动脉灌注化疗与癌内注射治疗胰腺癌肝转移

目的探讨胰腺癌肝转移治疗的有效方法。方法采用区域性动脉灌注化疗与癌内注射疗法治疗不能切除胰腺癌肝转移的患者。结果术中癌内直接注射5─FU8例，注射无水酒精3例。术后动脉灌注化疗5─FU、DDP、ADM共25个周期。11例患者均无治疗相关并发症，平均生存期11．4±8．7（5～36）月。其中1例术后7个月再手术行胰十二指肠切除，随访29月无复发。结论该方法用于不能切除胰腺癌肝转移的治疗，有助于改善患者的生存期，是一种安全有效的方法。     

内引流术加动脉区域灌注化疗治疗晚期胰腺癌应用

目的 探讨晚期胰腺癌的姑息治疗方法。方法 对26例晚期不能切除的胰腺癌行胆总管－－十二指肠T形管内引流术治疗，结扎胰十二指肠上动脉近心端，远心端插入化疗泵，术中、术后行动脉灌注化疗。结果 26例患者术在术后退黄；减轻患者症状，提高生存质量，延长生存时间等方面有显著疗效，其中1例生存18个月。结论 内引流术加动脉区域灌注化疗是治疗晚期不能切除胰腺癌的一个较好方法。     

307例胰腺癌的外科治疗体会

目的　探讨进一步提高胰腺癌外科治疗效果的措施。方法　回顾本研究所 1988年至1998年外科治疗 30 7例胰腺癌病人的临床资料 ,结合部分病人随访结果分析总结。结果　 30 7例中手术切除 118例 ,姑息性手术 178例 ,单纯剖腹探查 11例。切除 118例中行胰头十二指肠切除 95例 ,胰体尾部切除 14例 ,全胰切除 9例。姑息性手术 178例中行单纯胆肠和 (或 )胃肠转流 5 2例 ,转流 +胰周动脉结扎 4 5例 ,转流 +区域灌注化疗 4 2例 ,转流 +胰周动脉结扎 +区域灌注化疗 39例。随访 2 0 1例 ,手术切除组行胰十二指肠切除、胰体尾部切除及全胰切除者的平均生存期分别为 (2 9 6± 6 2 )个月、(10 3± 2 1)个月、(8 1± 1 1)个月 ,姑息手术组的平均生存期为 (8 9± 2 6 )个月 ,单纯剖腹探查者均于 3个月内病故。胰十二指肠切除组中行扩大切除者的 1、3、5年生存率较经典切除者显著提高 ;姑息手术组中合并胰周动脉结扎和 (或 )区域性化疗者的生存期较单纯转流手术者明显延长。结论　提高根治切除率是改善胰腺癌病人预后的关键 ,根据肿瘤进展程度选择适当适应证 ,合理地扩大切除范围可提高和改进手术切除的疗效 ;对不能切除病灶的中晚期病人 ,胰周动脉结扎和区域灌注化疗具有缓解症状 ,延长生存期的疗效。     

经药物输注装置行动脉区域栓塞灌注治疗不能切除的胰头癌

目的:探讨经术中留置药物输注装置(DDS)行动脉区域栓塞灌注治疗不能切除胰头癌的临床应用价值。方法:15例经手术探查无法切除并病理证实为胰头癌的患者术中留置DDS于肿瘤供血血管,术后经DDS行动脉区域栓塞灌注化疗药物。化疗后对患者的近期疗效、不良反应进行评价。结果:15例患者中近期疗效CR 0例,PR 10例,SD 5例,PD 0例,总有效率(CR+PR)66.7%。疼痛缓解率77.3%(11例)。不良反应中主要为胃肠道反应、骨髓抑制,无严重肝肾功能损害及死亡等严重并发症。15例患者DDS位置固定稳妥,未出现导管移位情况。结论:经术中留置DDS行动脉区域栓塞灌注化疗可明显提高无法切除的胰头癌患者的近期疗效,其操作安全可靠,且不良反应少。     

胰腺癌区域化疗和全身化疗时5-Fu在门、体静脉血中的动态分布及差异

目的 为胰腺癌区域化疗提供临床实验依据。方法 15例手术不能切除的胰腺癌患者行转流术后,分别经区域动脉或体静脉快速推注5-Fu1000mg,用反相高效液相色谱法测定门、体静脉血中5-Fu的浓度,也显著高于同期全身化疗组门静脉血中5-Fu的浓度;而体静脉血中的药物浓度略低于同期全身化疗组。结论 胰腺癌区域化疗可提高胰腺区域的化疗药物浓度,而体静脉血中的化疗药物浓度可保持在较低水平,从而增强胰腺癌化疗的效果并相对减轻药物的毒性反应。     

经给药装置造影在胰腺癌灌注化疗中的应用

目的　通过给药装置造影检查指导胰腺癌动脉灌注化疗的临床应用。方法　外科手术不能切除的胰头癌 2 7例 ,术中经胃网膜右动脉插管至胃十二指肠动脉 ,合并肝转移者插管至胃十二指肠动脉起始部。术后定期经给药装置造影检查。结果　 2 7例经给药装置造影平均 2 .1人次 ,经胃网膜右动脉置管胰头区域可获得满意灌注效果 ,插管至胃十二指肠动脉起始部可同时灌注肝脏和胰头。灌注化疗前造影剂腹腔渗漏 1例 ,灌注化疗后导管阻塞 2例 ,导管脱落腹腔 1例。结论　经给药装置造影对胰头血流分布的影像学研究 ,有助于指导选择最佳动脉置管途径。对开展胰腺癌个体化灌注化疗和防治导管并发症具有重要临床意义。     

DDS区域动脉灌注治疗晚期胰腺癌74例分析

目的 评价区域动脉灌注治疗晚期胰腺癌的价值。方法 选择不能手术切除的晚期胰腺癌病人，术中腹腔干或分支动脉旋转DS药盒28例，Seldinger介入技术旋转DS药盒46例，域动脉灌注以5－Fu为主的三联药物。回顾性总结、分析该组区域动脉灌注治疗晚期胰腺癌临床资料。结果 区域动脉灌注治疗晚期胰腺癌临床受益反应有效率为44.6%(33/74），明显优于同期外周静脉化疗组15.7%（14／89），（P＜0.05）；区域动脉灌注治疗晚期胰腺癌一年生存率11.5%；与同期外周静脉化疗组11.0%相比无显著性差异（P＞0.05）。结论 区域动脉灌注治疗晚期胰腺癌并不能显著提高生存率，但可明显提高临床受益反应。     

区域灌注化疗后肝癌二步切除8例

目的探讨不能切除肝癌区域灌注化疗后二步切除的必要性及手术指征和手术时机、手术方式。方法回顾性分析2004年2月至2010年9月收治的不能切除的肝癌患者8例,均经肝动脉门静脉双途径区域灌注化疗后获二步切除。结果二步切除距末次灌注化疗时间为20-46（34．5±4．6）d,术前接受化疗3-6（4．2±1．6）个疗程。8例二步切除标本均查见癌细胞,并有较多的纤维组织增生。切除后肿瘤直径平均（5．6±23）cm,1、2、3年生存率为87．5％、62．5％、50．0％。结论不能切除肝癌的二步切除是提高中晚期肝癌切除率、延长生存期的有效途径。二步切除手术时机一般以3-6个疗程区域化疗后、末次治疗后1个月左右为宜。     

吉西他滨区域性动脉灌注联合全身化疗治疗晚期胰腺癌

目的:评价吉西他滨区域性动脉灌注联合全身化疗对晚期胰腺癌的治疗效果。方法:对13例经手术病理或临床证实的晚期胰腺癌患者采用5-FU+MMC行静脉化疗,以介入方法用吉西他滨作区域性动脉灌注化疗。结果:13例可评价疗效者中部分缓解（PR）4例,病情进展（SD）6例,PD3例;临床受益反应评价有效率为76.9％;疼痛缓解率75.0%。中位生存时间为6.3个月,所有患者未出现严重毒副反应。结论:吉西他滨区域性动脉灌注联合全身化疗可缓解晚期胰腺癌患者癌性疼痛,改善患者一般状态,提高生存质量,延长生存期,且患者耐受良好。     

腹腔镜下治疗不可切除胰腺癌(附10例报道)

目的探讨腹腔镜诊断胰腺癌不可切除之后的微创治疗。方法回顾分析10例腹腔镜诊断胰腺癌不可切除后,进一步经腹腔镜微创治疗肿瘤的技术操作和患者恢复情况。结果3例腹腔镜下胃网膜右动脉置入化疗泵和7例无水乙醇注射均成功,肿瘤区域显影良好,无副损伤和并发症,患者早期恢复顺利。结论腹腔镜下胃网膜右动脉置入化疗泵和注射无水乙醇治疗晚期胰腺癌方法简单可靠,对于腹腔镜诊断胰腺癌不可切除的晚期肿瘤患者提供了微创治疗技术。     

Postoperative complications after resection of borderline resectable and locally advanced pancreatic cancer: The impact of neoadjuvant chemotherapy with conventional radiation or stereotactic body radiation therapy

Background

The impact of neoadjuvant stereotactic body radiation therapy on postoperative complications for patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma remains unclear. Limited studies have compared neoadjuvant stereotactic body radiation therapy versus conventional chemoradiation therapy. A retrospective study was performed to determine if perioperative complications were different among patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma receiving neoadjuvant stereotactic body radiation therapy or chemoradiation therapy.

术前介入动脉化疗对胰腺癌细胞凋亡和细胞增殖的影响

目的检测术前选择性介入动脉化疗对胰腺癌细胞凋亡和细胞增殖的作用,探讨区域性化疗抑制胰腺癌生长的分子机制.方法采用原位末端标记法(ISEL)对32例术前行介入化疗和未化疗的胰腺癌患者的病理切片进行细胞凋亡指数和增殖指数的检测,同时测定细胞凋亡调控基因bcl-2和bax的表达水平.结果(1)术前介入化疗组胰腺癌细胞凋亡率比未介入化疗组明显增高,两组的细胞凋亡率分别为(46.89±26.46)和(5.67±2.43)(P＜0.01);而细胞增殖指数(PCNA)在术前介入化疗组与非化疗组之间无显著差异(P＞0.05).(2)肿瘤细胞凋亡率与组织类型有关,高分化腺癌中的细胞凋亡率比低分化腺癌高(P＜0.05).(3)术前介入化疗组bcl-2表达率低于未介入化疗组,bax表达率高于未介入化疗组(P＜0.05).结论术前选择性的动脉介入化疗能够诱导胰腺细胞凋亡,诱导细胞凋亡是抑制胰腺癌细胞的生长重要途径.     

可切除性胰腺癌外科治疗中的随机对照试验分析

目的 从近10年的随机对照临床试验中总结出可切除性胰腺癌外科治疗的最佳证据。方法 对1995年01月至2004年4月间Medine中有关可切除性胰腺癌外科治疗的随机对照临床试验文献进行分析。结果 共检索到相关文献23篇代表19项不同的随机对照临床试验。结果表明：(1)标准的胰十二指肠切除术和保留幽门的胰十二肠切除术手术并发症和手术死亡率相似,术后患者生存率相当。(2)扩大淋巴结清扫术较标准淋巴结清扫术手术并发症增多,手术死亡率相当。长期生存率和生活质量无明显改善。目前仍缺乏联合门静脉／肠系膜上静脉切除的扩大根治术可提高胰腺癌患者长期生存率的有力证据。(3)闭塞胰管而不用吻合方法者术后胰瘘和胰腺分泌不足增多,胰肠或胰胃吻合仍然是胰十二指肠切除中的主要重建方式,同时经纤维蛋白胶闭塞主胰管并不能减少术后腹腔内并发症。(4)不主张在胰切端床常规置引流管。(5)胰切除术后常规使用生长抑素并不减少术后胰瘘的发生率。(6)胰腺癌治愈性切除后可以得益于辅助性化疗,而辅助性放疗则有害。结论 手术治疗仍为治愈胰腺癌的唯一手段,仍需经过大样本的前瞻性随机对照临床试验和长期随访的结果来找出合理的规范化手术操作和综合治疗方案,形成临床实践指导原则。     

Irreversible Electroporation of Locally Advanced Pancreatic Head Adenocarcinoma

Irreversible electroporation of locally advanced pancreatic adenocarcinoma has been used to palliate appropriate patients with locally advanced pancreatic adenocarcinoma. The setting was at a university tertiary care center. Subjects are patients with locally advanced pancreatic adenocarcinoma who have undergone appropriate induction chemotherapy for at least 3 to 4 months in duration. Technique of open irreversible electroporation of locally advanced pancreatic adenocarcinoma is described. The technique of open irreversible electroporation with continuous intraoperative ultrasound imaging and consideration of intraoperative navigational system is described. Irreversible electroporation of locally advanced pancreatic adenocarcinoma is feasible for locally advanced unresectable pancreatic cancer.     

全身性热化疗治疗晚期胰腺癌的临床观察

目的　探讨全身性热化疗治疗晚期胰腺癌的效果,以及化疗药物在此过程中代谢的变化。方法　将42例晚期胰腺癌病人分成2组,分别接受全身性热化疗和单纯化疗后,比较二者的疗效、不良反应及5 FU的药代动力学指标。结果　实验组具有较好的疗效,不良反应的发生率随之提高,其体内化疗药物的相对浓度升高。结论　全身性热化疗是一种有效的治疗晚期胰腺癌的方法,其机理与化疗药物在体内有效浓度的增加有密切的关系。     

Modern possibilities of chemotherapy in patients with ductal pancreatic adenocarcinoma

Experience of application of preparation Gemzar as a chemotherapy agent for ductal pancreatic adenocarcinoma was analysed. In 28 patients (main group) chemotherapy using Gemzar preparation was conducted, in 30 patients (control group) chemotherapy was not conducted. The trustworthy differences of life span in patients with unresectable tumors in the main and control groups were noted. Difference of the patients life span after performance of radical pancreatic resection was not trustworthy.     

Neoadjuvant chemoradiation may be associated with improved pathologic response in pancreatic cancer

BackgroundNeoadjuvant therapy is increasingly utilized in the management of pancreatic adenocarcinoma. The type of neoadjuvant therapy and its effect on pathologic response remains understudied.MethodsA retrospective review was performed on patients who underwent neoadjuvant therapy followed by pancreatectomy. Multivariable regressions were used to determine associations between neoadjuvant therapy regimens and pathologic response.ResultsSeventy-five patients with pathologic responses available for review received FOLFIRINOX (61%) or gemcitabine with nab-paclitaxel (39%). Demographics, histologic differentiation, and utilization of chemoradiation were similar between the groups. Multivariable logistic regression demonstrated that chemoradiation was associated with an increased likelihood of a complete or near-complete pathologic response and a decreased rate of lymphovascular invasion and lymph node positivity. Neither chemotherapy regimen nor number of cycles administered were associated with pathologic response.ConclusionsNeoadjuvant chemoradiation may be associated with complete or near-complete pathologic response regardless of chemotherapy regimen in pancreatic cancer patients.     

联合化疗治疗晚期胰腺癌的疗效分析

目的探讨吉西他滨和5-氟尿嘧啶联合治疗晚期胰腺癌的疗效和可能的影响机制。方法实验组22例接受吉西他滨、5-氟尿嘧啶和四氢叶酸联合化疗,对照组21例接受5-氟尿嘧啶 四氢叶酸联合化疗,比较他们的近期疗效、疾病相关症状改善状况和不良反应。通过高效液相色谱技术检测第1、5天时2组病人5-氟尿嘧啶的血浆浓度和半衰期。结果实验组病人的近期疗效、疾病相关症状改善均好于对照组,但不良反应也增加。实验组病人血浆中5-氟尿嘧啶的血药浓度增高,半衰期延长,上述变化贯穿于5-氟尿嘧啶的整个治疗过程。结论吉西他滨可改善5-氟尿嘧啶治疗晚期胰腺癌的疗效,其机制与它能长时间的提高5-氟尿嘧啶在体内的有效浓度有关。     

Nodal downstaging as a treatment goal for node-positive pancreatic cancer

BackgroundNodal metastases portend a poor prognosis in patients with localized pancreatic cancer. Neoadjuvant therapy is associated with pathologic nodal downstaging in up to 38% of patients. However, the optimal type of neoadjuvant therapy for achieving nodal downstaging is unclear.MethodsWe conducted a retrospective cohort study of patients with nonmetastatic, clinically node-positive pancreatic cancer treated with neoadjuvant therapy and surgery identified in the National Cancer Database (2006–2014). Patients were stratified based on the neoadjuvant therapy regimens they received: multiagent chemotherapy; single-agent chemotherapy; multiagent chemotherapy with radiation; and single-agent chemotherapy with radiation. Associations between nodal downstaging and the type of neoadjuvant therapy received and overall risk of death were evaluated using multivariable regression analyses.ResultsAmong the 603 pancreatic ductal adenocarcinoma patients treated with neoadjuvant therapy, 400 received multiagent chemotherapy (202 with radiation) and 203 received single agent chemotherapy (151 with radiation). Relative to multiagent chemotherapy, single-agent chemotherapy was associated with a lower likelihood of nodal downstaging (relative risk ratio 0.38 [95% CI 0.17–0.85]). Use of radiation was associated with a significantly greater likelihood of nodal response (single-agent chemotherapy with radiation: relative risk ratio 1.77 [1.36–2.30]; multiagent chemotherapy with radiation: relative risk ratio 1.91 [1.49–2.45]; radiation use overall (versus no radiation): relative risk ratio 2.12 [1.68–2.68]). Compared with patients who remained pathologically node positive after neoadjuvant therapy, node negative status was associated with a significantly lower risk of death (hazard ratio 0.61 [0.49–0.76]) regardless of whether radiation was used (hazard ratio 0.63 [0.48–0.82]) or not (hazard ratio 0.45 [0.29–0.72]).ConclusionNodal downstaging is associated with a survival benefit in patients with node-positive pancreatic ductal adenocarcinoma and is most likely to be achieved with neoadjuvant therapy that includes radiation. Single-agent chemotherapy neoadjuvant therapy was least likely to result in nodal downstaging.     

Combined modality therapy including cytoreductive surgery and heated intraperitoneal chemotherapy for synchronous low volume peritoneal carcinomatosis from adenocarcinoma of the tail of pancreas in a BRCA-2 carrier resulting in long-term disease-free survival: A case report

IntroductionA BRCA-2 mutation carrier with a metachronous pancreatic adenocarcinoma (PC) and established peritoneal metastases is presented. Combined modality therapy including Cytoreductive Surgery (CS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) was associated with long-term disease-free survival.Case presentationA 62-yr. old female underwent successful treatment for stage IIIa carcinoma of the right breast at age 48. 11 years later a cystic adenocarcinoma of the tail of the pancreas with peritoneal metastases was diagnosed. Platin based neoadjuvant chemotherapy followed by definitive resection of the pancreatic mass with cytoreductive surgery (CS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) with mitomycin C was performed. Postoperatively, a retro-gastric fluid collection developed from a pancreatic duct leak, successfully managed non-operatively. Maintenance poly ADP ribose polymerase (PARP) inhibitor therapy was initiated after recovery from surgery. The patient experienced a 30-month disease free survival and was subsequently found to have oligometastases to the brain.DiscussionCR and HIPEC have not been reported to be efficacious in patients with pancreatic carcinomatosis. However, PC arising in BRCA-2 carriers has a DNA repair defect, which is sensitive to platin based chemotherapy and mitomycin C. HIPEC has more severe postoperative complications following distal pancreatectomy. Isolated brain metastases from PC are rare. BRCA-2 mutation carriers are at significantly increased risk for PC.ConclusionLeveraging the DNA Repair defect in BRCA-2 pancreatic adenocarcinoma, including CS and HIPEC, led to long-term disease-free survival and good locoregional control in this patient. Complications from HIPEC are more severe. BRCA-2 carriers should undergo annual pancreatic cancer screening.