胰腺癌术前放化疗未能带来显著总生存获益

荷兰阿姆斯特丹大学Versteijne等报告的Ⅲ期临床试验显示,治疗可切除或交界可切除胰腺癌,术前放化疗相比直接手术并未带来明显的OS获益(J Clin Oncol 2020年2月27日在线版doi:10.1200/JCO.19.02274)。术前放化疗可能会提高可切除或交界可切除胰腺癌的根治性切除率,但其整体获益尚未得到证实。研究者设计了这项Ⅲ期临床试验,在16个医疗中心开展,入组可切除或交界可切除的胰腺癌患者.     

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...     

对"边缘可切除"胰腺癌的新认识

随着胰腺影像学和外科手术技巧的发展,外科医生在"可切除的"胰腺癌与"局部进展的"胰腺癌之间划分出一类"边缘可切除"胰腺癌.这一大类肿瘤包括部分累及肝动脉、门静脉、肠系膜上动静脉,并且其受累的血管有切除与重建可能的胰腺癌.对"边缘可切除"胰腺癌施行根治性手术,有助于提高以往被认为是"无法切除"的胰腺癌的手术切除率,但是根据现有的资料统计,"边缘可切除"肿瘤的术后切缘阳性发生率较高,直接影响患者的预后.因此,术前应对肿瘤进行准确的分期分级,并联合新辅助治疗有可能为此类患者获得RO切除创造条件,并改善预后.     

胰腺癌诊治的现状与展望

目前,手术仍然是胰腺癌的首要治疗手段,然而在确诊时80%以上的胰腺癌已进入中晚期,能手术切除的患者只有15%左右.因此,胰腺癌的术前诊断与分期对于采取正确的治疗方案非常重要.我们参照2008年版和2009年版美国国家综合癌症网(NCCN)胰腺癌临床指南,结合我国的实际情况,就胰腺癌的诊治现状与进展分析如下.     

超声内镜对胰腺癌可切除性评估的价值分析

目的探讨内镜超声检查术(EUS)对胰腺癌的可切除性评估的价值。方法收集在术前均经EUS、BUS以及CT检查,后经手术治疗,并最终为病理组织学证实为胰腺癌的病例。对EUS在术前对胰腺癌的可切除性评估进行回顾分析,以手术结果为金标准进行对比,并与BUS以及CT诊断结果进行比较。结果21例接受手术治疗,其中6例术前EUS认为可切除,实际术中切除5例,EUS评估胰腺癌可切除性的准确度为83.3%;15例术前EUS评估为不可切除,实际手术无法切除14例,EUS评估不可切除准确度为93.3%。提示EUS术前评估结果与手术结果一致性较好。EUS诊断胰腺癌准确率为95.2%,CT为90.5%,B超为71.4%。结论应用EUS评估胰腺癌的可切除性是一种有效的方法。     

多学科协作理念下胰腺癌的诊疗方针

胰腺癌早期诊断困难，病死率高，是一种难治的消化系统肿瘤。该文探讨了多学科协作理念下胰腺癌的诊断治疗方针。在诊断方面，重点探讨了CA19 9与Lewis和Secretor联合分组提高CA19 9诊断敏感性和特异性的新发现，以及B超、薄层CT、增强MRI、PET检查协作诊断胰腺癌的优势。讨论了可切除胰腺癌、转移性胰腺癌、局部进展期胰腺癌、交界可切除胰腺癌等的标准治疗手段，包括开放手术、腹腔镜或机器人辅助技术，辅助放化疗、靶向治疗等。此外，作者进一步介绍了国内外正在开展的临床实验研究。胰腺癌全程治疗涉及多个科室的协同合作，多学科团队（MDT）能整合各个科室优势，为患者提供最优化的诊疗方案，有助于进一步提升我国胰腺癌诊疗水平。     

2011年NCCN胰腺癌指南诊疗要点更新解读

胰腺癌作为一种消化系统高度恶性肿瘤,其发病率在全球范围内不断升高.美国2010年预计43,140人被诊断为胰腺癌,约36,800人将死于胰腺癌[1].胰腺癌已成为美国男性(位居肺、前列腺和结直肠癌之后)及女性(位居肺、乳腺和结直肠癌之后)最常见癌症死亡原因的第4位[1].胰腺癌在我国的发病率也有逐年升高的趋势.如何对胰腺癌进行有效的诊断和治疗显得极为重要.最新2011年美国国家综合癌症网络(National Comprehensive Cancer Network,NCCN)胰腺癌指南的更新主要集中在胰腺癌的诊断和辅助治疗中,本文将对指南更新要点进行解读.     

基于NCCN指南的直肠癌外科治疗

直肠癌的外科治疗策略在很大程度上有别于结肠癌。本文根据直肠癌临床实践指南（中国版）2008年（第一版）,拟就术前分期、术前新辅助治疗、可切除直肠癌的手术、肝转移癌、术后辅助治疗以及其他外科相关的问题予以讨论。     

胰、脾

超声内镜对胰腺及壶腹癌术前分期及可切除性的评估；胰腺转移性肿瘤的诊断和治疗；三维适形放疗联合S-Fu化疗治疗局部晚期胰腺癌的疗效观察；超声引导下直接注入无水乙醇治疗胰腺癌的探讨。     

2015年第2版美国国立综合癌症网络(NCCN)非霍奇金淋巴瘤诊疗指南Castleman病解读

美国国立综合癌症网络(NCGN)在2015年3月3日发布了第2版非霍奇金淋巴瘤治疗指南,首次包括了Castleman病,为该病的规范化诊断和治疗提供了参考依据.基于最新文献及临床试验结果,该指南明确指出了Castleman病的一线、二线治疗方案,使临床医生在治疗该病时有依据可循.     

局限期胰腺癌放化疗的临床试验研究进展

根据术前肿瘤与相邻血管的关系胰腺癌分为可手术切除、临界可切除和不可手术切除病变。就诊时大部分患者已为局部晚期或出现远处转移,只有20%患者有手术机会,放化疗对于胰腺癌至关重要。本文回顾近年来的相关文献,着重介绍局限期胰腺癌新辅助放化疗、立体定向放疗及放化疗联合免疫治疗的临床试验研究进展。     

The Role of the FOLFIRINOX Regimen for Advanced Pancreatic Cancer

In 2010, the FOLFIRINOX regimen (bolus and infusional 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) emerged as a new option in patients with metastatic pancreatic cancer and a good performance status. However, at that time, some doubts were raised regarding safety issues. Similarly, no data on FOLFIRINOX were published in patients with unresectable/locally advanced or borderline resectable pancreatic cancer. This article presents the available experience with FOLFIRINOX outside clinical trials in metastatic and locally advanced pancreatic cancer patients. The safety of the regimen in patients with biliary stents and in previously treated patients is also described. FOLFIRINOX usage in clinical practice, including modification of the regimen (omission of bolus 5-fluorouracil; FOLFOXIRI regimen), is also presented. These data suggest that a phase III randomized study is warranted to further explore the role of FOLFIRINOX in locally advanced pancreatic cancer.     

Resectable,borderline, and locally advanced pancreatic cancer—“the good,the bad,and the ugly” candidates for surgery?

The possibility of surgical resection strongly overrules medical oncologic treatment and is the only modality, causa sine qua non, long-term survival can be achieved in patients with pancreatic cancer. For this reason, the clinical classification of local resectability, subdividing tumors into resectable, borderline resectable, and locally advanced cancer, that is very technical in nature, is the one most widely used and accepted. As multimodality treatment with potent agents, particularly in the neoadjuvant setting, seems to be stepping forward as the new standard of treatment of pancreatic cancer, the established technical surgical landmarks tend to get challenged. This review aims to highlight the grey zones in the current classifications for local tumor involvement with respect to the observed patient outcome in the current multimodality treatment era. It summarizes the latest reported series on the outcome of resected primary resectable, borderline and locally advanced pancreatic cancer, and particularly vascular resections during pancreatectomy, in the background of different types of neoadjuvant therapy. It also hints what the new horizons of cancer biology tend to reveal whenever the technical hinders start being pushed aside. The current calls for the necessity of re-classification of the clinical categories of pancreatic cancer, from technically oriented to biology-focused individualized approach, are being elucidated.     

2020年中国临床肿瘤学会《食管癌诊疗指南》解读

基于循证医学证据,结合我国食管癌临床病理特点,中国临床肿瘤学会(CSCO)在2019年首次发表了《食管癌诊疗指南》,2020年进行了第二次更新,本文将对该指南的主要内容进行简要解读,以便加深对该指南的理解并更好地指导临床诊疗实践。     

Borderline resectable pancreatic cancer - a definition and effective treatment strategy

The survival benefit of extended surgery for advanced pancreatic cancer has been denied by four randomized controlled trials. However, there still is confusion and conflict over the definition and effective treatment strategy for so-called locally advanced or borderline resectable pancreatic cancer. Although there are a number of reports that showed outcomes of preoperative chemotherapy or chemoradiotherapy for this disease, the definitions and treatment regimens described in these studies vary. Moreover, all of the studies were Phase I / II trials or retrospective analysis, and there is no Phase III trial currently focused on this issue. It is urgently necessary to establish an international consensus on the definition of borderline resectable pancreatic cancer. The usefulness of neoadjuvant treatment for this disease should also be elucidated in future clinical trials. In this review article, we discuss the current understanding and definition of borderline resectable pancreatic cancer, and the value of neoadjuvant treatment strategy for treating it.     

Current Concepts in the Treatment of Resectable Pancreatic Cancer

Purpose of Review

The diagnosis of pancreatic cancer carries with it a high mortality rate. Despite advances in the field, this has remained relatively unchanged over the last few decades. Current options for the treatment of resectable pancreatic ductal adenocarcinoma will be reviewed here in conjunction with the historical data that support them. We will focus on updates in treatment guidelines and ongoing clinical trials of interest.

Recent Findings

For localized disease, standard of care includes resection followed by adjuvant chemotherapy ± chemoradiation. Recently, a report was published supporting the use of doublet therapy with gemcitabine and capecitabine (as opposed to gemcitabine monotherapy), which prompted a practice-changing update to major treatment guidelines. Multiple trials using neoadjuvant treatment, novel therapies, and different forms of radiation are ongoing.

Summary

Although pancreatic cancer is an active area of research, outcomes remain dismal. Clinical trials will need to be more robust and innovative to drastically improve survival statistics.

     

The integration of chemoradiation in the care of patient with localized pancreatic cancer

The use of chemoradiation for patients with localized pancreatic cancer is controversial. Although some randomized trials have indicated that chemoradiation improves the median survival of patients with locally advanced as well as resected pancreatic cancer, other more recent trials have called into question the role of chemoradiation and have supported the use of chemotherapy. In the adjuvant setting, the high local tumor recurrence/persistence rate in all trials probably reflects the inclusion of patients with incompletely resected tumors, whose prognosis is similar to the prognosis of patients with locally advanced who do not undergo resection, making these trials difficult to interpret. More precise clinical staging and selection of patients appropriate for surgical resection is an important goal. The keys to the successful integration of radiotherapy in the care of patients with localized pancreatic cancer are selection, sequencing and smaller treatment volumes. A strategy of initial chemotherapy followed by consolidation with a well-tolerated chemoradiation regimen both in the adjuvant and locally advanced settings maximizes benefits of both treatment options, which are in fact complementary. Herein, we discuss the rationale for this approach as well as the ongoing investigation of novel radiation approaches designed to enhance outcome through the molecular and physical targeting of disease as well as the investigation of neoadjuvant chemoradiation in radiographically resectable and borderline resectable pancreatic cancer.     

Surgical treatment of pancreatic cancer: the role of adjuvant and multimodal therapies.

Surgical treatment in specialized referral centers has improved the prognosis of resectable pancreatic cancer considerably despite the generally aggressive behavior of this malignancy. At the same time, adjuvant therapy for pancreatic cancer has been shown to be effective in providing a survival benefit. However, some controversy remains over whether to use chemotherapy alone or combined chemoradiation. Few prospective randomized controlled clinical trials (RCTs) on the use of adjuvant chemotherapy and chemoradiation have demonstrated a distinct survival advantage of systemic chemotherapy (5-FU/FA or gemcitabine) following surgical resection. The most notable published trial is the European Study Group for Pancreatic Cancer (ESPAC)-1 trial. In addition, there are several retrospective analyses and two randomized studies on adjuvant radiation and chemoradiation. Some of these suggested increased survival rates using chemoradiation, which was subsequently widely introduced in clinical routine, especially in the United States. RCTs and a recent meta-analysis of these RCTs confirm, however, the superiority of chemotherapy over chemoradiation, except for a subgroup of patients with positive resection margins. Thus, curative surgery followed by adjuvant systemic chemotherapy should be the standard treatment for patients with resectable, locally confined pancreatic cancer. Further RCTs may clarify potential benefits of chemoradiation in the adjuvant treatment setting. Moreover, the best chemotherapy, or a combination thereof, remains to be determined in large-scale randomized trials.     

Imaging preoperatively for pancreatic adenocarcinoma

Pancreatic cancer is a highly lethal malignancy which is increasing in incidence and mortality. The fourth leading cause of cancer death in the U.S., pancreatic cancer is projected to become the second leading cause of cancer death by 2020. Patients with pancreatic cancer have an abysmal 5-year survival of 6%, and 90% of these patients eventually die from the disease. This is in large part due to the commonly advanced stage of disease at the time of diagnosis. Currently, the only potentially curative therapy for pancreatic carcinoma is complete surgical resection. Patients who undergo incomplete resection with residual disease have similar survival rates to those patients with metastatic disease and should be spared this relatively morbid surgery. Thus, the key to impacting prognosis is the detection of smaller and earlier stage lesions, and the key to optimal management is accurately determining which patients have potentially resectable surgery and which patients would not benefit from surgery. Cross-sectional imaging plays an essential role in both the diagnosis and appropriate staging of pancreatic carcinoma. The diagnosis and staging of pancreatic adenocarcinoma is performed with cross-sectional imaging. Multi-detector computed tomography (MDCT) is the most commonly used, best-validated imaging modality for the diagnosis and staging of pancreatic cancer. Modern contrast-enhanced magnetic resonance imaging (MRI) has been demonstrated to be equivalent to MDCT in detection and staging of pancreatic cancer. Endoscopic ultrasound (EUS) is very sensitive for detecting pancreatic masses; however, due to limitations in adequate overall abdominal staging, it is generally used in addition to or after MDCT. Transabdominal ultrasound and positron emission tomography/computed tomography (PET/CT) have limited roles in the diagnosis and staging of pancreatic cancer. Preoperative imaging is used to characterize patients as having resectable disease, borderline resectable disease, locally advanced disease (unresectable) and metastatic disease (unresectable). As the definitions of borderline resectable and unresectable may vary from institution to institution and within institutions, it is essential to accurately assess and describe the factors relevant to staging including: local extent of tumor, vascular involvement, lymph node involvement and distant metastatic disease. To facilitate this, standardized reporting templates for pancreatic ductal adenocarcinoma have been created and published. Structured reporting for pancreatic cancer has been reported to provide superior evaluation of pancreatic cancer, facilitate surgical planning, and increase surgeons’ confidence about tumor resectability.