第 6 版与第 7 版 TNM 分期对胃癌患者预后预测的比较分析

目的：分析胃癌第7版TNM分期的临床应用价值.方法：对比分析874例胃癌术后患者第6版和7版TNM分期 与预后的关系.结果：第6版Ⅰa、Ⅰb、Ⅱ、Ⅲa、Ⅲb、Ⅳ期的5年生存率分别为98.1%、83.0%、56.5%、26.6%、20.6%和14.1%,差异有统计学意义（P=0.000）;第7版Ⅰa、Ⅰb、Ⅱa、Ⅱb、Ⅲa、Ⅲb、Ⅲc、Ⅳ期的5年生存率分别为98.1%、86.8%、80.4%、60.0%、40.6%、24.5%、15.4% 和0,差异有统计学意义 （P=0.000）.第6版Ⅱ期细分为第7版Ⅱa、Ⅱb和Ⅲa期,5年生存率差异有统计学意义（P=0.005）;第6版Ⅳ期细分为第7版Ⅲa、Ⅲb、Ⅲc和Ⅳ期,5年生存率差异有统计学意义（P=0.017）.第7版Ⅲ期增加最多,Ⅰ期减少最多.结论：第7版TNM分期更加详细,能够准确预测胃癌的预后.     

淋巴结转移数对食管癌预后和国际TNM分期的影响

目的：探讨淋巴结转移数对食管癌患者预后和国际食管癌TNM分期标准的影响。方法：以1146例10年以上的资料完整的食管鳞状细胞癌患者的临床病理和随访调查资料，通过Kaplan-Meier生存曲线法描述生存过程以转移淋巴结数1枚和≥2枚的不同，对受区域淋巴结转移影响的Ⅱ、Ⅲ期的食管癌以新的标准进行TNM分期：Ⅱa期（T2N0M0和T3N0M0）、Ⅱb期（T1N1M0）和T2N1（1）M0）、Ⅲa期（T2N1（2）M0和T3N1（1）M0和Ⅲb期（T3N1（2）M0和T4N_M0）.结果：①1146例食管鳞状细胞癌患者中发生淋巴结转移380例，转移率33．16％（380／1146）；共清除淋巴结4270枚．其中转移807枚，总转移度18．9％（807／4270）．②0、1和≥2枚转移淋巴结的5年生存率分别为59．79％．3338％和9．35％；三组间有显著差异（P〈0．001）。③1和≥2枚转移淋巴结的T2N1M0期的5年生存率分别为41．49％和24，12％：1和≥2枚转移淋巴结的T3N1M0期的5年生存率分别为31．16％和6．77％；组成间的生存率均有显著差异（P〈0．001）、并且T2N1M0期和T3N1M0期的生存率有交叉现象。④新分法Ⅱa期，Ⅱb期，Ⅲa期和Ⅲb期的5年生存率分别为57．06％，42．15％，28．57％和8．52％，各期之间的生存率差异均有显著性统计学意义（P〈0．001）结论：淋巴结转移数明显影响着食管癌的预后，以0、1和≥2枚转移淋巴结分三个级别较为适宜，能够准确地反映淋巴结转移数和预后的关系；基于淋巴结转移数的新法分期标准（0期、Ⅰ期、Ⅱa期、Ⅱb期、Ⅲa期、Ⅲb期和Ⅳ期）能更好地反映食管癌切除术后患者预后的变化；本研究结果为食管癌TNM分期标准提供了修订依据.     

RECIST标准评价食管癌临床分期的化疗效果

目的 以食管钡餐X线片和CT扫描结合的检测结果确定食管癌临床T分期的依据,探讨用于RECIST标准对食管癌化疗疗效的评价效果.方法 选择末行手术和放疗的食管癌83例,根据食管钡餐X线片病变长度和CT扫描管壁厚度以及病变与周围组织器官的关系,将病变局部分为T1、T2a、T2b、T3a、T3b、T4期,并结合区域淋巴结及远处转移对应临床分期Ⅰ、Ⅱ、Ⅲ、Ⅳ期.应用FLP方案化疗2个周期,比较食管钡餐X线片与CT扫描的食管病变长度的结果,按照RECIST标准评价食管癌化疗疗效.结果 83例中T1、T2a、T2b、T3a、T3b、T4期分别为7、11、15、26、19、5例,对应临床分期Ⅱ、Ⅲ、Ⅳ期分别为13、37、33例.食管钡餐X线片与CT扫描的食管平均病变长度分别为(4.6±1.4)cm和(4.8±0.7)cm,差异有统计学意义(t=3.58,P<0.05).化疗疗效CR 2例,PR 35例,SD 34例,PD 12例,RR 45%.结论 REClST标准更适用于评价食管钡餐x线片和CT 扫描确定的食管癌临床分期的化疔疗效.     

915例单纯根治放疗鼻咽癌分期系统比较及建议(二)--AJCC/UICC('97)分期的校验

背景与目的:本研究承起参考文献[1],旨在对鼻咽癌AJCC/UICC(1997)分期进行进一步验证和提出适当的建议。方法:同参考文献[1]。结果:Cox模型分析表明年龄、AJCC/UICC(1997)TNM分期或T和N分期与915例患者生存状况显著相关,统计学差异显著。选择年龄≤60岁患者803例再行Cox模型分析,生存状况仅与AJCC/UICC(1997)大体分期或T和N显著相关,而与年龄的相关不具统计学显著性。803例鼻咽癌的寿命表法分析表明,AJCC/UICC(1997)分期基本可反映预后,但Ⅰ和Ⅱa期,Ⅳa和Ⅳb期两两比较生存率差异不显著。Kaplan-Meier法分析表明在考虑N分期因素影响下,T1和T2a期,T3和T4期差异不显著。考虑T分期因素后,N2和N3a,N3a和N3b两两比较差异不显著。将无咽旁间隙受侵之T2a期下调为T1期;将下颈淋巴结受侵之N1上调为N2期;将N3a期和N3b期合并为N3期;将Ⅰ和Ⅱa期合并为Ⅰ期;Ⅳa和Ⅳb期合并为Ⅳa期;Ⅱb期改为Ⅱ期。重新进行分析,调整后大体分期、T和N各自组间比较差异具统计学显著性,分组更具合理性。结论:在充分考虑年龄对预后的影响及T分期和N分期相互影响的前提下,本组病例对AJCC/UICC(1997)鼻咽癌分期系统的验证提示可对其进行以上调整。     

915例单纯根治放疗鼻咽癌分期系统比较及建议(二)--AJCC/UICC('97)分期的校验

背景与目的：本研究承起参考文献[1],旨在对鼻咽癌AJCC／UICC（1997）分期进行进一步验证和提出适当的建议。方法：同参考文献[1]。结果：Cox模型分析表明年龄、AJCC／UICC（1997）TNM分期或T和N分期与915例患者生存状况显著相关,统计学差异显著。选择年龄≤60岁患者803例再行Cox模型分析,生存状况仅与AJCC／UICC（1997）大体分期或T和N显著相关。而与年龄的相关不具统计学显著性。803例鼻咽癌的寿命表法分析表明,AJCC／UICC（1997）分期基本可反映预后,但Ⅰ和Ⅱa期。Ⅳa和Ⅳb期两两比较生存率差异不显著。Kaplan-Meier法分析表明在考虑N分期因素影响下,T1和T2a期,T3和T4期差异不显著。考虑T分期因素后,N2和N3a,N3a和N3b两两比较差异不显著。将无咽旁间隙受侵之他a期下调为T1期;将下颈淋巴结受侵之N1上调为N2期;将N3a期和N3b期合并为N3期;将Ⅰ和Ⅱa期合并为Ⅰ期;Ⅳa和Ⅳb期合并为Ⅳa期;Ⅱb期改为Ⅱ期。重新进行分析,调整后大体分期、T和N各自组间比较差异具统计学显著性,分组更具合理性。结论：在充分考虑年龄对预后的影响及T分期和N分期相互影响的前提下,本组病例对AJCC／UICC（1997）鼻咽癌分期系统的验证提示可对其进行以上调整。     

胃癌新TNM分期的应用及其与预后的相关性研究

目的:探讨胃癌国际新TNM分期与预后的相关性.方法:采用胃癌国际统一的新TNM分期法对343例胃癌切除病例进行分析.结果:Ⅰa、Ⅰb、Ⅱ、Ⅲa、Ⅲb及Ⅳ期的5年生存率分别为100%、82.69%、70.37%、48.44%、25.00%及7.69%;同期各亚组间的3年、5年生存率亦十分接近;对新分期与预后作相关与回归分析,相关系数r=-0.996(P＜0.001),回归系数b=-0.188(P＜0.001),差异均有显著性.结论:新分期法与预后具有一致性.     

低龄肺癌患者手术后影响因素分析

目的探讨低龄肺癌患者手术后疗效相关影响因素.方法对118例低龄人肺癌手术后生存率进行回顾性调查,统计资料比较以χ2处理.结果总的1年生存率为34.75%(41/118).手术方式中的袖式肺叶切除术后1年生存率为61.11%,与其它手术方式比较有显著差异性(χ2=9.81,P＜0.05).TNM分期1年生存率分别为Ⅰ期82.61%、Ⅱ期35.90%、Ⅲa期14.71%、Ⅲb期14.29%、Ⅳ期13.33%;Ⅰ期与Ⅱ期比较有极显著差异性(χ2=10.87,P＜0.01),Ⅱ期与Ⅲa期比较有统计学意义(χ2=4.24,P＜0.05),Ⅲa期、Ⅲb期和Ⅳ期间比较无差异性(P＞0.05).鳞癌1年生存率为73.08%,与其它病理类型比较有极显著差异性(χ2=11.44,P＜0.01);大细胞癌1年生存率为7.41%,明显低于其它病理类型(χ2=14.68,P＜0.01).结论低龄人肺癌术后疗效与手术方式、TNM分期和病理类型有密切关系;早期明确诊断和袖式肺叶切除术可明显提高术后生存率;大细胞肺癌的治疗不宜首选外科手术方式.     

82例胸腺瘤新组织学分型与患者临床特征和预后的相关性分析

背景与目的:世界卫生组织(WHO)于1999年制定了新的胸腺瘤组织学分型标准。本研究探讨胸腺瘤WHO组织学分型与临床特征和预后的相关性。方法:回顾性分析82例经外科治疗的胸腺瘤患者的临床资料,经有经验的病理科医生按WHO组织学分型标准重新做出诊断,并结合患者的临床特征和预后进行分析。结果:胸腺瘤A型5例(6.1%),AB型21例(25.6%),B1型14例(17.1%),B2型12例(14.6%),B3型14例(17.1%),C型16例(19.5%)。根据Masaoka临床分期,Ⅰ期29例(35.4%),Ⅱ期13例(15.8%),Ⅲ期32例(39.0%),Ⅳa期8例(9.8%)。临床分期与组织学分型的相关性有显著性意义(χ2=47.29,P<0.001)。肿瘤外侵的程度与组织学分型的相关性也有显著性意义(χ2=30.78,P<0.001)。A﹑AB﹑B1和B2型胸腺瘤合计切除率较B3和C型胸腺瘤合计切除率高(84.6%vs.50.0%,χ2=11.29,P=0.002)。临床Ⅰ、Ⅱ、Ⅲ、Ⅳa期胸腺瘤切除术后5年生存率分别为100%、100%、69.5%和37.5%;10年生存率分别为88.1%、57.1%、47.5%和0。不同临床分期患者生存率的差异(log-rank=40.31,P<0.001)与组织学分型间生存率的差异(log-rank=16.0,P=0.007)均有统计学意义。结论:WHO组织学分型可在一定程度上反映胸腺瘤的生物学行为和临床特征,对临床诊断和治疗胸腺瘤有指导意义。     

调强放疗技术对鼻咽癌UICC/AJCC分期的影响

目的 探讨调强放疗(IMRT)技术的应用对鼻咽癌第六版UICC/AJCC分期系统的影响.方法 回顾分析2001-2007年间在本院接受IMRT的570例初诊鼻咽癌患者资料,比较不同T分期、N分期以及临床分期之间生存率的差异.结果 全组随访2～94个月,中位值42个月;随访满5年者为184例.全组5年局部无复发生存率、无远处转移生存率和总生存率分别为93.0%、85.4%和83.3%.T分期中T_1、T_(2a)与T_(2b)期间5年局部无复发生存率(100%、100%、94.5%)差异无统计学意义(χ~2=1.92,P=0.166;χ~2:035,P=0.555),T_(2b)与T_3、T_3和T_4期的差异亦无统计学意义(χ~2=2.62,P=0.106;χ~2=1.55,P=0.214).N分期中N_2与N_1、N_3期5年无远处转移生存率(80.2%、86.2%、61.4%)差异无统计学意义(χ~2=2.22,P=0.136;χ~2=1.92,P=0.165).临床分期中Ⅰ、Ⅱ_a、Ⅱ_b期间的5年总生存率(91.7%、100%、95.3%)差异无统计学意义(χ~2:0.32,P=0.574;χ~2=0.25,P=0.617),Ⅳ_a和Ⅳ_b期的差异亦无统计学意义(χ~2=0.25,P=0.616).结论 采用IMRT技术治疗鼻咽癌患者,目前的鼻咽癌第六版UICC/AJCC分期系统存在不同期别5年生存率差异不明显的现象.     

胸段食管癌切除术患者的预后分析

目的 探讨影响胸段食管癌切除术后患者预后的因素,以及淋巴结转移数目对患者预后和TNM分期标准的影响.方法 对1224例非手术死亡的食管癌切除术患者的临床病理和随访资料进行分析,选择15个可能影响预后的因素进行多因素分析.以淋巴结转移数目(0枚、1枚和≥2枚)的不同,对Ⅱ、Ⅲ期食管癌以新的标准进行TNM分期.结果 影响食管癌切除术后患者预后的主要因素为淋巴结转移数目、肿瘤侵及深度、部位、组织类型和肿瘤长度等(P<0.01).肿瘤侵及深度、肿瘤长度和组织分化程度与淋巴结转移呈正相关(P<0.01).0、1和≥2枚转移淋巴结组患者的5年生存率分别为59.1%、32.0%和8.9%(P<0.01).转移淋巴结为1枚和≥2枚的T2N1M0期和T3N1M0期患者的5年生存率分别为43.1%、18.0%(P<0.01)和28.0%、9.6%(P<0.01).新分期中Ⅱ a期、Ⅱb期、Ⅲ a期和Ⅲ b期的5年生存率分别为56.5%、43.9%、25.6%和11.1%(P<0.01).结论 影响食管癌切除术后患者预后的主要因素为淋巴结转移,而影响淋巴结转移的主要因素为肿瘤侵及深度、肿瘤长度和组织分化程度.为提高食管癌切除术后患者5年生存率,必须加强区域淋巴结的清扫和针对淋巴结转移的综合治疗.淋巴结转移数目明显影响食管癌患者的预后,以转移淋巴结为0、1和≥2枚进行分级,能够准确地反映淋巴结转移数目与患者预后的关系;根据淋巴结转移数目的 不同进行的新分期能更好地反映食管癌切除术患者预后的变化,为国际抗癌联盟食管癌TNM分期标准提供了修订依据.     

中晚期肾母细胞瘤的综合治疗

目的对中晚期肾母细胞瘤的不同治疗方式进行分析比较,探讨最佳治疗途径。方法分析中晚期肾母细胞瘤62例,入选标准:①肿瘤直径>10 cm或内侧边界超过腹中线;②影像学检查提示肿瘤侵犯临近脏器、有腹主动脉旁淋巴结转移或腹水;③下腔静脉瘤栓形成;④有肺、肝、骨等远处转移;⑤双侧肾母细胞瘤。按治疗方法分为3组:术前动脉化疗栓塞(TACE)组31例,肾动脉注入超液碘油+长春新碱(1．5 mg／m2)+表阿霉素或吡柔比星(40 mg／m2)混合的栓塞乳剂,1周后静脉滴注更生霉素15μg·kg-1·d-1,连用5 d,2周后手术切除瘤肾。术前化疗组20例,静脉滴注长春新碱1．5 mg／m2,每周1次,连用4～5周;更生霉素15μg·kg-1·d-1,连用5 d;表阿霉素20 mg·m-2·d-1,连用2 d,4～5周后切除瘤肾。初期手术组11例,入院后即行瘤肾切除术。结果治疗后,TACE组肿瘤平均缩小32．4％,术前化疗组肿瘤缩小20．3％,两组肿瘤减积率差异有统计学意义(P<0．05)。3组患者肿瘤完整切除率分别为87．1％、70．O％和18．2％,TACE组与术前化疗组比较,差异有统计学意义(P<0．05);TACE组与初期手术组比较,差异有统计学意义(P<0．01)。3组患者2年无瘤生存率分别为87．1％(27／31)、60．0％(12／20)和18．2％(2／11),TACE组与术前化疗组比较,差异有统计学意义(P<0．05),TACE组与初期手术组比较,差异有统计学意义(P<0．01)。3组患者4年无瘤生存率分别为84．6％(11／13)、56．3％(9／16)和18．2％(2／11),TACE组与初期手术组比较,差异有统计学意义(P<0．01)。3组患者手术相关死亡率分别为0、0和18．2％(2／11)。结论术前动脉化疗栓塞和常规术前静脉化疗,对中晚期肾母细胞瘤均有明显疗效,术前动脉化疗栓塞后,肿瘤缩小和坏死更明显,术前治疗时间缩短,全身毒副反应较小,肿瘤完整切除率较高,术后无瘤生存率更高。     

Chemotherapy of advanced gastric cancer

Gastric cancer is the second most frequent cancer in the world. Approximately 84% of patients with gastric cancer will have advanced disease and median survival of these patients without chemotherapy is only 3-4 months. "Classical" chemotherapy regimens, mainly CF (cisplatin plus infusional 5FU) and ECF (cisplatin plus infusional 5FU plus Epirubicin) obtain responses in 20-40% of the patients and improve quality of life. Nevertheless, duration of these responses is short with very few complete responses. Median time to tumor progression (TTP) with these regimens is only about 4-5 months and median survival does not exceed 7-10 months. Moreover, benefit seems to be limited to patients with good performance status and treatment toxicity and discomfort are not negligible, specially that of regimens with cisplatin or infusional 5FU. Trying to improve these results, the incorporation of new drugs has been explored. Among the new combinations, the more developed ones are those with Docetaxel (DCF), oxaliplatin (EOX, FLO), Capecitabine (EOX, cisplatin-Xeloda) and irinotecan (ILF). We have final results from Phase III trials that suggest that all these regimens could have a role in the treatment of these patients but survival is still very poor and toxicity remains important. It would be interesting to investigate other new combinations and the incorporation of drugs directed against new therapeutic targets in this setting. It would be of utmost interest that these clinical trials would also explore clinical and molecular prognostic and predictive factors.     

Chemotherapy of advanced ovarian cancer

Cisplatin containing chemotherapy has provoked an epic making revolution in the treatment of advanced ovarian cancer. However, the impact to the long-term survival is still discouraging. In this article, standard regime for first line chemotherapy, dose, administration method, routes, number of cycles and the second line chemotherapy which is the most embraced problem are described. Strategy for the treatment of advanced ovarian cancer would be continued until the development of new drugs which are effective comparable with cisplatin and have no cross resistance with cisplatin. In order to get significant improvement of 5 year survival, complete response by chemotherapy or complete resection by operation or by both is indispensable and partial response is not sufficient.     

Treatment of advanced colorectal cancer

Colorectal cancer is one of the most chemotherapy-resistant human malignancies. After 30 years of intensive research, 5-fluorouracil (5-FU) remains the most frequently used drug. The expected response rate is of about 15% without any proven benefit in survival. One of the combination most investigated recently has been methyl CCNU, 5-FU, vincristine and streptozotocine (MOF-S). It has shown a response rate of 30-40% but only little benefit in survival. Although cisplatin (CDDP) is inactive as a single agent, the combination of 5-FU and cisplatin (CDDP) might still be of interest when CDDP is fractionated over 3 to 5 days and 5-FU given as a continuous infusion. Local treatment using the intra-arterial and the intraportal route gives rather high response rates, but has not shown any benefit in survival. Biochemical modulation using allopurinol, methotrexate and leucovorin has raised considerable interest, but at the present time no major benefit in survival has been disclosed.     

Treatment of advanced Hodgkin's disease

MOPP chemotherapy was the significant breakthrough that improved the outlook for patients with advanced Hodgkin's disease. Results with alternating potentially non-cross-resistant drug combinations, including MOPP/ABVD, CAD/MOPP/ABV, and MOPP/ABV, are similar and seem to be slightly superior to those with MOPP alone. Limited adjuvant RT does not seem to add appreciably to the morbidity of chemotherapy, although its role in improving on results with chemotherapy alone has not been well studied in prospective, randomized, controlled clinical trials. There are two major challenges for the future. The first is to improve the outcome for advanced Hodgkin's disease patients, perhaps with more intensive chemotherapy and RT with use of cytokines such as the colony-stimulating factors or interleukin-1 or with rescue employing autologous bone marrow transplantation or both. The second challenge is to reduce the morbidity but not the effectiveness of treatment for advanced Hodgkin's disease patients without adverse prognostic factors.     

Chemotherapy of advanced soft-tissue sarcomas

The most active single agents in soft-tissue sarcomas are doxorubicin (Adriamycin) and ifosfamide, with response rates of 20-35%. Dacarbazine (DTIC) has a response rate of 16%. A randomized trial of 5 g/m2 of ifosfamide versus 1.5 g/m2 of cyclophosphamide noted a higher response rate for ifosfamide with less myelosuppression. Both randomized studies of doxorubicin with or without DTIC documented an increased response rate for the combination. In contrast, three randomized trials of doxorubicin-based regimens with and without cyclophosphamide have failed to detect an advantage for the addition of cyclophosphamide. Thus, the most active combination for soft-tissue sarcomas is doxorubicin and DTIC. The role of the addition of ifosfamide is currently under evaluation.     

Treatment of advanced carcinoid tumors

PURPOSE OF REVIEW: Carcinoid tumors often present with metastatic disease. Generally, these tumors can be treated conservatively. New evidence exists, however, that stage IV disease may be better managed with more aggressive medical and surgical treatment. Headway is also being made into understanding the associated fibrosis seen with advanced disease and in better understanding signaling pathways with the hope of offering future treatment options. RECENT FINDINGS: Recent literature has advocated for more aggressive surgical treatment of carcinoid tumors, especially in the setting of hepatic metastases and peritoneal carcinomatosis. Octreotide and lanreotide are further being described for treating metastatic carcinoids. Radiolabeled somatostatin analogues may prove to be as effective for treating carcinoids as for visualizing them. Other potential treatment modalities include pharmacologic activation of signaling pathways to control excess hormone production. Research into fibrosis - a cause of pain, bowel obstruction, retroperitoneal vascular constriction and right heart failure - has shown that serotonin and tachykinins may be the key mediators. SUMMARY: Patients with stage IV carcinoid tumors may benefit from more aggressive surgical management and new treatment modalities. The growing body of knowledge regarding important molecular signaling pathway may lead to new medical therapies and further understanding of the sequelae of excess hormone production.