结直肠癌腹膜转移的多学科综合治疗

腹膜转移是结直肠癌常见转移部位之一,传统观念认为其预后差,没有手术治疗的价值。近年来,随着外科技术、精确控温的腹腔热灌注化疗以及多学科综合治疗的进步,对结直肠癌腹膜转移的认识和治疗策略发生很大的变化,拟就这一问题进行综述。在预后方面,如果仅行姑息性化疗,结直肠癌腹膜转移的预后差于肝、肺等非腹膜部位的转移;但对于一部分合适的患者施行完全性腹膜减瘤术联合腹腔热灌注化疗,则可能使部分患者获得长期生存;腹膜转移癌的预后因素包括腹膜播散癌指数、减瘤术完全性程度、是否合并腹膜外转移(肝脏等)、腹膜表面疾病严重程度评分和日本腹膜分期等。在治疗方面,完全性腹膜减瘤术联合腹腔热灌注化疗以及全身治疗(化疗+靶向治疗),可能是最佳的多学科综合治疗策略。     

中国大陆腹腔热灌注化疗治疗胃肠癌腹膜转移癌的现状

对于胃、结直肠癌患者来说, 腹膜转移是肿瘤晚期的标志性事件。既往的全身化疗及姑息性手术治疗模式对其疗效很差, 细胞减灭术联合腹腔热灌注化疗可改善部分腹膜转移癌患者的生活质量、延长生存期, 已经成为结直肠癌腹膜转移的标准治疗策略。但是, 该方案在我国并未获得统一认识和广泛应用。本文在分析我国胃、结肠癌腹膜转移癌的诊治现状同时, 就我国未来开展胃肠癌腹膜转移瘤的规范治疗提出建议。      

胃癌腹膜转移癌治疗研究进展及我国治疗现状

腹膜转移是胃癌最常见的转移方式之一,是导致治疗失败的主因,严重影响患者预后。全身化疗、腹腔化疗以及姑息性手术的疗效有限,细胞减灭术加腹腔热灌注化疗是可大幅度提高疗效的治疗措施,本文综述了我国胃癌腹膜转移癌的治疗现状和国际研究进展。     

腹膜转移癌的肿瘤微环境研究进展

癌症患者肿瘤出现腹膜转移通常预示预后较差,目前常规的治疗方法是细胞减灭术联合腹腔热灌注化疗(cytoreductive surgery/hyperthermic intraperitoneal chemotherapy,CRS/HIPEC),但是仅适用于少数具备手术条件的患者。现有的研究结果表明,腹膜转移癌的生物学特征已发生显著改变,腹膜局部免疫微环境也有明显异常,腹膜脂质更是腹膜转移癌微环境中的特殊组分。针对腹膜转移癌局部微环境的深入研究,将有助于揭示腹膜转移的机制,并为开拓新型治疗方法提供有益地探索。     

胃肠道肿瘤腹腔内化疗的进展

我国胃肠道肿瘤的发病率和死亡率都很高,手术切除是首选治疗方法,但术后局部复发和远处转移率可高达到37％～50％,肿瘤一旦浸润至浆膜,腹膜种植转移的发生率可达28.6％.当浆膜浸润面积超过15～20mm2时几乎所有的胃癌患者腹腔内均可检到肿瘤细胞。胃肠道肿瘤腹膜转移后,肠梗阻和腹腔积液等并发症可相继出现,严重影响患者的生活质量和预后,所以胃肠道肿瘤蝮膜转移的治疗是临床上急需解决的问题。由于胃肠道肿瘤腹腔内化疗(In—traperitoneal Chemotherapy,IPCT)直接作用于腹膜,对防治胃     

腹膜转移癌内科治疗新进展

腹膜转移癌因发现较晚且预后差,目前正成为研究热点。随着细胞减灭术及腹腔热灌注治疗的推广,部分经选择的患者获益。针对不同肿瘤的不同时期,大量的临床研究显示,用药选择、用药时机、用药方法方面均取得进展,尤其是加压腹腔内气溶胶化疗的使用减轻了治疗相关不良反应,并提高了疗效。本文就近年来腹膜转移癌的内科治疗进展进行阐述。     

结直肠癌腹膜转移治疗的临床研究进展

腹膜是结直肠癌转移的第三常见部位。结直肠癌腹膜转移通常被认为是终末期疾病,预后差。随着系统性药物治疗的进展,转移性结直肠癌患者预后明显改善,但腹膜转移患者生存获益仍然较少。腹膜肿瘤细胞减灭术和腹腔热灌注化疗能够显著改善腹膜转移患者的预后。新型治疗方法如腹腔加压气溶胶化疗、腹腔MOC31PE抗毒素治疗等也随之出现。本文将对结直肠癌腹膜转移治疗的临床研究进行综述。     

专栏寄语

腹膜癌是我国临床肿瘤诊治工作中的难题之一,多发于胃癌、结直肠癌、卵巢癌等腹腔内的播散转移,长期以来被认为是终末期疾病,在其发生发展机制及治疗措施研究方面,尚无重大进展。但是,国际肿瘤学界已经有一批专家致力于该领域研究长达三十余年,在结直肠癌腹膜癌、腹膜假性黏液瘤、阑尾癌腹膜癌等领域取得了重大突破,已经把肿瘤细胞减灭术加腹腔热灌注化疗治疗腹膜癌增加到临床治疗指南中。相比之下,我国在该领域的发展相对缓慢。     

国际腹膜癌治疗指南:肿瘤细胞减灭术加腹腔化疗临床路径

腹膜癌是一种预后较差的恶性肿瘤，肿瘤来源较广泛，开展规范化治疗对腹膜癌患者至关重要。腹膜表面肿瘤协作组国际联盟（Peritoneal Surface Oncology Group International，PSOGI）制订了腹膜癌临床指南，本文为国际腹膜癌治疗指南中文版，该指南共分四部分:术前评估、腹膜癌手术、腹膜癌化疗及临床路径。其中，术前评估主要包括术前CT检查、预后评估模型、诊断性腹腔镜探查、腹膜癌指数及细胞减灭程度评分；腹膜癌治疗原则是以肿瘤细胞减灭术（cytoreductive surgery，CRS）和围手术期化疗为核心的综合治疗，但完全CRS是患者获得长期生存的关键；腹膜癌化疗主要包括围手术期化疗及区域性化疗。最后，本指南概述了腹膜癌的临床路径。经PSOGI执行委员会秘书长许可，发表该指南中文版。      

结直肠癌腹膜转移的治疗

全球结直肠癌发病率逐年增加,对于无远处播散的患者,手术切除原发肿瘤和区域淋巴结清扫是唯一可能治愈的方法。但一些患者仍会出现肝脏、肺和腹膜等部位转移。全身化疗联合肿瘤细胞减灭术（cytoreductive surgery,CRS）联合腹腔热灌注化疗（hyperthermic intraperitoneal chemotherapy,HIPEC）应作为腹膜转移癌的标准治疗,是迄今治疗效果最好的方案。本文将对结直肠腹膜转移的发病现状、机制、特点及诊疗进展进行综述。      

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in treatment of gastric cancer with peritoneal carcinomatosis

Although gastric cancer with peritoneal carcinomatosis is associated with poor prognosis and is generally treated with palliative systemic therapy,recent studies have shown that cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may prove to be an efficacious treatnent option.In addition to reviewing the natural history of gastric cancer with peritoneal carcinomatosis,this mini-review examines literature on the efficacy of CRS and HIPEC as compared to chemotherapy and surgical options.Both randomized and nonrandomized studies were summarized with the emphasis focused on overall survival.In summary,CRS and HIPEC are indeed a promising treatment option for gastric cancer with peritoneal carcinomatosis and large randomized clinical trials are warranted.     

Histological response of peritoneal carcinomatosis after hyperthermic intraperitoneal chemoperfusion (HIPEC) in experimental investigations

Background  

In selected patients with peritoneal carcinomatosis from colorectal cancer prognosis can be improved by hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery. The aim of this study was to evaluate the tumor response of peritoneal carcinomatosis in tumor-bearing rats treated with HIPEC.     

Rhabdomyolysis after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Case Report

Gastric cancer with peritoneal carcinomatosis is a disease with a poor prognosis. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal perioperative chemotherapy (HIPEC) can improve prognosis, although in most cases this should still be considered as a palliative treatment. Therefore, morbidity has to be avoided at all cost as quality of life is of utmost importance. We describe the case of a 64-year-old female with an adenocarcinoma of the stomach that was initially treated with a Billroth II gastrectomy, adjuvant chemotherapy and radiotherapy. During follow-up, the diagnosis of peritoneal carcinomatosis was made, and the patient was referred for CRS and HIPEC. Postoperatively, she developed rhabdomyolysis in both gastrocnemius muscles. Renal function remained within normal limits, but ultrasonography of the lower legs suggested the presence of bilateral abscesses. Drainage with pigtail catheters was necessary for more than 1 month, significantly impairing quality of life. The objective of this case report is to heighten awareness for this complication. Rhabdomyolysis is a rare complication of CRS and HIPEC, with a significant impact on quality of life. Prevention is necessary and can be achieved by adequate surgical positioning, using the altered lithotomy position, sufficient padding and by preventing hypovolemia.Key Words: Gastric cancer, Peritoneal carcinomatosis, Cytoreductive surgery, Hyperthermic intraperitoneal perioperative chemotherapy, Rhabdomyolysis, Compartment syndrome     

Improved prognosis following peritonectomy procedures and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis from appendiceal carcinoma.

AIMS: The prognosis of patients with peritoneal carcinomatosis from gastrointestinal malignancies is poor. The aim of this study was to analyse the results of multimodality treatment for peritoneal carcinomatosis of appendiceal carcinoma. PATIENTS AND METHODS: From 07/95 to 01/00, 17 patients (13 males, 4 female, median age 58 years) underwent peritonectomy procedures in combination with intraperitoneal hyperthermic chemotherapy. Surgical, pathological and survival data were analysed retrospectively. RESULTS: All patients had undergone previous surgical treatment and one patient had received chemotherapy. In all patients peritonectomy procedures, as described by Sugarbaker, were performed with the aim of achieving a macroscopically complete cytoreduction (range 2-6, median 4 procedures per patient). Following resection, open hyperthermic intraperitoneal chemotherapy with cisplatin was performed. Eleven patients had postoperative complications (predominantly "non-surgical") and two patients died postoperatively. The 4-year survival rate was 75%. Complete cytoreducion had a statistically significant positive influence on long-term survival. CONCLUSIONS: In selected patients (WHO status 0/1, minimal residual disease, no distant metastases, complete cytoreduction), the prognosis for patients with peritoneal carcinomatosis of appendiceal origin can be improved by peritonectomy procedures and hyperthermic intraperitoneal chemotherapy. Postoperative morbidity may be increased due to "non-surgical" complications. Copyright Harcourt Publishers Limited.     

Peritonealkarzinose bei gastrointestinalen Malignomen

Peritoneal carcinomatosis is defined as the seeding of malignant cells in the peritoneum. In primary peritoneal carcinomatosis, the cancer cells originate from the peritoneum itself, whereas they spread from another solid tumor in secondary peritoneal carcinomatosis. Amongst tumors of gastrointestinal origin, metastases from colorectal cancer are the most common, although the incidence in gastric cancer (30?%) is higher. The best method for diagnosis is computer tomography of the abdomen (with intravenous, oral, and rectal administration of contrast agent). Systemic chemotherapy is significantly less effective in patients with peritoneal metastases than in patients with metastases in solid organs (e.?g. liver). Carefully chosen patients can be treated with cytoreductive surgery (CRS) in combination with intraabdominally applied hyperthermic intraperitoneal chemotherapy (HIPEC). The prognosis is highly dependent on the histology of the primary tumor as well as the extent of peritoneal seeding; the life expectancy can be between a few months and several years.     

Current status and future directions: management of colon cancer with peritoneal dissemination

Colorectal cancer is one of the most common cancers worldwide, and although it carries a favorable prognosis when detected at early stages, it is associated with limited survival when metastatic disease is present. Modern systemic therapy has improved median survival in those patients with hematogenous dissemination, but the role of these newer combinations of cytotoxic chemotherapy and biological agents remains undefined in patients with peritoneal carcinomatosis. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy have resulted in long-term good outcomes for patients whose carcinomatosis can be completely removed, but offers no advantage over supportive care for those patients with incomplete tumor removal. At the present time, we lack proven therapeutic strategies on how to treat a patient newly diagnosed with peritoneal carcinomatosis of colorectal origin. A large Phase III multi-institutional trial is being developed to address these issues, and will need full collaboration between medical and surgical oncologists.     

Intraoperative hyperthermic versus postoperative normothermic intraperitoneal chemotherapy for colonic peritoneal carcinomatosis: a case–control study

BackgroundCytoreductive surgery and intraperitoneal chemotherapy has improved prognosis in patients with peritoneal carcinomatosis. The main modes of intraperitoneal chemotherapy treatment are peroperative hyperthermic intraperitoneal chemotherapy (HIPEC) and normothermic sequential postoperative intraperitoneal chemotherapy (SPIC). The aim of this study was to compare HIPEC and SPIC with respect to overall survival, disease-free survival, morbidity, and mortality in patients with peritoneal carcinomatosis from colon cancer.Patients and methodsA matched case–control study was conducted in patients with surgical macroscopic complete removal of carcinomatosis; matching was according to the peritoneal cancer index score. Thirty-two patients were included, 16 in each group (HIPEC and SPIC). Overall survival, disease-free survival, morbidity, mortality, and clinicopathological parameters were compared.ResultsMedian overall survival was 36.5 months in the HIPEC group and 23.9 months in the SPIC group (P = 0.01). Median disease-free survival for these groups was 22.8 (HIPEC) and 13.0 months (SPIC; P = 0.02). Morbidity was not statistically different, 19% in SPIC and 37% in HIPEC. Postoperative mortality was observed in one patient in each group.ConclusionHIPEC was associated with improved overall survival and disease-free survival compared with SPIC at similar morbidity and mortality, suggesting that HIPEC is the treatment of choice in colonic peritoneal carcinomatosis.