伊立替康肝动脉化疗栓塞联合5-Fu/CF静脉化疗治疗结直肠癌肝转移的临床观察

目的评价伊立替康介入栓塞联合5-Fu/CF静脉化疗治疗结直肠癌肝转移的疗效和毒性。方法结直肠癌肝转移患者行TACE术,伊立替康（CPT-11）加超液化碘油化疗栓塞,介入完成后即行5-Fu/CF静脉化疗,每3周重复。结果全组26例患者共接受了98个周期化疗,平均4个周期（3~6周期）。CR 2例（7.69%）,PR 8例（30.77%）,SD13例（50%）,PD 3例（11.54%）;临床获益率88.46%（23/26）;中位疾病进展时间7.3月;中位生存期14.2月。最常见的毒副反应是中性粒细胞减少,消化道反应,多为Ⅰ～Ⅱ级。结论伊立替康肝动脉化疗栓塞联合CF/5-Fu静脉化疗治疗结直肠癌肝转移疗效肯定,毒性反应可以耐受。     

中晚期直肠癌的综合治疗

目的探讨中晚期直肠癌综合治疗方法。方法术前行股动脉插管化疗,然后行根治性手术切除。术后行静脉化疗和／或放疗。结果插管化疗后病人临床症状减轻,肿瘤变小。肿瘤缩小约＞50％3例,25-50％4例,＜25％1例,无明显变化1例。9例病人均行根治性手术切除,术后近期无局部复发,无肝转移。结论首先应用动脉插管化疗然后行手术、化疗和／或放疗,能够提高手术切除率、降低局部复发及肝转移,是治疗中晚期直肠癌较为合理的综合治疗模式。     

伊立替康用于结直肠癌术后辅助化疗患者的护理体会

目的 探讨结直肠癌术后应用伊立替康辅助化疗的常见不良反应及护理体会.方法 回顾性分析根治术后应用伊立替康进行辅助化疗的42例结直肠癌患者的临床资料,并总结护理体会.结果 42例患者总体耐受性良好,37例患者按计划完成治疗,其余5例更改方案或停止治疗.其中发生中性粒细胞减少25例、腹泻7例、恶心呕吐12例、急性乙酰胆碱能综合征2例、肝功能损害3例、外周静脉炎2例.结论 伊立替康用于结直肠癌根治术后辅助化疗的安全性良好,通过化疗期间科学的护理干预,做好患者的心理护理及健康教育,能减轻伊立替康化疗的不良反应,保证化疗方案顺利实施.     

直肠癌低位保肛术后局部复发的临床分析

目的探讨直肠癌低位保肛术后局部复发的原因及治疗。方法回顾性分析17例直肠癌低位保肛术后局部复发的临床病理资料。结果直肠癌低位保肛局部复发病例17例,以吻合口及周围组织复发为主,复发原因有未能保证全系膜切除、肠管切除不足、侧方淋巴结清扫不足等。复发病例中再行Miles术6例,术后1年生存率为75．0％（4例）,3年生存率为33．3％（2例）。结论对低位保肛患者术前肿瘤病理类型、临床分期的判断,是减少局部复发的关键。     

ＡＴＰ生物荧光体外药敏检测在中晚期结直肠癌化疗药物筛选中的应用

目的　探讨ＡＴＰ生物荧光体外药敏检测法（ＡＴＰ-ＴＣＡ）的特点及其在中晚期结直肠癌患者化疗方案中的指导价值。方法　应用ＡＴＰ-ＴＣＡ体外检测５９例结直肠癌细胞对常用抗癌药物的敏感性。结果　ＡＴＰ-ＴＣＡ法对结直肠癌标本的可评估率为９６.６１％。５７例结直肠癌细胞对４组联合化疗药物氟尿嘧啶＋丝裂霉素、氟尿嘧啶＋奥沙利铂、氟尿嘧啶＋伊立替康、氟尿嘧啶＋奥沙利铂＋伊立替康相比氟尿嘧啶、丝裂霉素、伊立替康、奥沙利铂４种单药的敏感度有高度显著性差异（Ｐ＝０.０００６）。应用ＡＴＰ-ＴＣＡ检测结果指导中晚期结直肠癌患者化疗,临床近期有效率为５９.６５％（３４／５７）,总预测准确率为６３.１６％（３６／５７）,阳性符合率为６１.８２％（３４／５５）,阴性符合率为１００％（２／２）。结论　ＡＴＰ-ＴＣＡ能有效检测化疗药物的敏感性,对指导中晚期结直肠癌患者化疗有重要的临床意义。     

晚期直肠癌放疗联合替吉奥化疗的效果

目的观察放疗同步替吉奥化疗治疗术后复发或晚期及局部晚期直肠癌的近期疗效和毒副反应。方法16例直肠癌术后复发患者,应用放疗（前后野等中心2Gy／次,每周5次,总剂量N46～56Gy）同步口服替吉奥胶囊化疗（40嘴每天2次,连续21d,休息14d）,放疗结束后继续化疗2个周期。结果全组患者均完成治疗,依从性好,同步放化疗后全部症状缓解率为70％,疼痛缓解率为40％,停止便血100％,镇痛有效率为100％,中位控制时间为5个月。治疗结束后1个月,全组患者的卡氏评分平均为57分。总有效率为70％,症状改善率为90％,1年生存率为70％,1年局部控制率为62．5％。主要毒副反应为消化道反应、血液性毒性和放射I生波肤反应,多为1～2级,仅1例患者出现3级腹泻。结论放疗联合替吉奥同步化疗治疗直肠癌术后复发的疗效确切,副反应可耐受,能明显改善患者生活质量,延长生存期。     

术前应用FOLFOX方案联合放疗治疗中低位直肠癌35例报告

目的探讨术前应用FOLFOX4方案化疗联合放疗治疗中低位局部进展期直肠癌的安全性和有效性。方法对本院2006年3月以来35例术前应用FOLFOX4方案联合放疗进行新辅助治疗的中低位局部进展期直肠癌患者资料进行分析。结果低位前切除术20例,腹会阴联合切除15例,保肛率为57．1％（20／35）。30例患者（85．7％）新辅助治疗后排便困难、便次增多、便血等症状得以改善。肿瘤完全消退5例,肿瘤部分缓解26例,病情稳定4例,治疗有效率为88．6％（31／35）。病理完全缓解率为14．3％;肿瘤分期降低25例,降期率为71．4％。结论FOLFOX4术前化疗方案应用于中低位局部进展期直肠癌的新辅助治疗安全有效,可达到大部分患者术前肿瘤降期。     

进展期结直肠癌术后腹腔热灌注化疗联合静脉化疗的临床研究

目的观察和比较腹腔热灌注化疗联合静脉化疗与单纯静脉化疗对进展期大肠癌术后腹腔局部复发、肝转移率及3年生存率的影响和不良反应。方法将90例大肠癌根治术后的进展期结直肠癌患者随机分成腹腔热灌注化疗联合静脉化疗组（治疗组）和静脉化疗组（对照组）,比较其疗效和生存率。结果治疗组3年腹腔局部复发率、肝转移率及3年生存率分别为15．6％、8．9％、82．2％,而对照组为37．8％、26．7％、62．2％,差异均有统计学意义（P〈0．05）,两组不良反应差异无统计学意义（P〉0．05）。结论影响进展期大肠癌术后生存率的主要原因是癌细胞的肝转移和腹腔局部复发,而腹腔热灌注化疗联合静脉化疗是预防进展期大肠癌术后肝转移和腹腔局部复发非常有效的方法。     

盐酸伊立替康对局部晚期宫颈癌放射增敏的临床研究

目的：探讨盐酸伊立替康对局部晚期宫颈癌的放射增敏作用及毒副反应。方法．41例经病理确诊的局部晚期宫颈癌患者（ⅡB～ⅣA期）随机分为两组：单纯放疗组21例，给予常规根治性放疗；增敏组20例，常规根治性放疗＋伊立替康，在放疗后1h内给予伊立替康40mg／m^2，静滴，每周1次，放疗第1天开始，共用5周。观察两组的宫颈局部肿瘤消退50％所需时间（T钟）、近期疗效（局部控制率）及毒副反应。结果：增敏组的T50为10．5天，单纯放疗组的T50为15天，两者比较有显著性差异（P〈0．05）；增敏组局控率为85．0％（17／20），单纯放疗组局控率为52．4％（11／21），两者比较差异显著（χ^2=5．02，P=0．025）。伊立替康增敏组胃肠道反应较单纯放疗组发生率高，但多为Ⅰ～Ⅱ度反应，未见Ⅳ度反应，其他的毒副反应在两组间差异无统计学意义。结论：在局部晚期宫颈癌中，低剂量盐酸伊立替康与放疗联合使用可使肿瘤消退50％所需时间缩短，提高局部控制率，改善近期疗效，无严重毒副反应发生。     

结直肠癌可切除肝转移灶的术前化疗文献复习

结直肠癌是常见的肿瘤之一,近一半的患者最终会发生肝转移,肝转移灶切除是唯一的治愈方法。对于评估为可切除的肝转移灶,由于其术后复发率高,患者生存时间并未有显著延长,术前影像学难以发现的肝内微小转移灶成为局部复发的重要因素之一。术前化疗可以减少微小转移灶,增加R0切除（完整切除）率,减少术后复发风险。但是,是否所有术前评估为可切除肝转移灶的结直肠癌患者均可以从术前化疗中获益仍存在争议。     

影响低位直肠癌局部切除选择的因素分析

目的探讨低位直肠癌局部切除选择的影响因素。方法回顾性分析101例局部切除治疗低位直肠癌患者的临床资料。Kaplan-Meier法计算生存率,并对预后进行单因素及多因素分析。结果经肛门切除91例,经骶骨切除9例,经阴道切除1例,并发症发生率为5.9%,全组无手术死亡病例。术前放疗5例,术后放疗34例。5年生存率为91.0%,Tis、T1、T2及T3或T4病变的5年生存率分别为100%、92.6%、77.1%和83.3%;局部复发率为15.8%。单因素分析显示,肿瘤的侵袭深度、直径>3 cm、有脉管瘤栓、溃疡型癌、放射治疗和局部复发与预后有关(P<0.05)。多因素分析显示,肿瘤直径>3 cm、局部复发是影响预后最重要的因素(P<0.05)。结论低位直肠癌病理为高中分化、直径≤3 cm、无脉管瘤栓的T1病变及原位癌,是局部切除术的合理适应证。     

直肠类癌手术方式的探讨

目的探讨直肠类癌手术方式的合理选择。方法对我院1982年4月-2008年12月间手术治疗的51例直肠类癌病例进行回顾性研究及随访。结肠镜下肿瘤电切术3例,经肛门局部切除术13例,经肛门括约肌的直肠外科手术（Mason术）7例,经肛门内镜微创手术（TEM）18例,直肠前切除术（Dixon术）2例,经腹直肠切除经肛门结肠肛管吻合术（Parks术）2例,腹会阴联合直肠肿瘤切除术（Miles术）4例,其他手术2例。结果术后病理确诊直肠类癌残灶显慢性炎11例,直肠类癌局限于粘膜下层以内者（pT0或pT1期）28例,直肠恶性类癌（神经内分泌癌）12例（23．5％）。全组51例患者手术并发症的发生率为3．9％。12例直肠恶性类癌中1例Miles术后发生肝转移,2例经肛门切除术后复发。本组中7例Mason术和18例TEM术后均未发生并发症或肿瘤局部复发。结论选择直肠类癌的手术方式应综合考虑类癌的具体部位、大小以及术前活检的病理结果,对于疑诊恶性的病例还应考虑肿瘤浸润肠壁的深度。Mason术和TEM为适合局部切除的直肠类癌患者提供了理想的术式选择。     

Oncological outcomes of transanal local excision for high risk T(1) rectal cancers

AIM:To evaluate the oncological outcomes of transanal local excision and the need for immediate conventional reoperation in the treatment of patients with high risk T1 rectal cancers.METHODS:Twenty five high risk T1 rectal cancers treated by transanal local excision at the Guangdong General Hospital were analyzed retrospectively.Twelve patients received transanal local excision and 13 patients underwent subsequent immediate surgical rescue after transanal local excision within 4 wk.Differences in the local recurrence rates and 5-year overall survival rates between the two groups were analyzed.The prognostic value of immediate conventional reoperation for high risk T1 rectal cancers was also evaluated.RESULTS:The median follow-up period was 62 mo.The local recurrence rates after transanal local excisionfor high risk T1 rectal cancer were 50%.By immediate conventional reoperation,the local recurrence rates were significantly reduced to 7.7%.The difference between these two groups was statistically significant(P = 0.030).Kaplan-Meier survival analysis showed a trend for decreased 5-year overall survival rates for patients treated by transanal local excision compared with immediate conventional reoperation(63%vs 89%).CONCLUSION:Transanal local excision cannot be considered sufficient treatment for patients with high risk T1 rectal cancers.Immediate conventional reoperation should be performed if the pathology of the local excision is high risk.     

腔镜直线切割吻合器用于T1期中低位直肠癌经肛门局部切除术的疗效及安全性

目的:探讨应用腔镜直线切割吻合器（endoscopic linear cutters,ENDOPATH）行经肛门局部切除术治疗T1期中低位直肠癌的疗效和安全性。方法:回顾性分析2011年01月至2017年12月我院收治的92例T1期中低位直肠癌患者的临床资料。根据手术方式分为经肛门局部切除术组（TAE组）与直肠癌传统根治术组（根治术组）。TAE组使用腔镜直线切割吻合器行经肛门全层局部切除术,共39例;根治术组按全直肠系膜切除原则行传统根治术,共53例(包括16例Miles手术和37例Dixon手术)。对两组患者的一般资料、术中及术后相关指标及预后情况进行比较。结果:TAE组和根治术组患者在性别、年龄、肿瘤病理分型、肿瘤大小、距肛缘距离方面对比分析,无显著性差异（P＞0.05）,两组资料有可比性。两组患者在手术时间［（TAE组:(37.74±10.66)min,根治术组:(117.66±41.78)min］、术后住院时间［TAE组:(6.85±1.06)天,根治术组:(10.70±1.72)天］、术中出血量［TAE组:(30.21±2.97)mL,根治术组:(78.96±12.65)mL］、术后并发症发生率（TAE组:2.56%,根治术组:43.39%）方面差异均有统计学意义（P＜0.01)。两组患者的3年无病生存率均为100.00%,两组患者3年内均无复发,相比较无统计学差异（P＞0.05）。两组患者的生存质量评分［TAE组:(90.31±3.82)分,根治术组:（71.59±6.33）分］差异有统计学意义（P＜0.01)。结论:与传统根治术相比,应用腔镜直线切割吻合器对T1期中低位直肠癌行经肛门局部切除术同样安全有效。应用腔镜直线切割吻合器行经肛门局部切除术创伤小、并发症少、恢复快,患者术后生活质量等方面明显优于根治术。应用腔镜直线切割吻合器行经肛门局部切除术可作为早期无淋巴转移的中低位直肠癌患者优先选择的一种术式。     

Conservative management of extensive low-lying rectal carcinomas with transanal local excision and combined preoperative and postoperative radiation therapy. A report of a phase I-II trial.

Between 1986 and 1990, 16 patients were enrolled in a prospective Phase I/II study of transanal local excision and combined preoperative and postoperative radiation therapy (RT). All patients had biopsy-proven adenocarcinoma extending to within 6 cm of the anal verge and involvement of at least one third of the rectal circumference with tumor. Five of 16 patients (32%) had T3 tumors, and only two patients had T1 tumors. Patients received a single 500 cGy fraction of RT to the pelvis within 24 hours before surgery and underwent transanal excision followed by postoperative RT (median dose, 5040 cGy). With a median follow-up of 33 months, overall 3-year actuarial survival was 94%. Two patients had isolated local recurrences (both successfully salvaged), and four had distant metastases but maintained local control. The 3-year actuarial rates of continuous freedom from any relapse, continuous local control, and no evidence of disease at last follow-up were 53%, 80%, and 71%, respectively. Only three of 16 patients required colostomy, resulting in a 3-year actuarial colostomy-free rate of 77%. There was a trend toward a higher rate of relapse (P = 0.066) in patients with T3 tumors than those with T1 and T2 tumors. Sphincter-preserving therapy for low-lying rectal carcinomas using local excision and combined preoperative and postoperative RT is feasible, although improved local and adjuvant therapy is needed for patients with T3 lesions.     

直肠癌新辅助治疗后临床完全缓解患者不同处理措施预后效果的Meta分析

目的以Meta分析评价针对新辅助治疗后达临床完全缓解的直肠癌患者行根治性手术、局部切除以及非手术临床观察的效果,为临床决策提供临床依据。方法以"rectal cancer"、"rectal adenocarcinoma"、"rectal neoplasms"、"neoadjuvant therapy"、"preoperative therapy"、"radiochemotherapy"、"radiotherapy"、"clinical complete response"、"complete pathological response"为主题词,在PubMed上收集有关直肠癌临床完全缓解患者进行根治性手术、局部切除和非手术治疗临床观察的公开发表的英文文献。纳入局部切除与根治性手术预后情况对比文献5篇,非手术临床观察与局部切除对比文献5篇。经两名研究者独立提取相关数据资料后进行Meta分析,用定性方法比较各预后指标在非手术组与根治性手术组、局切组与根治性手术组间的差异。利用漏斗图法评价发表偏倚。结果定性分析结果显示,与根治性手术组相比,非手术治疗临床观察组局部复发RR为5.33,95%CI为1.64~17.36,总复发RR为2.37,95%CI为1.15~4.85,差异有统计学意义;但远处转移率(RR=0.87,95%CI:0.16~41.11)及3~5年总生存率(RR=0.89,95%CI:0.66~1.21)则无统计学差异。与根治性手术组相比,局部切除组局部复发率(RR=1.25,95%CI:0.64~2.44)、远处转移率(RR=0.55,95%CI:0.27~1.10)及总复发率(RR=0.77,95%CI:0.49~1.22)均无统计学差异,且5年总生存率局部切除组界值性高于根治性手术组(P0.05)。结论直肠癌新辅助治疗后达临床完全缓解患者行非手术观察的局部复发率、总复发率高于根治性手术,但远处转移、长期生存与根治性手术相比无显著差异。局部切除术的局部复发率、远处转移率与根治性手术相比无显著差异,行局部切除者术长期生存甚至优于根治性手术。     

Advances in minimally invasive surgery in the treatment of colorectal cancer

Colorectal cancer (CRC) is the second leading cause of cancer-related death in the USA. Surgery is the primary treatment for most patients with CRC. Over the past 15 years, minimally invasive techniques for colorectal surgery have been developed. There is growing evidence that these techniques have significant advantages in short-term outcomes (e.g., postoperative pain and length of hospital stay) with similar long-term recurrence and overall survival. While transanal local excision has been shown to be inferior to radical resection for early rectal cancer, transanal endoscopic microsurgery (TEM) is a minimally invasive technique that appears to facilitate local excision in appropriate patients. TEM combined with radiotherapy has demonstrated promising early results and is currently being investigated in clinical trials as a potential alternative to radical surgery. We summarize the current literature on these minimally invasive approaches to CRC.     

Role of Combined-Modality Therapy in the Management of Locally Advanced Rectal Cancer

The majority of patients with nonmetastatic rectal cancer are candidates for an aggressive multimodality approach with curative intent. Preoperative staging is critical in determining which patients should be offered neoadjuvant therapy. Available staging tools include digital rectal examination, transrectal ultrasound, computed tomography, positron-emission tomography, and magnetic resonance imaging scans. Magnetic resonance imaging has emerged as the most accurate staging modality in experienced centers. Multidisciplinary preoperative patient evaluation, better staging techniques, neoadjuvant chemoradiation, acceptance of shorter distal rectal margins, and transanal excision of T1 N0 rectal tumors in close proximity to the anal sphincter have resulted in decreased rates of abdominoperineal resections. Total mesorectal excision has been adopted as the standard surgical approach because of a reduction in rates of pelvic relapse. Preoperative and postoperative radiation therapy was shown to decrease the local recurrence rate, but not overall survival, in patients with resectable rectal cancer. The addition of chemotherapy to radiation was consistently shown to improve local control, and in some trials, improved overall survival. Neoadjuvant combined chemotherapy and radiation therapy are superior to adjuvant combined-modality therapy because of higher rates of sphincter preservation, less toxicity, and lower local recurrence rates. For patients with stage II or III disease, neoadjuvant continuous-infusion 5-fluorouracil (5-FU), concurrently with pelvic radiation, followed by postoperative 5-FU–based chemotherapy, remains the standard multimodality approach. Ongoing trials are testing the integration of newer cytotoxic agents such as capecitabine, oxaliplatin, irinotecan, and biologic agents such as cetuximab and bevacizumab to chemoradiation.     

乳腺癌根治术局部复发后影响预后的相关因素分析

目的研究乳腺癌根治术局部复发后影响预后的相关因素,探讨乳腺癌根治术后局部复发的最佳治疗方案。方法回顾性分析天津肿瘤医院1975年1月至2003年1月期间收治的1067例乳腺癌根治术后复发患者,采用χ2检验或秩和检验对患者年龄、绝经情况、原发瘤临床分期、腋窝淋巴结转移情况、无病间期、复发部位、胸壁复发灶数目及其最大直径、雌激素受体(ER)或孕激素受体(PR)表达、人类表皮生长因子受体2(HER-2)表达等临床病理特征以及不同治疗方案与局部复发治疗的近期疗效和远处转移率之间的关系进行单因素分析;使用Kaplan-Meier法及COX回归模型对乳腺癌根治术复发后影响5年生存率的相关因素进行单因素与多因素分析。结果对全部1067例病例进行随访,778例(72.9%)出现远处转移,复发后5年总生存率为42.4%。复发部位、胸壁复发灶数目及其最大直径、有无放射治疗、放射治疗范围、有无化疗、有无手术切除或切除活检等因素的不同亚组间局部控制率的差异有统计学意义(P0.050);腋窝淋巴结转移情况、无病间期、ER或PR表达、HER-2表达以及再治疗中有无化疗等因素的不同亚组间远处转移率的差异有统计学意义(P0.050);无病间期、复发部位、胸壁复发灶数目、ER或PR表达、HER-2表达、治疗方法等因素的不同亚组间5年总生存率的差异有统计学意义(P0.050);无病间期≤2年、复发部位多、治疗方案单一、局部控制率低及ER、PR均阴性是导致复发性乳腺癌预后差的独立因素(P0.050)。结论多部位复发、胸壁多发结节及胸壁复发灶最大直径3cm者局部控制不佳,局部扩大野放射治疗结合化疗和(或)手术是改善局部控制率的较好模式;有腋窝淋巴结转移、2年内复发、ER、PR均阴性以及HER-2阳性表达的乳腺癌复发后容易发生远处转移,复发再治疗中化疗能减少远处转移的发生;对于复发性乳腺癌采取综合治疗方案可以提高复发患者的生存率;无病间期长,多部位复发,ER或PR阴性者提示预后不良。     

低位直肠癌术前同步放化疗的远期疗效及安全性研究

目的评估术前口服卡培他滨（希罗达）与放疗联合治疗局部进展期低位直肠癌的远期疗效及安全性。方法对局部进展期（T3／T4）低位直肠腺癌（距肛缘≤9Ccm）患者51例,术前给予口服卡培他滨（希罗达）并联合放疗。放疗结束后休息3—4周,按TME原则进行手术。结果3例患者临床完全消退（cCR）,占5．88％,未行手术;其余48例患者均行根治性切除术（R0）,实际保肛率90．20％（46／51）,10例术后病理检查未见肿瘤细胞,为病理消退（pCR）,总消退率为25．49％（13／51）。肿瘤降期41例,占80．39％。5年无病生存率为70．59％,总生存率为80．39％。放化疗过程中出现3、4级不良反应5例,无疾病进展、手术死亡者。结论术前口服卡培他滨联合放疗治疗局部进展期低位直肠癌是有效安全的。