管组进行对比观察。通过胃网膜右动脉插管皮下植入动脉给药装置化疗,经长时间随访发现插管组生存期明显长于探查组和转流组,而转流加插管组又长于插管组,也明显长于国外统计大宗胰腺癌姑息转流及探查手术的平均生存期。该方法为胰腺癌的姑息治疗寻求了一新的有效途径。     

直肠癌Miles根治术乙状结肠单腔造口Ⅰ期开放法的探讨

总结了近６年４１例直肠癌Ｍｉｌｅｓ根治术乙状结肠单腔造口的临床体会。其中乙状结肠造口Ⅰ期开放组２１例；Ⅱ期开放组２０例，并对两组病例的临床效果进行了比较。认为造口Ⅰ期开放法具有肠道减压好，肠功能恢复快，造口并发症少等优点。尤其适用于合并肠梗阻的病例。     

直肠全系膜切除并直肠癌保肛手术

目的：探讨中低位直肠癌根治术中直肠系膜全切除后保瘤肛门的可行性、保肛术的适应证及维持术后肛门功能的可能性。方法：回顾性总结了１９９３年至１９９９年保留肛门的中低位直肠癌根治术１２４例,讨论保肛手术的可行性和术后直肠感觉与肛门功能恢复的可能行,提出保肛手术的适应证。结果：９７．５％（１２１／１２４）的病人下切缘无癌浸润,术后２年内局部复发率为４．８％（６／１２４）。９２．７％（１１５／１２４）的病人     

低位直肠癌保肛手术适应证选择与评价

目的：探讨低位直肠癌保肛手术适应证选择标准评价保肛术后临床效果。方法：根据肛门指诊、直肠腔内超声、盆腔ＣＴ、ＭＲＩ、术前活检病理，在２６５例低位直肠癌中选择１５５例和支撑吻合管经肛门环扎式结肠－直肠（肛管）吻合术。低位直肠保肛手术适应证选择标准：高中分化腺癌、隆起型、未浸透深肌层、环周度≤１／２周，无肠旁淋巴结肿大、距齿状线１ｃｍ以上。高中分化腺癌、溃疡型≥１／２周，浸透肠壁深肌层、无盆腔淋巴结肿     

局部进展期直肠癌单纯应用新辅助化疗研究进展

近年来,我国局部进展期直肠癌病人的发病率和病死率逐年上升,新辅助放化疗+全直肠系膜切除成为病人的首选治疗方案。新辅助放化疗被认为是局部进展期直肠癌病人的标准治疗方案,但其中放疗并未提高病人的总存活率,且对手术决策和术后恢复方面有不良影响。因此,单纯新辅助化疗的应用价值越来越受到重视,有潜力成为更佳的治疗选择方案。     

TRIPLE THERAPY FOR ADVANCED SQUAMOUS CELL CANCER OF THE HEAD AND NECK

This study presents the results of treatment for Stage III and IV squamous cell carcinoma of the head and neck at the Princess Alexandra Hospital and Queensland Radium Institute, Brisbane. Patients were treated using a programme of sequential chemotherapy, surgery and radiotherapy. Between 1980 and 1988, 116 patients commenced the programme and 85 completed the treatment as planned. The Price-Hill regimen of chemotherapy was used until 1986 after which time it was replaced by cisplatin/5-fluorouracil (5FU). Two courses were usually given achieving an overall response rate of 36% (12% complete response). Cisplatin/5FU produced an overall response rate of 56% compared with 24% for the Price-Hill regimen. Radical surgical resections were performed using a free flap reconstruction in the majority of patients. Radiotherapy fields usually covered the primary site and both cervical lymph node areas to a dose of 50–60 Gy in 5–6 weeks. The lengthy treatment was generally well tolerated although there were two chemotherapy and two peri-operative deaths. The overall actuarial survival for the 85 patients completing the triple therapy was 60%. These patients were analysed in more detail for possible prognostic factors.     

Postoperative complications in patients irradiated pre-operatively for rectal cancer: report of a randomised trial comparing short-term radiotherapy vs chemoradiation

OBJECTIVE: The primary outcome was sphincter preservation. No benefit was found with chemoradiation. The aim of this report is to analyse postoperative complications, which were the secondary outcome. MATERIAL AND METHODS: Patients with resectable T3-4 low rectal carcinoma were randomised to receive either pre-operative 5 x 5 Gy irradiation with subsequent total mesorectal excision (TME) performed within 7 days or chemoradiation (50.4 Gy, 1.8 Gy per fraction plus bolus 5-fluorouracil and leucovorin) followed by TME after 4-6 weeks. RESULTS: Three hundred and five patients (153 in 5 x 5 Gy group and 152 in chemoradiation group) were analysed. The rates of patients with postoperative complications for the 5 x 5 Gy group and for the chemoradiation group were 27 vs 21%, respectively (P = 0.27). If the values were expressed in terms of number of complications, the rates were 31 vs 22%, respectively (P = 0.06). The corresponding values for severe complications were 10 vs 11% (P = 0.85) of patients with complications and 12 vs 11% (P = 0.85) of events. CONCLUSION: The study did not demonstrate a statistically significant difference in the rate of postoperative complications after short-course pre-operative radiotherapy compared with full course chemoradiation.     

中下段直肠癌保肛术201例临床分析

报道１９８６年１月～１９９４年１２月间收治直肠癌患者７８３例，其中，中下段直肠癌５５２例（占７０．５％）。该５５２例中施行各类保肛术２０１例（占３６．４％），其中经腹骶切除５例，经耻骨切除５例，Ｄｉｘｏｎ式６７例，拉下式吻合４４例，拖出式吻合６８例及局部切除１２例。术后３年生存率达９０．９％。文中就保肛手术的根治性、术后排便功能的恢复、并发症的产生和处理以及综合治疗的必要性等问题进行了分析讨论。认为保肛术是治疗中下段直肠癌的一种合理术式，其主要适用于Ｄｕｋｅ’ｓＡ和Ｂ１期病例。采取综合治疗则是预防癌肿复发和提高生存率的重要措施。     

PREVIOUS INTRAVENOUS CHEMOTHERAPY DOES NOT ALTER RESPONSE RATE OR SURVIVAL TIME OF PATIENTS WITH HEPATIC METASTASES FROM COLORECTAL CANCER TREATED BY HEPATIC ARTERY CHEMOTHERAPY

Background : The present paper addressed the issue of whether pretreatment with intravenous (IV) chemotherapy affects response rate or survival in patients receiving hepatic artery chemotherapy (HAC). Methods : Case note reviews of 164 patients treated in a teaching hospital from June 1990 to July 1996 were carried out. Results : The response rate and carcino-embryonic antigen (CEA) fall in the two groups was almost identical. There was a nonsignificant survival advantage in the non-pretreatment group. Conclusions : Previous administration of IV chemotherapy did not affect the CEA response of patients receiving HAC.