局部进展期胰腺癌的综合治疗

胰腺癌是恶性度最高的恶性肿瘤之一,但其早期缺乏典型的临床症状和体征,就诊后能够手术切除的病例仅20%左右,其余大部分患者确诊时已无法手术切除,其中因肿瘤浸润肠系膜血管或邻近脏器者被称为局部进展期胰腺癌。对这部分患者如何能够有效改善生存期,提高生活质量是胰腺癌临床治疗的重点。     

局部进展期直肠癌新辅助治疗研究进展

直肠癌是常见的消化道恶性肿瘤，手术难度大，术后并发症较为常见，局部复发率较高，尤其以局部进展期直肠癌(LARC)的治疗效果差。随着多学科综合治疗理念在恶性肿瘤诊疗过程中受到重视，局部进展期直肠癌患者的预后也在术前新辅助治疗的应用下得以改善。因新辅助放化疗能有效降低术后局部复发率，新辅助放化疗联合全直肠系膜切除术(TME)已成为局部进展期直肠癌国际公认的治疗模式，临床医生也逐渐重视该疾病的术前治疗。为探求更佳的直肠癌患者的综合治疗方案，通过阅读国内外相关文献，就直肠癌新辅助治疗的现状与研究进展进行综述。     

局部进展期GEJA综合治疗的现状与思考

胃食管交界部腺癌（gastroesophageal junction adenocarcinoma,GEJA）具有独特的生物学特性和预后,且发病率显著增加,但其诊断和治疗仍存在争议。新辅助治疗和辅助治疗联合手术治疗较单纯手术均可改善局部进展期GEJA患者生存。而新辅助治疗中的新辅助放化疗较新辅助化疗可提高患者手术切除率和局部控制率,改善患者生活质量,联合分子靶向药物可进一步增加疗效。局部进展期GEJA患者的综合治疗数据多来源于食管癌或胃癌的随机临床研究,应开展更多大样本前瞻性随机对照研究,优化新辅助和辅助综合治疗,改善局部进展期GEJA患者的生存。本文对局部进展期GEJA综合治疗的研究进展进行综述。      

局部进展期胃癌新辅助治疗的现状与未来

胃癌是中国常见的恶性肿瘤之一。目前,手术切除是可以治愈胃癌的唯一方法,然而局部进展期胃癌（locally advanced gastric cancer,LAGC）患者单纯接受手术疗效较差,术后复发风险较高。新辅助治疗可使部分患者的肿瘤降期、提高R0切除率,降低局部及远处复发的风险,延长患者的生存期,现已成为LAGC治疗中的重要组成部分。随着新辅助治疗的不断发展,各类临床试验和新的治疗理念不断涌现,其治疗模式也从曾经单一的化疗,转变为新辅助放化疗、新辅助化疗联合靶向治疗、新辅助化疗联合免疫治疗等新型治疗模式。本文就LAGC的新辅助治疗进展及目前存在的争议进行综述。      

局部进展期乳腺癌的新辅助治疗

局部进展期乳腺癌(locally advanced breast cancer,LABC)包括进展期原发乳腺癌、区域淋巴结广泛转移和炎性乳癌。虽然经过积极治疗,患者预后仍然很差。综合治疗包括化疗、放疗、外科手术和新靶向药物的应用已显著提高了其临床疗效。但LABC仍然是临床面临的一个难题,尤其在发展中国家和难以普及乳腺癌筛查的国家。LABC的合理治疗方案需要内科、外科和放疗科之间的多学科讨论制定。作者就LABC目前的治疗现状展开讨论。     

中国胰腺癌多学科综合治疗模式专家共识(2020版)

胰腺癌的病因尚未完全明确, 预防便尤为困难。辅助检测手段的灵敏度和特异度低, 早诊是世界性难题, 现有的治疗手段疗效不满意, 且短期内难以突破, 总的5年生存率仅7.2%。面对胰腺癌的现状, 要加强基础研究、探究其病因和发病机制, 去除病因、切断发生发展路径。研发高灵敏度、高特异度的外周血和尿液等检测技术以及影像诊断技术以提高早期诊断率和疗效, 但基础和早期诊断技术的研究时间长、费用高, 短期内难以见效。因此, 急需解决的问题是通过规范的多学科综合治疗(MDT)、优化组合现有的诊疗方法, 制定个性化的治疗方案, 达到改善疗效的目的。本共识是在第1版的基础上, 基于胰腺癌的诊治现状且短期内难以突破的窘境, 参照国际、国内成功的诊治经验, 结合中国国情、由国内业界众多知名专家参与, 经反复推敲、讨论、几易其稿成文。本共识就MDT的意义和宗旨、主要任务、开展的必要客观条件、工作流程、注意事项、相关临床和基础研究、多中心MDT模式探索、eMDT模式探索等方面进行了详细论述, 希望能为推动我国胰腺癌MDT的规范化开展、改善胰腺癌的疗效、总结成功经验、促进国际交流、加强人才培养和梯队建设有所裨益;...     

胰腺癌肝转移患者多学科综合治疗临床分析

目的 对胰腺癌肝转移患者的临床特征及不同治疗模式分析,探讨不同治疗模式对患者生存预后的影响。方法 回顾性分析2009年1月至2012年1月重庆医科大学附属第一医院64例胰腺癌肝转移患者的临床资料,对其临床特征和治疗模式分别用Kaplan-Meier法及Cox模型进行单因素及多因素分析。结果 64例患者总的中位生存时间（median survival time, MST）为4月,6月、1年及2年生存率（overall survival, OS）分别为39.1%、21.9%和7.8%。单因素分析显示,年龄、疼痛、厌食、CA19-9水平、ALT和GGT水平、手术、介入化疗栓塞/介入化疗、积极治疗及多学科综合治疗是预后影响因素。多因素分析示：肝外转移、疼痛、CA19-9、积极治疗、手术、介入化疗栓塞/介入化疗及多学科综合治疗与生存预后密切相关。结论 对胰腺癌肝转移患者,疼痛、CA19-9≥1 000 u/ml及合并肝外转移提示预后不良。积极治疗、手术、介入化疗栓塞/介入化疗及多学科综合治疗可明显提高患者生活质量,延长生存时间。     

局部进展期胃癌的新辅助治疗

胃癌位居中国恶性肿瘤发病率和死亡率第2位, 严重危害国人的生命和健康。由于早期症状不典型、筛查体系不完善, 中国约70%的胃癌患者确诊时已处于局部进展期。根治性手术是局部进展期胃癌最主要的治疗方式, 但单纯手术治疗和传统的手术联合术后辅助治疗效果均不甚理想。术前新辅助治疗具有降低肿瘤分期、减小肿瘤原发灶、消除肿瘤微转移、减少术中散播和术后复发、提高胃癌根治性切除率等优点。近年来, 化疗、放射治疗、靶向治疗、免疫治疗在局部进展期胃癌术前新辅助治疗中的探索和应用不断取得进展。新辅助治疗已成为局部进展期胃癌重要的治疗模式。     

胰腺癌的治疗进展

近年来，胰腺癌手术切除5年生存率已从3％上升到17％－24％，对于不能手术切除者和晚期病人，各种治疗手段对减轻症状、延长生存期亦取得一定成效。本文介绍了手术、放疗、化疗和内分泌治疗等方面的进展概况，并对其疗效作了评述。     

局部晚期胰腺癌的治疗进展

局部晚期胰腺癌是发病率较高的肿瘤,治疗效果差,1年生存率很低。近几年对于其治疗研究较多,吉西他滨联合放疗的疗效得到肯定,同时新的药物如靶向药物以及紫杉醇类抗肿瘤药物和放疗技术的应用为局部晚期胰腺癌的治疗提供更多途径。     

Induction gemcitabine and oxaliplatin therapy followed by a twice‐weekly infusion of gemcitabine and concurrent external‐beam radiation for neoadjuvant treatment of locally advanced pancreatic cancer

BACKGROUND:

Chemoradiotherapy (CRT) may render curative resection feasible in patients with locally advanced pancreatic carcinoma (LAPC). The authors previously demonstrated the achievement of significant disease control and a median survival of 14 months by CRT in patients with LAPC. In this study, they evaluated the use of induction chemotherapy followed by a CRT neoadjuvant protocol.

METHODS:

Patients first received induction gemcitabine and oxaliplatin (GEMOX) (gemcitabine 1000 mg/m², oxaliplatin 100 mg/m²). Patients without disease progression then received gemcitabine twice weekly (50 mg/m² daily) concurrent with radiotherapy (50.4 grays) and were re‐evaluated for resectability.

RESULTS:

Thirty‐nine patients (15 with borderline resectable disease and 24 with unresectable disease) entered the study. The treatment was well tolerated. Disease control was obtained in 29 of 39 patients. Two patients progressed after GEMOX, and 7 progressed after CRT. After a median follow‐up of 13 months, the median progression‐free survival (PFS) was 10.2 months. The median PFS of patients with borderline resectable and unresectable disease was 16.6 and 9.1 months, respectively (P = .056). For the whole group, the median overall survival (OS) was 16.7 months (27.8 months for patients with borderline resectable disease, 13.3 for patients with unresectable disease; P = .045). Eleven patients (9 with borderline resectable disease and 2 with unresectable disease at diagnosis) underwent successful resection. Patients who underwent resection had a significantly longer median PFS compared with nonresected patients (19.7 months vs 7.6 months, respectively). The median OS among resected and nonresected patients was 31.5 months and 12.3 months, respectively (P < .001).

CONCLUSIONS:

The current results indicated that induction GEMOX followed by CRT is feasible in patients with LAPC. Both those with borderline resectable disease and those with unresectable disease received clinical benefit, a chance to obtain resectability, and improved survival. The authors concluded that this protocol warrants further evaluation. Cancer 2013. © 2012 American Cancer Society.     

局部晚期乳腺癌的治疗体会

目的：观察85例III期乳腺癌患者治疗的疗效,寻找提高疗效的策略。方法：2003年6月至2005年12月85例III期乳腺癌患者接受了外科手术治疗,根据是否接受新辅助化疗分为手术组（41例）和新辅助化疗组（44例）,比较两组的手术性质及治疗结果。结果：新辅助化疗组的无病生存期为59.1个月,明显高于手术组的43.1个月（P〈0.05）,新辅助化疗组的5年无病生存率为36.16%,手术组为34.14%（P〉0.05）。结论：局部晚期乳腺癌患者接受新辅助化疗后手术可提高无病生存时间,值得临床推广。     

局部晚期乳腺癌的治疗体会

目的:观察85例III期乳腺癌患者治疗的疗效,寻找提高疗效的策略。方法:2003年6月至2005年12月85例III期乳腺癌患者接受了外科手术治疗,根据是否接受新辅助化疗分为手术组(41例)和新辅助化疗组(44例),比较两组的手术性质及治疗结果。结果:新辅助化疗组的无病生存期为59.1个月,明显高于手术组的43.1个月(P<0.05),新辅助化疗组的5年无病生存率为36.16%,手术组为34.14%(P>0.05)。结论:局部晚期乳腺癌患者接受新辅助化疗后手术可提高无病生存时间,值得临床推广。     

Long-term outcomes of neoadjuvant chemotherapy before chemoradiation for locally advanced pancreatic cancer

BACKGROUND:

Neoadjuvant chemotherapy before chemoradiation therapy (CRT) may improve outcomes for patients with locally advanced pancreatic cancer, but optimal management remains controversial, and prior reports have limited follow‐up.

METHODS:

Seventy consecutive patients with unresectable (n = 46) or borderline resectable (n = 24) locally advanced pancreatic cancer were treated with CRT from 2005 to 2009. Patients typically received 50.4 grays in 28 fractions (91%) with concurrent 5‐fluorouracil (84%) or capecitabine (14%). Forty patients received CRT alone, and 30 patients received neoadjuvant chemotherapy before CRT for a median of 4 months, typically gemcitabine (93%). All patients without progression after neoadjuvant chemotherapy were offered CRT.

RESULTS:

Median follow‐up was 14.2 months (range, 3‐57 months). Fifty‐three percent of patients in the CRT group versus 83% in the neoadjuvant chemotherapy before CRT group had unresectable tumors at diagnosis; after completion of CRT, 20% of patients in both groups underwent resection. Compared with CRT alone, the neoadjuvant chemotherapy before CRT group demonstrated improved median overall survival (OS; 18.7 vs 12.4 months; P = .02) and progression‐free survival (11.4 vs 6.7 months; P = .02). On multivariate analysis, receipt of neoadjuvant chemotherapy (adjusted hazard ratio [HR], 0.49; 95% CI, 0.28‐0.87; P = .02) and surgical resection (adjusted HR, 0.38; 95% CI, 0.17‐0.85; P = .02) were associated with increased OS.

CONCLUSIONS:

Gemcitabine‐based neoadjuvant chemotherapy confers a significant OS advantage by allowing the selection of patients who will derive greatest benefit from CRT. Median survival with this approach was similar to that seen with surgical resection. Cancer 2012;118: 3026–35. © 2011 American Cancer Society.     

Fast neutron irradiation for locally advanced pancreatic cancer

Nineteen patients with locally advanced pancreatic cancer and one patient with islet cell cancer were treated with 1700–1750 neutron rad alone or in combination with 5-flourouracil to exploit the theoretic advantages of higher linear energy of transfer, and lower oxygen enhancement ration of neutrons. Only 5 of 14 (36%) obtained partial tumor regression. The median survival for all patients with pancreatic cacer was 6 months, which is less than that reported with 5-flouracil and conventional photon irradiation. Gastrointestinal toxicity was considerable; hemprrhagic gastritis in five patients, colitis in two and esophagitis in one. One patient developed radiation myelitis. We therefore, caution any enthusiasm for this modality of therapy until clear evidence of a therapeutic advantage over photon therapy is controlled clinical trials.     

Staging for locally advanced pancreatic cancer

Aim

To address the role of a dedicated radiologist and high quality CT scanning in staging of patients referred with suspected locally advanced pancreatic cancer. Furthermore, the value of laparoscopy in detecting CT-occult metastases in these patients was assessed.

Methods

In a prospective cohort study, 116 patients with suspected unresectable pancreatic cancer referred from peripheral hospitals (107) or our own gastroenterology department (9) were analysed. CT scans from referral centres were reviewed and in case of locally advanced disease or uncertain metastatic disease, patients underwent a laparoscopy to detect CT-occult metastases. Patients without metastases were offered 5-FU based chemoradiotherapy.

Results

After reviewing 107 abdominal CT scans from referral centres, 73 (68%) scans had to be repeated due to unacceptable quality. Locally advanced disease was confirmed in 59 (55%) patients and metastatic disease was found in 24 patients (22%). During laparoscopy, metastases were found in 24/68 (35%) patients with locally advanced disease on CT scan and metastases were confirmed in 3/5 (60%) with suspected metastases.Overall, only 46/116 (40%) patients with suspected unresectable disease appeared to have locally advanced pancreatic cancer after adequate staging including laparoscopy in our centre.

Conclusion

Correct staging is difficult in patients with suspected locally advanced pancreatic cancer and should preferably be performed in centres with technically advanced equipment and experienced radiologists. Laparoscopy should be offered to patients before locoregional therapy.     

盐酸吉西他滨联合伽玛射线立体定向体部放疗治疗局部晚期胰腺癌的临床研究

目的:观察盐酸吉西他滨联合伽玛射线立体定向体部放疗治疗不能手术的局部晚期胰腺癌的疗效及安全性。方法:205例不能手术切除的胰腺癌患者按治疗方法分为3组:A组67例为盐酸吉西他滨联合立体定向放射治疗组,B组72例为单用立体定向放射治疗组,C组66例为单用盐酸吉西他滨治疗组。盐酸吉西他滨1000mg/m2,第1、8天静脉输注,21-28天为1个周期,治疗4-6周期。联合治疗组第一周期化疗的第1天同步行伽玛射线立体定向体部放疗,等剂量曲线为55%-70%,肿瘤≤5cm的单次周边剂量4.0-5.5Gy,肿瘤>5cm的单次周边剂量3.0-4.0Gy,治疗总剂量为32-48Gy,治疗次数8-12次,5次/周。结果:2个月后增强CT复查肿瘤病灶。A组肿瘤病灶治疗有效率(RR)为32.8%(22/67),疾病控制率(DCR)为86.6%(58/67),临床受益反应为86.6%(58/67),中位生存时间(MST)为12.3个月(范围4-42个月),1年生存率为49.3%(33/67),治疗期间常见毒副反应为白细胞、血小板下降及消化道反应;B组RR为18.1%(13/72),DCR为68.1%(49/72),临床受益反应为66.7%(48/72),MST为8.6个月(范围4-30个月),1年生存率为31.9%(23/72),治疗期间常见毒副反应为恶心及呕吐;C组RR为13.6%(9/66),DCR为66.7%(44/66),临床受益反应为48.5%(32/66),MST为7.8个月(范围3-22个月),1年生存率为28.8%(19/66),治疗期间常见毒副反应为白细胞、血小板下降。盐酸吉西他滨联合立体定向放射治疗组的近期疗效(RR)及远期疗效(1年生存率)均优于单用立体定向放射治疗组(P=0.045;P=0.038)或单用盐酸吉西他滨(P=0.009;P=0.016)。结论:盐酸吉西他滨单药联合伽玛射线立体定向体部放疗治疗不能手术的局部晚期胰腺癌具有较好的疗效和安全性。     

Irreversible electroporation of locally advanced pancreatic neck/body adenocarcinoma

Objective

Irreversible electroporation (IRE) of locally advanced pancreatic adenocarcinoma of the neck has been used to palliate appropriate stage 3 pancreatic cancers without evidence of metastasis and who have undergone appropriate induction therapy. Currently there has not been a standardized reported technique for pancreatic mid-body tumors for patient selection and intra-operative technique.

Patients

Subjects are patients with locally advanced pancreatic adenocarcinoma of the body/neck who have undergone appropriate induction chemotherapy for a reasonable duration.

Main outcome measures

Technique of open IRE of locally advanced pancreatic adenocarcinoma of the neck/body is described, with the emphasis on intra-operative ultrasound and intra-operative electroporation management.

Results

The technique of open IRE of the pancreatic neck/body with bracketing of the celiac axis and superior mesenteric artery with continuous intraoperative ultrasound imaging and consideration of intraoperative navigational system is described.

Conclusions

IRE of locally advanced pancreatic adenocarcinoma of the body/neck is feasible for appropriate patients with locally advanced unresectable pancreatic cancer.     

Preliminary efficacy of CyberKnife radiosurgery for locally advanced pancreatic cancer

Background and Objective:CybeKnife is a newly developed technology in the field of stereotactic radiosurgery/radiotherapy (SRS/SRT).Compared with conventional SRS/SRT, there are many advantages for CyberKnife in terms of treating tumors that move with respiration, being real-time image-guidance, frameless, high accurateness, and so on.Recently, it has been used to treat different types of malignant carcinoma including intracranial and caudomedial tumors.This study was designed to evaluate the short-term eff...     

局部进展期胃癌围手术期治疗研究进展

对于初始不可切除的局部进展期胃癌患者,东西方治疗方法不尽相同,以手术为基础的多学科综合诊疗是目前的基本治疗策略。在西方国家,围手术期化疗或术后辅助放化疗是首选治疗方式;而亚洲胃D2切除术后辅助化疗是标准治疗方案,近年来,亚洲也在积极开展关于胃癌围手术期治疗的研究,虽然围手术期化疗的疗效已得到保障,但是否联合放疗、是否联合靶向治疗或免疫治疗仍未有统一标准,如何优化治疗模式和疗效预测仍是急需解决的问题。本文综述了局部进展期胃癌围手术期治疗的研究现状,并对其存在的问题及未来的发展前景进行了展望。