维持治疗在晚期结直肠癌化疗后达稳定患者中的价值及预后分析*

目的:探讨晚期结直肠癌姑息化疗后获得疾病稳定患者的预后异质性及个体化治疗策略的应用。方法:研究收集2008年4 月至2014年10月204 例在天津医科大学肿瘤医院接受标准一线和（或）二线化疗后获得疾病稳定的晚期结直肠癌患者,分析该人群临床病理特征,筛选预后异质性分层因子,并评估姑息化疗后治疗手段（即单纯观察或维持治疗）对于特殊人群的影响。结果:单因素生存分析表明化疗线数、基线CA724、CEA 、CA19- 9 水平、血小板淋巴细胞比率（PLR ）、姑息化疗后治疗手段为预后影响因素。多因素Cox 比例风险回归模型分析显示,一线化疗、基线CA19- 9 低水平、PLR 低水平、姑息化疗后维持治疗患者预后较好。亚组分析显示PLR 高水平患者中,维持治疗组与观察组无进展生存期分别为13.43个月和10.63个月（P = 0.003）。 结论:基线CA19- 9、PLR 水平及姑息化疗后治疗手段为获得疾病稳定的晚期结直肠癌患者的独立预后因子。疾病稳定人群尤其是PLR 高水平者宜接受维持治疗。      

结直肠癌肝转移患者预后因素分析

目的：探讨结直肠癌肝转移患者外科治疗后的预后影响因素及临床意义.方法：分析本院1995年1月至2000年12月158例经病理证实、随诊资料完整的结直肠癌肝转移病例临床资料，对影响患者生存的12项因素进行单因素、多因素分析.结果：根治性切除67例（42.4%）、姑息性切除53例（33.5%）、探查术或最佳支持治疗38例（24.1%） 术后化疗82例（51.9%）、术后未化疗76例（48.1%） 切缘阴性132例（83.5%）、切缘阳性26例（16.5%） 中位生存期41个月，5年生存率27.0%.单因素分析表明，外科治疗方式（P=0.013＜0.05）、原发瘤N分期（P=0.003＜0.05）、转移灶大小（P=0.037＜0.05）及分布（P=0.032＜0.05）和切缘（P=0.000＜0.001）、辅助性治疗（P=0.041＜0.05）为预后影响因素 多因素回归分析显示，仅有原发瘤N分期（P=0.004＜0.05）为预后的独立影响因素，淋巴结转移的相对危险度为2.086.结论：结直肠癌肝转移的根治性切除是患者获得长期生存的有效治疗手段 对于结直肠癌肝转移患者应恰当选择病例，力求一期根治性切除 不适合一期根治性切除者，应采用新辅助化疗手段，降级肿瘤的临床病理分期，以期提高根治性切除率，提高患者生存期.     

局部晚期直肠癌新辅助治疗后病理完全缓解者的预后分析

目的:总结局部晚期直肠癌新辅助治疗后病理完全缓解（pCR）者的长期预后,探讨术后辅助化疗的必要性。方法:回顾性分析2005年至2014年间,323例在我院进行新辅助治疗及根治性手术的局部晚期直肠癌患者的临床资料,分析pCR者的长期预后,同时比较术后辅助化疗组和术后未化疗组的预后。结果:52例（16.1%）获得pCR,其中1例患者失访;全组患者中位随访时间为53个月,全组5年无病生存率和总生存率分别为82.7%和90.9%。其中22例（43.1%）患者接受术后辅助化疗,29例（56.9%）未接受术后化疗。两组患者的性别、年龄、肿瘤临床分期、肿瘤位置、大小、分化程度、术前CEA水平、新辅助化疗的方案、新辅助治疗结束至手术的间隔周期、手术方式、术后并发症、淋巴结清扫的数目以及随访时间均无统计学差异。两组患者的5年无病生存率以及总生存率亦无统计学差异。结论:局部晚期直肠癌新辅助治疗后病理完全缓解者可获得良好的生存预后;对于pCR者,实施术后辅助化疗不会影响其预后。     

无法治愈的晚期结直肠癌肝转移患者的临床病理特征与姑息性治疗预后的生存分析

目的：通过分析无法治愈的晚期结直肠癌肝转移患者临床病理特征与姑息性治疗预后的相互关系,探讨姑息性治疗对患者预后生存的影响。方法：回顾性分析第二军医大学东方肝胆外科医院自2009年1月至2009年12月收治的82例无法治愈的晚期结直肠癌肝转移患者临床资料。采用 Kaplan －Meier 法计算生存率及生存曲线,并进行单因素分析,采用 Log －rank 进行统计学检验。经单因素分析对预后有统计学意义的危险因素带入 COX 多因素回归模型,计算独立预后因素。结果：总体中位生存期为19．09个月,1、2、3年累计生存率分别为82％、28％、13％;对经过严格筛选,评估原发病灶与肝内转移灶可以完整切除而肝外不可切除的转移灶未予以手术处理但生长局限,术中发现肿瘤侵犯周围组织、器官仍可局部切除,且具备强烈手术意愿的晚期结直肠癌肝转移患者实施姑息性手术切除,术后中位生存期、1年、2年累计生存率均显著优于非手术治疗者：27．00个月 vs 16．36个月,85％ vs 79％,57％ vs 0（P ＜0．001）。对于总体生存期而言,单因素分析显示：不同的治疗方式、肝转移瘤生长位置、肝内转移灶数目为影响患者预后的因素（P ＜0．05）;COX 多因素分析结果显示：非手术治疗方式、肝内转移灶多发是对无法治愈的晚期结直肠癌肝转移患者姑息性治疗预后产生影响的独立危险因素。结论：对于经过严格筛选,评估原发病灶与肝内转移灶可以完整切除而肝外不可切除的转移灶未予以手术处理但生长局限,术中发现肿瘤侵犯周围组织、器官仍可局部切除且具备强烈手术意愿的结直肠癌肝转移患者,接受姑息性手术治疗,其生存优于非手术治疗患者。     

结肠、直肠、肛门

腹腔镜结直肠手术中暴露和分离的技巧;多学科协作诊治模式下新辅助化疗对直肠癌术后近期并发症影响的临床对照研究;右半结肠癌根治切除术中寻找解剖平面的体会（附36例报告）;PET／CT对结直肠癌术后转移患者治疗方案的影响;富含脯氨酸的酪氨酸蛋白激酶2在原发性大肠癌中的表达及其对预后的意义……     

结直肠癌腹膜转移伴卵巢转移的治疗现状与挑战

腹膜是结直肠癌转移的好发部位。出现腹膜转移的女性结直肠癌患者常伴有卵巢转移。通常认为出现腹膜转移和卵巢转移的女性结直肠癌进展迅速且预后极差,目前仍无有效的治疗手段。虽然结直肠癌患者接受化疗及靶向药物后可显著改善预后,但同时伴有腹膜转移和卵巢转移的女性结直肠癌患者却无法明显获益。许多研究证实肿瘤细胞减灭术（CRS） 联合腹腔内热灌注化疗（HIPEC）可延长这类患者的生存期,改善生活质量。本文综述了结直肠癌腹膜转移和卵巢转移患者的诊治现状和相关进展。     

新辅助化疗在结直肠癌中的应用（附62例报告）

目的：观察新辅助化疗在结直肠癌中的临床疗效。方法：收集2008年6月-2012年6月住院患者资料。对62例进展期结直肠癌患者行术前全身化疗4个周期（ FOL FOX4方案）,并于术后2周行辅助化疗2个周期（ FOL FOX4方案）。结果：经新辅助化疗,病人肿瘤平均直径缩小了32.5％,肿瘤的TNM分期得到降低。本组62例患者行4周期化疗后行腹腔镜辅助下结直肠癌根治术,手术顺利,无中转开腹,平均手术时间180min（120-240min）,平均术中出血150ml（100-300ml）,术后胃肠功能恢复时间1-2d,平均住院时间10d （8-14d）,术中及术后无严重并发症。本组中有3例因术后并发肝肺转移于术后2年内死亡,1例脑转移死亡,失访5例,余53例均存活至今未发现局部复发、远处转移。结论：新辅助化疗在结直肠癌的治疗中,使肿瘤分期得以降期,不同程度缩小了肿瘤体积,减少局部复发,对中晚期结直肠癌有积极意义。     

结直肠癌新辅助化疗患者术后预后的相关影响因素分析

目的 探讨结直肠癌新辅助化疗患者术后预后的相关影响因素。方法 选取接受新辅助化疗与根治术治疗的85例结直肠癌患者作为研究对象,术后随访2年,记录患者随访期间复发情况与患者基线资料,分析结直肠癌新辅助化疗患者预后的影响因素。结果 85例结直肠癌患者术后2年内复发16例(18.82%),未复发69例(81.18%)。复发患者与未复发患者在年龄、吸烟史、肿瘤分化程度、术前癌胚抗原(CEA)方面比较,差异有统计学意义(P<0.05);经Logistic回归分析结果显示,年龄大、有吸烟史、肿瘤分化程度低、术前CEA高表达是导致结直肠癌新辅助化疗患者预后不佳的因素(OR>1,P<0.05)。结论 结直肠癌新辅助化疗患者术后预后情况受患者年龄、吸烟史、肿瘤分化程度、术前CEA水平的影响。     

144例结直肠癌肝转移原发灶切除术后临床病理特征和预后分析

目的:分析144例结直肠癌肝转移原发灶切除术后患者的临床病理特征和预后。方法:回顾性分析病理证实的144例结直肠癌肝转移原发灶切除术后患者的临床病理特征和预后,Kaplan-Meier法分析生存率,Log-rank检验比较组间生存差异。结果:144例结直肠癌肝转移组及其中77例结直肠癌同时性肝转移亚组的中位生存期分别为28个月和21个月,所有病例分析显示原发肿瘤分化程度、肝转移发生时间、肝转移灶数目及治疗方法与预后显著相关(P＜0.05);同时性肝转移亚组分析显示原发肿瘤分化程度、性别、TNM分期与预后显著相关(P＜0.05);两组病例分析显示年龄对患者总生存期的影响无统计学差异(P＞0.05)。结论:原发肿瘤低分化、同时性肝转移、多发肝转移及单纯化疗是结直肠癌肝转移原发灶术后患者独立预后不良因素。原发肿瘤低分化、男性及Ⅱ-Ⅲ期是结直肠癌同时性肝转移原发灶术后患者独立预后不良因素。年龄对结直肠癌肝转移原发灶切除术后患者总生存期的影响无统计学意义。     

结直肠癌术后门静脉化疗对NK细胞活性的影响

肝脏是结直肠癌远处转移的好发部位,一旦发生转移预后很差。随机临床研究证明结直肠癌术后门静脉灌注化疗(5-FU或5-FU/MMC)可预防肝转移。而门静脉化疗对患者抗肿瘤免疫功能的影响尚不清楚。本文旨在研究门静脉化疗对结直肠癌患者NK细胞活性的影响,进一步阐明结直肠癌术后门静脉化疗的利与弊。 1992～1994年作者将35例进展期结直肠癌患者随机分为2组,19人行术后门静脉化疗,15人作对照组,所有病人均行根治性切除术。伴有远处转移、其他严重疾病和已接受过上腹部手术者未列于本组研究。     

Adjuvant postoperative 5-fluorouracil chemotherapy combined with pelvic radiation for rectal cancer: results from an Asian population

Prospective randomized clinical trials have shown the effectiveness of combined adjuvant 5-fluorouracil-based chemotherapy and radiotherapy after surgical resection of rectal cancer. To assess toxicity of this therapy, prospective data were collected from 236 Asian rectal cancer patients treated with combined 5-fluorouracil-based chemotherapy and radiotherapy after surgery. Almost 82% of patients completed planned therapy. Grade 3 and 4 diarrhea, stomatitis, and granulocytopenia occurred in approximately 18-21% of patients. There were two treatment-related deaths from granulocytopenia and sepsis. With median follow-up of 3.5 years, median disease-free and overall survival was 75 and 88 months, respectively. In conclusion, combined adjuvant 5-fluorouracil-based chemotherapy and radiotherapy after surgical resection of rectal cancer is tolerable in Asian patients with moderate toxicity.     

Safety of epirubicin adjuvant chemotherapy in a breast cancer patient with chronic renal failure undergoing hemodialytic treatment

Anthracycline-based adjuvant chemotherapy is very effective in early breast cancer, but there are limited data on the use of epirubicin in patients with chronic renal failure undergoing hemodialytic treatment. We report the case of a patient with early breast cancer and chronic renal failure who was treated with adjuvant weekly epirubicin. Treatment was well tolerated. The patient is still alive and relapse free 58 months after surgery. If the patient will be disease free after 5 years, she will be reconsidered for renal transplantation. In conclusion, weekly epirubicin appears to be a safe adjuvant chemotherapy option for early breast cancer patients with chronic renal failure undergoing hemodialytic treatment.     

Use of adjuvant chemotherapy in stage C (III) rectal cancer: Comparison of data from matched patients in a teaching hospital's clinico‐pathological database

Aims: Controversy continues regarding the treatment of patients with resectable rectal cancer, particularly in regard to the effects of adjuvant therapies on long‐term survival. The benefits of adjuvant chemotherapy alone in patients with stage III rectal cancer after curative resection remain unclear. The aim of this study was to compare the overall survival of patients who had received adjuvant chemotherapy after resection of a stage III rectal cancer (111 patients) with the survival of a historical control group who had surgery alone before chemotherapy was introduced (129 patients). Methods: Treatment and outcomes data were drawn from a prospective hospital registry of consecutive patients who had a resection for stage III rectal cancer. Results: The estimated Kaplan–Meier overall 5‐year survival rate in patients who received chemotherapy (68.7%, 95% CI 58.3–77.1%, log‐rank P < 0.001) was improved compared with the historical controls (40.5%, 95% CI 31.4–49.5%, log–rank P < 0.001 ). No systematic differences between the treated and control group were found. Conclusion: This study has shown improved survival after adjuvant chemotherapy in patients with stage III rectal cancer as compared with historical controls treated by surgery alone. Hence, there could be subsets of patients whom when treated with surgery in a specialized surgical unit, may benefit from chemotherapy and spared the toxicities of adjuvant radiotherapy. This should be explored further in a cooperative trial group setting.     

Intraperitoneal cisplatinum chemotherapy in patients with carcinomatous peritonitis due to colorectal scirrhous cancer--case report

Two patients received intraperitoneal cisplatinum chemotherapy for carcinomatous ascites due to colorectal cancer recurrence. The patients were a 47-year-old man who had rectal cancer and 51-year-old woman who had colon cancer. They had received the operation and adjuvant chemoradiation therapy and chemotherapy respectively. However, five months and two years after resection, respectively, they presented massive ascites due to carcinomatous peritonitis and were given cisplatin injection intraperitoneally. The amount of ascites was significantly diminished. One patient had been discharged and been able to stay at home, and the other patient underwent gastrostomy for ileus. The results suggested that intraperitoneal cisplatinum chemotherapy may be useful for the patient with carcinomatous ascites due to colorectal cancer.     

A case of recurrent rectal cancer with paraaortic lymph node metastasis treated by FOLFIRI therapy leading to complete response

A 56-year-old woman was referred to our hospital because of melena. After examinations she was diagnosed with rectal cancer. Anterior resection was performed and the final diagnosis was Stage IIIa. She was treated with adjuvant chemotherapy consisting of UFT/Uzel for one year, followed by UFT alone for one year. Two years after the surgery, abdominal CT suggested solitary paraaortic lymph node metastasis. As the patient denied a surgical treatment, mFOLFOX6 chemotherapy was induced. However, the patient developed a grade 3 allergic side effect, FOLFIRI was administered. Six months after the chemotherapy was started, the paraaortic lymph node metastasis had disappeared. After 50 courses, the case was considered to have achieved a clinical CR which has been maintained now. FOLFIRI was effective for recurrent rectal cancer with paraaortic LN metastasis.     

Adjuvant Chemotherapy for Rectal Cancer After Neoadjuvant Treatment: FOLFOX, 5-FU,or Observation

A multimodality approach incorporating concurrent chemotherapy with radiotherapy prior to surgery has become the standardized approach in the management of localized rectal cancer. However, it is unknown whether any further therapy after surgery may be beneficial in improving patient outcomes. Previous completed randomized clinical trials have not added any clarity in this regard, whether adjuvant chemotherapy or intensified chemotherapy regimens improve patient outcomes in those who have previously received neoadjuvant therapy. Despite the lack of evidence, based off the survival data in stage III colon cancer, adjuvant chemotherapy has become a standardized practice in the management of resected rectal cancer. Furthermore, recommendations include the consideration of added oxaliplatin to adjuvant therapy in this disease. While it is unclear whether all patients should receive adjuvant chemotherapy, a subset of patients, including those who achieve a pathologic response may benefit from further treatment. Ongoing studies utilizing an individualized, stepwise multimodality approach may define the role of adjuvant therapy and the appropriate regimen in patients with resected rectal cancer.     

Experience of gemcitabine therapy after non-curative resection for biliary tract cancer

We report a patient in which gemcitabine therapy was effective for controlling relapse of cancer after noncurative resection for bile duct cancer. A 75-year-old man suffering from bile duct cancer underwent resection of extrahepatic bile duct on December 3, 2002, but surgical margins were positive at the hepatic site and the pancreatic site. Two months after surgery, he began to undergo gemcitabine therapy (1,000 mg/body, biweekly) as adjuvant chemotherapy in the outpatient clinic. The chemotherapy has been continued up to the present. No severe side effect has been observed throughout the treatment. The patient remains well with no evidence of relapse of the cancer 26 months after surgery. Gemcitabine therapy is considered effective as adjuvant chemotherapy for bile duct cancer.     

Neoadjuvant chemoradiation followed by interstitial prostate brachytherapy for synchronous prostate and rectal cancer

PurposeTo describe outcomes with the use of neoadjuvant pelvic chemoradiation followed by prostate interstitial brachytherapy for the treatment of synchronous prostate and rectal cancers.Methods and MaterialsAn Internal Review Board approved retrospective review was undertaken of 4 patients with synchronous prostate and rectal cancer treated between 2006 and 2008. Patients underwent pelvic chemoradiation followed by prostate brachytherapy, then low anterior resection of the rectum with diverting loop ileostomy and adjuvant chemotherapy. Follow-up evaluation included imaging and laboratory analysis of cancer markers in addition to routine interval history and physical examination.ResultsAt 38-62 months postdiagnosis (24-53 months post-treatment), 6 of 8 cancers remained without evidence of relapse. One patient had rising carcinoembryonic antigen levels but no clinically evident rectal cancer relapse; another developed bony metastasis of his high-risk prostate cancer. Three patients experienced grade 1-2 treatment-related toxicity; one patient had grade 3 gastrointestinal toxicity from radiation and surgery, which precluded his receiving adjuvant chemotherapy and ileostomy reversal.ConclusionsChemoradiation followed by prostate brachytherapy, surgery, and adjuvant chemotherapy may be utilized to manage patients with synchronous prostate and rectal cancers.     

直肠癌前切除术后吻合口复发治疗方式选择与预后分析

 目的　探讨适合直肠癌前切除术后吻合口复发的治疗方式以及不同治疗方法对预后的影响。 方法　回顾分析1999年1月至2009年12月收治的41例直肠癌前切除术后吻合口复发病例的临床资料,利用寿命表法计算中位生存时间和生存率,Kaplan-Meier法比较不同治疗方式对预后的影响,Log-rank检验差异性,以P＜0.01为有统计学意义。结果　41例中33例（80.5 %）3年内复发,中位生存时间23个月。根治手术率41.5 %（17／41）,根治手术与非根治手术的中位生存时间分别为49和18个月,差异有统计学意义（χ2＝12.245,P＝0.000）。31例接受放化疗病例的中位生存期（39个月）明显优于10例未接受放化疗的病例（9个月）,两组差异有统计学意义（χ2＝17.533,P＝0.000）。结论　直肠癌前切除术后吻合口复发绝大多数发生在术后3年内,根治性手术及放化疗能显著改善预后。     

A Successfully Resected Case of Recurrent Lung and Liver Metastases of Rectal Cancer Treated with XELIRI + Bevacizumab Therapy

It has been reported that many colorectal cancer (CRC) patients with synchronous or metachronous liver metastases underwent surgery subsequent to neoadjuvant combination chemotherapy with folinic acid, fluorouracil, and oxaliplatin (FOLFOX), folinic acid, fluorouracil, and irinotecan (FOLFIRI), or capecitabine and oxaliplatin (XELOX). However, there are very few reports of the use of capecitabine and irinotecan (XELIRI). We herein report a successfully resected case of recurrent lung and liver metastases of rectal cancer treated with combination chemotherapy with XELIRI + bevacizumab (BV) therapy. A 63-year-old male developed recurrence of a solitary nodule in the right lower lobe of the lung and multiple liver metastases after low anterior resection for rectal cancer 1 year previously. Partial resection of the right lower lobe of the lung was performed and treatment with XELIRI + BV was initiated. A computed tomography scan revealed a reduction in tumor size without any new lesions after four cycles of XELIRI + BV therapy. Partial hepatectomy of S1, S5, and S7 was safely performed. The patient is now undergoing adjuvant chemotherapy and has been free from recurrence for 18 months following surgery. There are only few studies with relatively low patient numbers reporting on the outcome after resection of both pulmonary and hepatic metastases of CRC. We therefore report a patient who underwent sequential resection of pulmonary and hepatic metastases with XELIRI + BV therapy.Key words: Colorectal cancer, Liver metastasis, XELIRI