胰腺癌外科治疗的现状与展望

胰腺癌的发病率呈逐年上升趋势,根治性切除是目前治疗胰腺癌的首选治疗手段。近年来胰腺癌的外科治疗取得了很大的进步,围手术期并发症和死亡率均显著下降,但胰腺癌患者切除后远期生存率仍不高。标准胰卜二指肠切除术是目前治疗胰头癌的主要术式,扩大淋巴清扫术并不能改善患者的预后。全胰切除术可用于治疗胰管内乳头状黏液性肿瘤,对胰腺癌不主张常规采用。本文就胰腺癌外科治疗的现状和发展趋势作一概述。     

癌的诊治 第十九讲:原发性肝癌治疗的进展

原发性肝癌（下称肝癌）的治疗同其它肿瘤治疗一样，宜采用包括外科、放疗、化疗、生物治疗、免疫治疗、中医治疗等手段综合施治。外科手术切除是治疗的主要手段；早期诊断、早期切除是提高疗效的主要途径。对于手术切除困难的中晚期病人，应用化疗、放疗、免疫、生物等综合治疗也可取得一定的疗效。一、外科治疗肝癌的外科治疗包括手术切除肿瘤、求切除肿瘤以外科途径施治的两部分内容。1．手术切除手术切除肿瘤是目前治疗肝癌的最有效方法。经过近30年肝脏外科的发展，手术技术的提高，已使肝癌术后5年生存率达到25％左右，部分文献报告甚…     

胰腺癌放疗研究进展

近年来的研究表明,对于可手术切除胰腺癌患者,不论手术切缘状况、原发肿瘤大小、有无淋巴结转移、肿瘤分化程度等,均能从术后辅助放化疗中获益;术前新辅助放化疗的多项Ⅱ期临床研究均提示治疗耐受性良好.对于局部晚期不能手术切除胰腺癌患者的治疗目前尚无金标准,但以吉西他滨为基础的化疗或以吉西他滨为基础的放化疗与最佳支持对症治疗相比延长了总生存率.     

32例气管肿瘤的外科治疗

目的：总结32例气管肿瘤患者外科治疗经验。方法：回顾性分析我科1980～2005年收治的32例气管肿瘤患者外科治疗临床资料。结果：32例气管肿瘤患者中，23例行气管袖状切除端-端吻合术；8例行气管隆凸切除重建术；1例行气管开窗、肿瘤刮除术。术后2例死亡，另有8例发生术后并发症。结论：手术切除是治疗气管肿瘤最有效的方法。气管袖状切除端-端吻合术是治疗气管恶性肿瘤最主要的术式，良性肿瘤可以考虑保守的术式。手术治疗应该兼顾手术的根治性和安全性。     

胰腺癌术前诊断和手术适应证

胰腺癌手术切除目前仍然是唯一有效的治疗措施。对术前影像诊断的要求是:早期识别较小的肿瘤;准确鉴别肿瘤和局部炎症;准确显示肿瘤范围,以判断手术切除的可能性。 术前诊断应把已不能切除的肿瘤患者排除于手术之外,这对有效的术前治疗具有重要意义,少数不能手术的患者尚可行内镜保守治疗,使患者在术前诊断的基础上有选择治疗的可能性。     

胰腺癌根治术及扩大根治术的观点和评价

胰腺癌发病率逐年上升,上海、天津市肿瘤统计胰腺癌癌亡死因已由15年前10位以下,上升到第5位。作为人体重要的内脏实体瘤,胰腺癌至今无论在早期诊断和治疗难度上是最棘手的恶性肿瘤之一。胰腺癌首选外科治疗,但胰腺癌外科治疗效果仍不理想,Gud-jonsson综合了世界各国外科治疗37,000例胰腺癌,其中4.100例行根治手术,全部病例中.5年生存率仅156例,其中尚有12例为非根治手术,5年生存率0.4％,近200所医院资料,无任何作者报告5年生存率超过3.4％。可见胰腺癌治疗远期效果差。目前对胰腺癌外科治疗主要有如下见解:(1)认为胰腺癌外科治疗疗效差,主张不论病变早晚一律采用内引流     

新技术带来新希望

随着外科技术的提高和新的治疗方法的产生,目前肝癌的治疗技术在以下几方面取得了新的进展。1手术切除手术切除仍然是治疗肝癌最有效的方法,随着手术方式不断改进,从规则性肝叶切除发展到不规则性肝叶切除、无血肝切除和原位肝移植,手术切除率大为提高。大于5cm的巨大肝癌一直被认为是中晚期肿瘤,大多放弃外科治疗。但通过我院的临床观察证实:肿瘤大小并非决定     

可切除胰腺癌的围手术期治疗与全程管理

胰腺癌是恶性程度和致死率极高的消化道恶性肿瘤.可切除胰腺癌是指可以通过手术达到根治性切除的胰腺癌,临床研究表明辅助化疗能延长可切除胰腺癌患者的生存期,但总体预后仍不乐观.目前国内缺乏一套规范的可切除胰腺癌患者全程管理模式.本文通过对可切除胰腺癌近20年来辅助治疗、新辅助治疗、分子靶向治疗、靶向肿瘤微环境的治疗如免疫治疗...     

专家评语

胰腺癌患者预后不佳,至今尚无突破性的治疗进展,根治性手术对于可切除性肿瘤患者仍是唯一可以获得长期生存的治疗方法。影响胰腺癌预后的因素众多,如肿瘤分期、病理类型、肿瘤DNA倍体、切缘、淋巴结转移状况、脉管内癌栓、神经侵犯以及潜在的远处转移等,均直接影响肿瘤可切除患者的术后生存期;不可切除的胰腺癌患者则与治疗的依从性和对     

不能手术切除的晚期胰腺癌的序贯治疗（附30例临床观察报告）

不能手术切除的晚期胰腺癌的序贯治疗（附３０例临床观察报告）宋蔚青教授李瑞祥，刘合心西安医大一附院外科（７１００６１）五十年来胰腺癌的发病率增加了３～４倍［１］，已跃居消化道常见肿瘤的第三位。现代医学对胰腺癌的治疗，仍以手治疗为主，但由于患者多数就诊过...     

胰腺癌根治术与术后辅助外放疗的疗效比较

目的 探讨术后放疗对胰腺癌患者生存率的影响.方法 44例胰腺癌患者分为手术组(根治性外科切除)和手术+放疗组(根治性外科切除后接受外放疗),比较两组患者的治疗效果.结果 手术组平均生存期为453 d,中位生存期为379 d.手术+放疗组平均生存期789 d,中位生存期为665 d.手术组和手术+放疗组的1、3、5年生存率分别为46.3%、8.3%、4.2%和65.2%、20.2%、14.1%,手术+放疗组优于手术组(P=0.017).手术+放疗组局部复发率及区域淋巴结转移率低于手术组(P<0.05),且并发症发生率并不高于手术组(P>0.05).结论 胰腺癌根治术后结合放疗有助于改善患者生存期.     

Imaging-guided curative surgical resection of pancreatic cancer in a xenograft mouse model

Pancreatic cancer is the fourth leading cause of cancer related deaths in North America. The poor survival statistics are due to the fact that there are no reliable tests for early diagnosis and no effective therapies once metastasis has occurred. Surgical resection is the only curative treatment for pancreatic cancer; however, only less than 15% of the patients are eligible for surgery at diagnosis. New therapies are urgently needed for this malignant disease. And combinational therapy including surgery, chemotherapy and molecular targeted therapy may further improve the efficacy of individual therapies. However, a reliable mouse model which mimics the human disease and can be used for testing the surgical treatment and surgery-based combinational therapy is not available. In this study, we have established a mouse model for curative surgical resection of pancreatic cancer. Human pancreatic cancer cells were used to create orthotopic xenografts in nude mice, distal pancreatectomy was performed using imaging-guided technology to remove the pancreatic tumors, and sham surgery was performed in the control group. All mice survived the operation and no complication was observed. Surgical resection at early stage improved the survival rate and quality of life of the mice compared with the sham surgery and surgical resection at the late stage. If combined with other therapies such as chemotherapy and molecular targeted therapy, it could further improve the outcome of pancreatic cancer. This mouse model is a useful tool to study the surgical therapy and the tumor recurrence of pancreatic cancer, and could potentially impact the therapeutic choices for this deadly disease.     

Survival after attempted surgical resection and intraoperative radiation therapy for pancreatic and periampullary adenocarcinoma

PURPOSE: To evaluate a single institution's experience with intraoperative radiation therapy (IORT) in combination with attempted surgical resection for pancreatic and periampullary adenocarcinoma. METHODS AND MATERIALS: From May 1986 until June 2001, 77 patients at LDS Hospital underwent attempted surgical resection and IORT for pancreatic or periampullary adenocarcinoma. A potentially curative resection was defined as surgery with negative or microscopic positive margins. No patients had metastatic disease at the time of surgery and IORT. Forty-four patients with tumors located in the pancreas and 9 patients with periampullary tumors underwent potentially curative surgical resection and IORT. Twenty-four patients had pancreatic tumors deemed unresectable and underwent surgical bypass and IORT. Actuarial survival was calculated from the date of IORT until last follow-up or death by use of the Kaplan-Meier method. RESULTS: Patients undergoing a potentially curative resection and IORT for periampullary adenocarcinoma had a median survival of 167 months and a 56% 5-year actuarial survival, compared with a median survival of 16 months and a 19% 5-year actuarial survival for patients undergoing the same treatment for pancreatic adenocarcinoma (p = 0.03). Patients with unresectable disease who underwent bypass and IORT had a median survival of 11 months and a 0% 3-year survival, significantly worse than patients able to undergo surgical resection and IORT (p = 0.0002). The operative mortality for all patients undergoing potentially curative resection and IORT was 3.7%. CONCLUSIONS: Intraoperative radiation therapy is well tolerated and does not increase the morbidity or mortality of potentially curative surgical resection for pancreatic or periampullary adenocarcinoma. Patients with periampullary adenocarcinoma have a better prognosis than those with pancreatic adenocarcinoma, and patients with unresectable pancreatic disease fared worse.     

胰腺癌:新辅助治疗

In spite of the high mortality in pancreatic cancer, significant progress is being made. This review discusses multimodality therapy for patients with pancreatic cancer. Surgical therapy currently offers the only potential monomodal cure for pancreatic adenocarcinoma. However only 10%-20% of patients present with tumors that are amenable to resection,and even after resection of localized cancers, long term survival is rare. The addition of chemoradiation therapy significantly increases median survival. To achieve long-term success in treating this disease it is therefore increasingly important to identify effective neoadjuvant/adjuvant multimodality therapies. Preoperative chemoradiation for potentially resectable pancreatic cancer has the following advantages:(1) neoadjuvant treatment would eliminate the delay of adjuvant treatment due to postoperative complications; (2) neoadjuvant treatment could avoid unnecessary surgery for patients with metastatic disease evident on restaging after neoadjuvant therapy; (3) downstaging after neoadjuvant therapy may increase the likelihood for negative surgical margins; and (4) neoadjuvant treatment could prevent peritoneal tumor cell implantation and dissemination caused during surgery. This review systematically summarizes the current status, controversies, and prospects of neoadjuvant treatment of pancreatic cancer.     

胰腺癌:新辅助治疗

In spite of the high mortality in pancreatic cancer, significant progress is being made. This review discusses multimodality therapy for patients with pancreatic cancer. Surgical therapy currently offers the only potential monomodal cure for pancreatic adenocarcinoma. However only 10%-20% of patients present with tumors that are amenable to resection, and even after resection of localized cancers, long term survival is rare. The addition of chemoradiation therapy significantly increases median survival. To achieve long-term success in treating this disease it is therefore increasingly important to identify effective neoadjuvant/adjuvant multimodality therapies. Preoperative chemoradiation for potentially resectable pancreatic cancer has the following advantages： （1） neoadjuvant treatment would eliminate the delay of adjuvant treatment due to postoperative complications; （2） neoadjuvant treatment could avoid unnecessary surgery for patients with metastatic disease evident on restaging after neoadjuvant therapy; （3） downstaging after neoadjuvant therapy may increase the likelihood for negative surgical margins; and （4） neoadjuvant treatment could prevent peritoneal tumor cell implantation and dissemination caused during surgery. This review systematically summarizes the current status, controversies, and prospects of neoadjuvant treatment of pancreatic cancer.     

Kurativ-operative Therapie des Pankreaskarzinoms

Pancreatic cancer is still a devastating disease, which is presently the fourth or fifth leading cause of cancer-related death in Western countries with a poor prognosis even after tumor resection. Approximately 150,000 people worldwide and 40,000 people in Europe die each year of pancreatic cancer, making it one of the most aggressive human tumors. An overall 5-year survival of less than 1% is frequently reported and little has changed in recent decades. Complete resection of the entire tumor is still the only possibility to cure pancreatic carcinoma. Despite many clinical improvements, only little has changed in the long-term survival of patients with pancreatic cancer. Due to essential improvements in the field of surgery in the last decade, it is nowadays possible to resect more patients and the operative procedures have become safer in terms of morbidity and mortality. It is still a challenging task to diagnose pancreatic cancer in early tumor stages, because the disease usually becomes symptomatic at an advanced stage. Therefore, the overall resectability rate of pancreatic cancer is only 10–15%. On the other hand, low responsiveness to chemotherapy, radiotherapy, immunotherapy, and antihormonal treatment contributes to the poor prognosis. These facts together result in low resectability rates after diagnosis, early tumor recurrence after resection, and poor overall survival rates.     

Surgical treatment of pancreatic adenocarcinoma; actual survival and prognostic factors in 343 patients

Survival data of patients with pancreatic carcinoma are often overestimated because of incomplete follow-up. Therefore, the aim of this study was to approach complete follow-up and to analyse survival and prognostic factors of patients who underwent surgical treatment for pancreatic adenocarcinoma. Between 1992 and 2002, 343 patients underwent surgical treatment for pancreatic adenocarcinoma. One hundred and sixty patients underwent a resection with a curative intention and 183 patients underwent bypass surgery for palliation. Follow-up was complete for 93% of patients. Median survival after resection and bypass was 17.0 and 7.5 months, and 5-year survival was 8% and 0, respectively. In multivariate analysis, tumour-positive lymph nodes, non-radical surgery, poor tumour differentiation, and tumour size were independent prognostic factors for survival after resection. For patients treated with bypass surgery, metastatic disease and tumour size independently predicted survival. In conclusion, actual survival of patients with pancreatic adenocarcinoma is disappointing compared with the actuarial survival rates reported in the literature. The independent prognostic factors for survival of patients who underwent surgical treatment for pancreatic adenocarcinoma are tumour-related.     

2015年胰腺癌研究及诊疗前沿进展

随着发病率和死亡率的增加，癌症不仅成为中国疾病致死的重要原因，也同样是困扰世界的一个重大公共卫生问题。尤其令人担忧的是，全世界每年新发胰腺癌病例数呈现逐年上升的趋势。胰腺癌患者的预后较差，其5年生存率仅约6%，其主要原因包括：①在疾病的早期缺乏典型的临床症状，早期诊断困难；②高侵袭转移特性导致难以控制的复发和转移；③缺乏有效的化疗及靶向治疗药物；④容易对现有化疗药物产生耐药。手术根治性切除仍是目前最有效的治疗方式，但是根治术后早期转移复发仍是造成手术预后不良的主要问题。本文将就2015年全球范围内针对胰腺癌发病因素、流行病学调查、基础研究热点、外科手术相关进展、内科治疗和精准医学等方面的研究及诊疗前沿进展进行回顾性分析。     

Pancreatic resection

BACKGROUND:

Blacks are affected disproportionately by pancreatic adenocarcinoma and have been linked with poor survival. Surgical resection remains the only potential curative option. If surgical disparities exist, then they may provide insight into outcome discrepancies.

METHODS:

Patients with pancreatic adenocarcinoma were identified using the National Cancer Institute's Surveillance, Epidemiology, and End Results data from 1992 to 2002. Univariate analyses were used to compare demographics, tumor characteristics, and surgical data; and logistic regression was used to determine independent predictors for recommendation/performance of surgery. Kaplan‐Meier survival was assessed, and a Cox proportional hazards model was used to examine adjusted predictors of survival.

RESULTS:

In total, 27,828 patients were identified; 81.4% were white, 11.5% were black, 7.2% were of other race. White patients and black patients presented with similar stage and had surgery recommended at similar rates (34.5% vs 34%, respectively; P = .57). Black patients underwent fewer resections (10.6% vs 12.7%; P < .001). Multivariate analysis confirmed that black patients were less likely to undergo resection (adjusted odds ratio, 0.69; 95% confidence interval [95% CI], 0.57‐0.84). Overall, black patients had worse univariate survival. The survival among black patients who underwent resection did not differ statistically from the survival of similar white patients, although the median survival trended lower (11 months vs 13 months; P = .13). In a multivariate Cox model, black race predicted worse survival (hazards ratio, 1.11; 95% CI, 1.07‐1.16), and pancreatic resection was protective (hazards ratio, 0.56; 95% CI, 0.53‐0.59).

CONCLUSIONS:

Black and white patients with pancreatic adenocarcinoma presented with similar stages and were recommended for pancreatectomy at similar rates, yet black patients underwent fewer resections. After resection, crude survival did not differ significantly between white and black patients, although multivariate analysis demonstrated a survival disadvantage for blacks despite adjusting for resection. The current results suggested that pancreatectomy may be underused for blacks. Maximizing resection rates for appropriate patients may be an important component in reducing outcome disparities for pancreatic adenocarcinoma. Cancer 2009. © 2009 American Cancer Society.