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食管胃结合部腺癌(AEG)的首要治疗方式是手术切除,但根治性切除病例中5年内复发率或病死率均超过50%,提示AEG围手术期放化疗的多学科综合治疗的必要性。近年来AEG的新辅助治疗受到较多关注,当前认为术前新辅助放疗能够提高术后5年总体存活率。而且欧洲癌症研究与治疗组织亦制定了AEG术前新辅助放疗的共识性指南,其对临床实践有很好的指导意义。术前新辅助化疗对提高R0切除率有重要意义,但需与术后辅助化疗序贯应用以提高总体存活率。术后辅助化疗和胃癌相同,NCCN推荐的多药方案为经典的ECF或改良ECF方案,而单药S1的试验结果也有不错的远期存活率。目前术中和术后放疗的证据令人遗憾,并不能提高远期存活率。因此,目前来说术前同步新辅助放化疗联合术后序贯辅助化疗应该是较为理想的方式。     

Value of radiotherapy and chemotherapy in treatment of operable cancers of the esophagus

Radiotherapy and chemotherapy have been used for more than twenty years as adjuvant treatment of operable cancer of the esophagus. The palliative effect of adjuvant (or neoadjuvant) radio- and/or chemotherapy has been demonstrated in numerous randomized trials. The purpose of this review is to present the principal randomized trials conducted in the treatment of operable cancer of the esophagus. Alone, radiotherapy does not significantly improve survival in patients with operable cancer of the esophagus, irrespective of the pre- or postoperative timing (three trials and one meta-analysis for preoperative, three trials for postoperative, and one trial for pre- and postoperative radiotherapy). Likewise, alone chemotherapy does not significantly improve survival whether given preoperatively (four trials), postoperatively (two trials) or pre- and postoperatively (one trial). Radiochemotherapy combinations appear to provide more hope, but preliminary results are insufficient to draw a clear conclusion. Nevertheless, trial comparing radiotherapy results with chemotherapy, conducted pre- or postoperatively (four trials) appear to demonstrate a significant effect of chemotherapy. The two trials using neoadjuvant therapy have been conducted on patients with adenocarcinomas of the cardia and/or the lower esophagus and have demonstrated very encouraging results for a small number of patients. Finally, the Herslovic trial, while conducted in patients who were initially inoperable, is the only one which has demonstrated superiority of radiochemotherapy over radiotherapy alone. In conclusion, there is still much room for improvement in survival using combined radio- and chemotherapy with different forms (new agents, new associations) and treatment modes (pre- and postoperative or postoperative alone). Despite the wide use of radiotherapy and chemotherapy for cancer of the esophagus, it must be recalled that surgical resection remains the method providing the best chances of survival.     

Postoperative chemotherapy in nonsmall cell lung cancer: a systematic review

A systematic review of the evidence for postoperative chemotherapy in completely resected nonsmall cell lung cancer was conducted. Seven meta-analyses and 25 randomized trials met the pre-defined eligibility criteria for the review. The evidence indicates that postoperative platinum-based chemotherapy improves survival compared with surgery alone; for patients with a good performance status who are fit enough for chemotherapy, the survival benefits strongly outweigh the adverse effects of treatment. To date the trials restricted to stage IB or II disease have obtained the greatest survival benefits with postoperative platinum-based chemotherapy. The evidence does not support the use of postoperative radiotherapy with chemotherapy.     

PRE-OPERATIVE RADIOTHERAPY AND CHEMOTHERAPY FOR NON-RESECTABLE RECTAL CANCER

Background : The treatment results of combined pre-operative radiotherapy and chemotherapy followed by surgery for patients with initially non-resectable primary rectal cancer were reviewed. Methods : Thirteen patients with locally advanced non-resectable rectal cancer were treated with pre-operative irradiation consisting of 50.4–54 Gy plus concomitant 5-fluorouracil (5-Fu) delivered during the 1st and 5th weeks of radiotherapy. Results : Following pre-operative therapy, the resectability rate was 91%, with all but one patient undergoing complete resection. The pathologic complete response rate was 10%. The overall peri-operative and postoperative complication rate was 0.8 complications per patient. There was no postoperative mortality. Conclusions : This early experience indicates that high resectability rates are achievable with pre-operative radiotherapy and chemotherapy for non-resectable rectal cancer while maintaining acceptable postoperative morbidity.     

Adjuvant radiotherapy and chemotherapy in breast cancer

Three hundred and twenty-two women with involvement of axillary lymph nodes following surgery for operable breast cancer were randomized to receive either postoperative radiotherapy, chemotherapy (CMF) or radiotherapy followed by chemotherapy. There was an increase in disease free interval in pre- and postmenopausal patients receiving radiotherapy and chemotherapy regardless of the number of nodes involved. However, there was a trend towards an improvement in disease related survival only in those patients with more than three nodes involved.     

结直肠癌术后局部复发因素分析33例报告

目的探讨导致结直肠癌术后局部复发的可能因素。方法将结直肠癌术后局部复发３３例与无复发３１例的临床及病理资料进行对比分析。结果直肠癌局部复发２２例,占６７％（Ｐ＜００５）。Ｍｉｌｅｓ术后局部复发６例,占２７％,Ｄｉｘｏｎ术后复发１６例占７３％（Ｐ＜００１）。术后正规化学药物治疗或放射治疗与非治疗者比较差异有显著意义。结论结直肠癌发生的部位、手术方式、淋巴结清扫程度及术后正规化学药物治疗或放射治疗是影响其术后局部复发的因素。     

74例Ⅲ期非小细胞肺癌患者术后放疗、化疗或联合放化疗的疗效比较

目的观察和评价Ⅲ期非小细胞肺癌（non-small cell lung carcinoma,NSCLC）患者术后放疗、化疗和放化疗同步综合治疗的临床疗效及毒副反应。方法将在我院住院治疗的74例Ⅲ期NSCLC患者随机分成：A组（单纯术后放疗）24例、B组（单纯术后化疗）24例、C组（术后放化疗综合治疗）26例,A组采取60Coγ射线或者8MV．X射线常规分割治疗;B组采用以顺铂（cis-diamminedichloro．platinum,DDP）为主的化疗方案;C组采用NP方案联合放射治疗方案,比较三组近期疗效、中位生存时间及毒副反应。结果总有效率A组54．2％,B组62．5％,C组80．8％。结果显示C组明显高于A、B组（P〈0．05）。毒副反应主要为骨髓抑制、消化道反应、放射性肺炎、放射性食管炎,经对症治疗后好转。结论化疗综合治疗Ⅲ期NSCLC可提高有效率,减少远处转移率,从而提高远期生存率。     

Pancreatic carcinoma. Optimizing therapy by adjuvant and neoadjuvant therapy?]

Increasing resection rates for pancreatic tumors and decreasing postoperative mortality rates in specialised centres let arise the question of an additional benefit of adjuvant therapy. Despite of extended and radical surgery the recurrence rates after resection of pancreatic cancer remain high. Several studies have indicated some chemo- and radiosensitivity of these tumors. Whether a (combination-)chemotherapy alone or a combined radiochemotherapy should be recommended can actually not be answered yet. However, adjuvant radiotherapy alone seems to be inferior to combined radiochemotherapy. Intraoperative radiotherapy as well as preoperative radiotherapy are not superior to postoperative percutaneous radiotherapy regarding recurrence rate and survival. Preoperative radiotherapy, preferably in combination with chemotherapy, should be considered in patients with non resectable or borderline resectable pancreatic tumors with the aim of downstaging and secondary resection. The preliminary results of regional adjuvant chemotherapy are impressing, but need to be confirmed in further, randomised studies. Overall, the availability of a good or even optimal adjuvant therapy for pancreatic cancer still seems to be far away. Therefore, all surgeons need to be encouraged to include their patients with resected pancreatic carcinoma in a current study protocol of adjuvant treatment, since only tenacious and multicentric research can lead to progress in this severe disease.     

Recent experience in the treatment of rhabdomyosarcoma.

Twenty-two patients with rhabdomyosarcoma have presented in the years 1970--1977. Of 8 patients who had inadequate postoperative chemotherapy and radiotherapy, or none at all, only 2 patients with small completely resectable tumors are alive and well at 6 and 4 yr after surgery. Fourteen patients had intensive combination chemotherapy in addition to appropriate surgery and radiotherapy. Five have died and the remaining nine are well and free of disease at follow up ranging from 9 mo to over 5 yr. A continued place in the treatment regime is advocated for early surgery aimed at total excision of the primary tumor where this is feasible.     

Postoperative complications after induction chemoradiotherapy in patients with non-small-cell lung cancer

Objective: This study evaluates the risks of postoperative complications in 124 patients with non-small-cell lung cancer who received pre-operative induction chemoradiotherapy and surgery. Methods: All patients with non-small-cell lung cancer who underwent surgery after induction therapy between January 1990 and December 2003 were reviewed. We adopted univariate and multiple logistic regression models to identify predictors that increased the incidence of postoperative complications. Results: Of 124 patients, 59 received carboplatin and docetaxel, 53 received cisplatin and etoposide, and 12 received other platinum-based combinations. Pre-operative thoracic radiotherapy was performed concurrently with chemotherapy. The median dose to the primary tumor was 40 Gy, and 29 patients (23.4%) received radiotherapy of more than 45 Gy before surgery. There were 25 pneumonectomies (20.2%). The overall postoperative mortality was 9 of 124 patients (7.3%), and complications developed in 54 patients (43.5%). Multivariate analysis demonstrated that only thoracic radiotherapy of more than 45 Gy predicted postoperative complications (P = 0.021; odds ratio, 3.620; 95% confidence interval, 1.214–10.797). Conclusions: Thoracic radiotherapy of more than 45 Gy, in combination with chemotherapy, was a significant risk factor for postoperative complications.     

Treatment outcome of N3 nodal head and neck squamous cell carcinoma.

OBJECTIVE: The aim of this study was to investigate the treatment outcome of N3 nodal disease.Study design A single institution retrospective nonrandomized study was conducted. A total of 53 patients with primary presentation of squamous cell carcinomas from various head and neck sites from 1980 to 1994 were recruited for this study. Eight patients with nasopharyngeal cancers who underwent treatment with palliative intent were excluded from the study. Treatment options were broadly divided into 4 treatment categories; postoperative radiotherapy; preoperative radiotherapy; surgery alone; and chemotherapy pre- or postoperatively with or without radiotherapy. RESULTS: Mean age of the participants was 63 years (SD = 8.2); 93% were men. Median follow-up period was 12 months (range, 5 to 184 months). Of the 45 N3 patients, 21 patients had a recurrence in the neck after treatment, with 1 in the contralateral neck. The overall rates of control in the neck at 1, 3, and 5 years were 73.1%, 34.6%, and 26.9%, respectively. The 1, 3, and 5-year neck control rates for each main group were 92.3%, 46.1%, and 46.1% with postoperative radiotherapy; 66.7%, 33.3%, and 11.1% with preoperative radiotherapy and 33.3%, 0%, and 0% with surgery alone. Overall survival rates at 1, 3, and 5-years were 52.8%, 25%, and 22.2%. Survival rates in those who received radiotherapy were better than those who only had surgery. The 5-year survival rate was significantly higher for those who had postoperative radiotherapy (38.9%) compared with patients who had preoperative radiotherapy (9.1%) and surgery alone (0%). CONCLUSION: Our treatment outcomes, particularly those in the group receiving postoperative radiotherapy, were similar to other studies. The prognosis of N3 neck disease was poor but improved with radiotherapy, particularly postoperative radiotherapy. The role of definitive chemotherapy and/or radiotherapy and salvage surgery is difficult to evaluate as the results are inconsistent and the available data are limited. Future studies in particular with quality of life assessment are needed to evaluate the management of N3 head and neck cancer.     

Management of high-risk node-positive breast cancer by standard-dose chemotherapy and loco-regional radiotherapy

One-hundred, thirty-six women, aged up to 76 years, with high-risk breast cancer were treated with postoperative radiotherapy and 9 cycles of adjuvant chemotherapy in standard doses. Treatment-related toxicity was mild. At a median follow-up of 7.3 years, 39.6% are disease-free. At 5 and 10 years overall survival was 55% and 34% respectively; disease-free survival was 39% and 33% respectively. Eighteen patients (13.2%) developed loco-regional recurrence, which was uncontrolled in four. When compared to series treated with adjuvant chemotherapy, but without radiotherapy, there are apparent survival gains of 10-15% at 5 and 10 years. These results in both pre- and post-menopausal patients compare favourably with results of high-dose chemotherapy and stem-cell rescue in much more highly selected patients.     

新辅助化疗方案在可切除结肠癌中的应用进展

新辅助化疗（NACT）是指针对潜在可根治切除的肿瘤患者,以消除微转移、降低肿瘤分期和手术难度、改善术后局部复发和远处转移等为目的,在肿瘤手术切除或放疗之前,先予以全身化疗,待手术或放疗之后继续完成全程化疗的综合方案。结肠癌是最常见的癌症之一,肿瘤根治性切除联合术后辅助化疗是临床潜在可根治切除结肠癌的主要治疗方式。虽然这种治疗模式较前显著改善了患者的预后,但术后局部复发和远处转移仍是患者最主要的致死因素。近年来NACT方案开始被引入局部进展期结肠癌和原发灶可切除的肝转移患者等潜在可根治切除结肠癌患者的治疗。然而,结肠癌患者是否适合NACT及其方案的选择还存在较大的争议。笔者就局部进展期结肠癌、可切除结肠癌肝转移等在NACT中的进展与争议,以及影像学检查对NACT的作用作一综述。     

Management of chiasmatic-hypothalamic gliomas in children: report of nine pediatric cases

Radical resection of chiasmatic-hypothalamic glioma (CHG) carries a significant risk of morbidity and the optimum treatment remains undecided. The authors reported 9 children with CHG, who were treated with surgical resection with or without postoperative chemotherapy. Age at the time of diagnosis ranged from 4 months to 7.7 years (mean 3.1 years), and no patient had evidence of neurofibromatosis type 1. Surgical resections of the tumors were performed in all patients because of severe visual impairment or intracranial hypertension caused by large tumors. All of the surgical interventions resulted in partial resections. Pathological examination revealed pilocytic astrocytomas in 7 patients, low grade astrocytoma in 1 and anaplastic astrocytoma in 1. Seven patients with residual tumors received postoperative chemotherapy consisting of cisplatin, cyclophosphamide, etoposide and vincristine. Reduction in tumor size was noticed in 5 patients, although 2 patients had no response and switched to local radiotherapy. Although minor complications of chemotherapy were noticed in 5 patients, severe sequelae such as neuropsychological deficits or endocrinopathies did not occur, and all patients completed chemotherapy programs. Additional treatments are recommended in case of incomplete tumor resections, because our experience demonstrates that the majority of the residual tumors have potential to progress. Our present data suggests that the chemotherapy of the aforementioned regimen is effective in controlling CHGs after partial resections and is relatively well tolerated even in young children who are vulnerable to radiotherapy.     

Extensive vertebral haemangioma with cord compression in two patients: review of the literature

Two cases of extensive vertebral haemangioma with progressive neurological deficits are described. Successful treatment was accomplished with palliative surgical decompression after preoperative embolization in one case and with postoperative radiotherapy in the other. Preoperative embolization, palliative surgical decompression and postoperative radiotherapy appear to provide satisfactory outcome in patients with extensive haemangiomas.     

Lokalrezidiv- und Überlebensraten nach Rektumkarzinomoperationen und multimodaler Therapie

Introduction. In the guidelines of the German specialist medical societies, postoperative chemoradiotherapy is recommended for rectal carcinomas in stages II and III. In the meantime, there are important study findings favoring preoperative radiotherapy as against postoperative irradiation. In the present unicentric study, the clinical results after preoperative irradiation and postoperative chemotherapy are to be determined. In period I, sandwich radiation without total mesorectal excision was applied. In period II, the treatment was developed further with exclusive preoperative radiation and total mesorectal excision. Since from 1994 the therapy regimen has changed with the introduction of total mesorectal excision and improved radiotherapy, the present study was carried out to check whether this has led to better results of therapy. Patients and Methods. Over a period of 7 years, data from 607 patients with rectal carcinoma were recorded and stored in an Excel file. The carcinomas were grouped into lower, middle and upper segment levels and classified endosonographically. Multimodal treatment was administered in stage uT3. In period I, sandwich radiation was carried out with 24 Gy preoperatively and 24 Gy postoperatively, followed by adjuvant chemotherapy. Total mesorectal excision was not performed. In period II, 50.4 Gy were applied preoperatively, followed by adjuvant chemotherapy. The operation comprised total mesorectal excision of the lower two thirds of the rectum. Calcium folinate and 5-fluoroucil were administered in six chemotherapy cycles. Primarily inoperable patients received preoperative irradiation with up to 50.4 Gy in both periods to attain down-staging. The following surgical procedures were applied: abdominal perineal extirpations, deep anterior resections, coloanal anastomoses, colon pouch anal anastomoses and transanal microsurgical resections. Results. In 469 curatively operated patients, including primarily inoperable patients after down-staging radiotherapy, the rates of local recurrence were 5.8% with a mean follow-up observation of 4.29 years, and the carcinoma-specific 4-year actuarial survival was 84%. The rate of recurrence was highest in the lowest segment level of the rectum (7.6 as compared to 2.4%, P=0.042). The rates of local recurrence were 7.4% in period I and 4.3% in period II (P=0.44). The carcinoma-specific 4-year actuarial survivals were 81% in period I and 87% in period II (P=0.202). Investigation of the subgroups of irradiated patients showed complete freedom from recurrence after a mean follow-up observation time of 3.58 years for patients in stage uT3 with total mesorectal excision, preoperative radiotherapy and postoperative chemotherapy (n=51). The difference from patients without postoperative chemotherapy was significant (P=0.018). After radiotherapy, the complication observed was a raised rate of sacral cavity infections after total resection of the rectum (p=0.039). Conclusion. Total mesorectal excision, preoperative radiotherapy and postoperative chemotherapy can effectively influence the rate of local recurrences after rectal carcinoma operations (0–4.3% after a mean period of follow-up observation of 3.58 years). No appraisal can be made with regard to the benefit resulting from the individual measures.     

Management of stage III primary breast cancer. An analysis of 221 cases]

From Jan. 1978 to Dec. 1987, 221 patients of stage III breast cancer were treated by surgery combined with adjuvant chemotherapy and/or radiation therapy. The overall 5-year survival rate was 50.4%. The 5-year survival rate in patients with negative lymph node was 72.3% as compared with 37.5% in patients with more than 7 lymph nodes involved (P < 0.05). In patients who received postoperative adjuvant chemotherapy, the 5-year survival rate in premenopausal or postmenopausal group was 62.1% and 41.4% respectively (P < 0.05). The regional lymph node recurrence rate was 4.0% in patients who received postoperative radiotherapy as opposed to 9.6% for those without radiotherapy postoperatively. The distant metastasis rate was 19.1% in lymph node negative group as compared with 45.9% in patients with more than 7 lymph nodes involved (P < 0.05). To decrease the distant metastasis will improve the survival rate in the treatment of breast cancer. We believe that preoperative chemotherapy combined with radical surgery and postoperative adjuvant therapy may improve the survival rate in stage III breast cancer.     

Treatment of thymomas. A report of 67 cases.

From 1979 to 1989, 126 patients were treated for thymic tumors. Of these, 67 (53%) had thymomas occurring in 27 men and 40 women; the mean age was 46 years: 24 patients had no symptoms and myasthenia gravis was present in 21 cases. A complete resection was performed in 45 patients, associated in 22 with postoperative adjuvant treatment (radiotherapy, 2; radio- and chemotherapy, 20). Two patients had a partial resection followed by radiotherapy and chemotherapy. Twenty patients had initially only a biopsy and were treated by irradiation in 3 cases, radio- plus chemotherapy in 16, radio- plus chemotherapy and subsequent resection in 1 case. The staging was carried out according to the GETT Classification (stage I A:26; I B:6; II:12; III A:1; III B:18; IVA:4). Thymomas were found to be of predominant epithelial type in 12 cases, predominantly lymphocytic type in 9, and mixed in 46. No recurrence occurred after complete resection. The overall 10-year survival was 71.1%. A good correlation was found according to staging: 96% in stage I; 80% in stage II; 35% in stage III. Presence of myasthenia gravis did not affect the results. The best prognostic factor remains complete resection with postoperative radiotherapy to prevent recurrences. The role of adjuvant chemotherapy needs further evaluation.     

Radiotherapy of urothelial carcinomas of the urinary bladder

Radiotherapy of bladder cancer is a locally effective therapeutic approach. It is increasingly becoming part of the multimodal protocols aimed at the preservation of both organ and organ function. In this context, it is an alternative to cystectomy. The addition of chemotherapy to radiotherapy enhances the curative potential of this non-surgical approach and may be useful especially in older, multimorbid patients. If chemotherapy can not be applied, the use of radiotherapy alone is reasonable, although in advanced tumors the results are disappointing. After the transurethral resection of bladder cancer, postoperative radiotherapy should be considered in muscle-invasive cancer as well as when other negative prognostic factors occur. The prerequisites for an effective, minimally toxic, state of the art radiotherapy are a subtle treatment-planning procedure and an accurate delivery of the radiation.     

辅助治疗对高级别胶质瘤复发时间的影响

【摘要】〓目的〓分析高级别胶质瘤术后辅助治疗(伽玛刀、常规分割放射治疗、化疗以及同步放化疗)对其平均复发时间的影响。评估辅助治疗对高级别胶质瘤的临床疗效。方法〓收集德阳市人民医院神经外科2008年1月~2013年12月间收治的具有完整病历资料的高级别脑胶质瘤复发患者64例。分为28例单纯手术治疗患者(A组);36例行辅助治疗患者(B组)包括:10例术后行伽玛刀治疗患者(Ⅰ组);4例术后行常规分割放射治疗患者(Ⅱ组);3例术后行化疗患者(Ⅲ组);19例术后行同步放化疗患者(Ⅳ组)。分析不同组别平均复发时间。结果〓A组平均复发时间为7.804个月;B组平均复发时间为13.431个月;Ⅰ组平均复查时间为11.450个月;Ⅱ组平均复发时间为8.000个月;Ⅲ组平均复发时间为13.167个月;Ⅳ组平均复发时间为15.659个月。A组与B组及Ⅳ组之间有统计学差异。A组与Ⅰ组、Ⅱ组及Ⅲ组间无统计学差异。结论〓同步放化疗对高级别胶质瘤的平均复发时间有一定延缓作用。