直肠癌新辅助放化疗临床完全缓解后处理的争议与共识

直肠癌的治疗目标包括病人的长期生存和功能的保留。直肠癌新辅助治疗后约有20%的病人达到病理完全缓解（pCR）,如何利用现有检测手段甄选出真正pCR病人,使临床完全缓解（cCR）与pCR获得最大程度的符合度,提高保肛率或非手术治疗率,最终减少根治性手术创伤和功能损害,是目前研究的焦点。同时,cCR病人后续处理策略的选择,如‌“等待-观察”,还是局部切除或根治性手术,目前尚缺少循证医学证据支持,亦是目前争议热点。直肠癌新辅助放化疗后cCR后处理应遵循目标导向、分层治疗和全程管理原则。建议在拥有丰富直肠癌综合治疗经验的多学科诊疗团队的临床中心开展,严格筛选病例,综合考虑病人的治疗意愿、基线分期、病灶特征选择治疗策略。同时,不断完善cCR 的评估标准和随访策略,及时补救根治性手术,才能保证肿瘤学安全性和良好的功能和预后。     

Effect of exercise on cigarette cravings and ad libitum smoking following concurrent stressors

The health consequences of smoking are well documented, yet quit rates are modest. While exercise has supported decreased cravings and withdrawal symptoms in temporarily abstinent smokers, it has yet to be applied when smokers are experiencing concurrent stressors. This study examined the effect of an acute bout of moderate intensity exercise on cravings (primary outcome) and ad libitum smoking (secondary outcome) following concurrent stressors (i.e., temporary abstinence and environmental manipulation—Stroop cognitive task + cue-elicited smoking stimuli). Twenty-five smokers (> 10 cig/day; Mean age = 37.4 years) were randomized into either exercise (n = 12) or passive sitting conditions. A repeated measure (RM) ANOVA showed that psychological withdrawal symptoms (a measure of distress) were significantly exacerbated after temporary abstinence and then again after the environmental manipulation for all participants (p < .0001, η² = .50). Furthermore, a treatment by time RM ANOVA revealed decreases in psychological withdrawal symptoms for only the exercise condition (p < .001, η² = .42). A treatment by time RM ANOVA also revealed craving reductions for only the exercise condition (p < .0001, η² = .82). Exercise had no effect on ad libitum smoking. This is the first study to use a lab-based scenario with high ecological validity to show that an acute bout of exercise can reduce cravings following concurrent stressors. Future work is now needed where momentary assessment is used in people's natural environment to examine changes in cigarette cravings following acute bouts of exercise.     

新辅助治疗反应对局部进展期直肠癌患者预后的影响

目的探究新辅助治疗反应对局部进展期直肠癌患者远期预后的影响。 方法回顾性收集中国医学科学院肿瘤医院218例接受术前新辅助放化疗的局部进展期直肠癌患者（LARC）的临床病理资料。根据Dowrak/R?del肿瘤退缩分级（TRG）标准将患者分为治疗反应良好（TRG3~4）和治疗反应不佳（TRG0~2）。采用Cox风险比例回归单因素和多因素分析确定无病生存（disease-free survival,DFS）和肿瘤总生存（overall survival,OS）影响因素。采用Kaplan-Meier法绘制生存曲线并利用Log-rank检验比较肿瘤生存差异。 结果本研究纳入患者218例,其中治疗反应良好126例,治疗反应不佳92例。单因素和多因素Cox回归分析确定新辅助治疗反应不佳是DFS（HR=3.85,95%CI：1.40~10.60;P=0.009）和OS（HR=3.81,95%CI：1.02~14.20;P=0.046）的独立危险因素。5年DFS分别为反应良好93.46%,反应不佳65.04%（χ²=28.23,P＜0.001）;5年OS分别为反应良好95.38%,反应不佳78.99%（χ²=18.51,P＜0.001）。 结论新辅助治疗反应是LARC患者DFS和OS的独立预后因素;良好的治疗反应预示着更好的肿瘤学预后,为进一步的临床研究风险分层提供了理论基础。     

Resection surgery with neoadjuvant chemoradiotherapy improves outcomes of patients with T4 esophageal carcinoma

The prognosis of patients with T4 esophageal carcinoma is poor, and thus an effective treatment needs to be established. The present study assessed the effect of chemoradiotherapy (CRT), postoperative morbidity and mortality, and survival time in 41 patients with T4 esophageal carcinoma. Of these, 24 received CRT followed by surgery (group A) and the remaining 17 were treated with CRT alone (group B). Postoperative complications in group A were compared with 251 patients (group C) who underwent surgery without CRT during the same period. Postoperative complications were more frequent in group A than group C (29.2% vs 8.4%, P < 0.05). The overall median survival of group A was statistically longer than that of group B (13.8 months and 3.3 months respectively, P < 0.001). Complete histologic response (grade 3) was documented in 4 group A patients (16.7%). The overall median survival of grade 3 patients was statistically longer than the rest of group A (38.9 months vs 8.8 months, P < 0.05). The data confirm that chemoradiotherapy creates tumor regression in some patients and allows resection surgery in T4 esophageal carcinoma. Moreover, surgery with CRT confers a survival advantage in T4 esophageal carcinoma.     

Assessment of the value of carcinoembryonic antigen reduction ratio as a prognosis factor in rectal cancer

Background

Carcinoembryonic antigen (CEA) is the most widely used tumor marker for colorectal cancer. This study aimed to investigate the role of CEA reduction ratio after preoperative chemoradiotherapy (CRT).

Methods

We enrolled 284 patients who underwent preoperative CRT followed by radical surgical resection. Patients were divided into 3 groups: serum CEA levels before CRT (pre-CRT CEA) less than 5 ng/mL (group 1); pre-CRT CEA of 5 ng/mL or more with CEA reduction ratio of 50% or more (group 2); and pre-CRT CEA of 5 ng/mL or more with CEA reduction ratio less than 50% (group 3).

Results

The 5-year disease-free survival (DFS) rate was not different between groups 1 (71.8%) and 2 (69.4%) but was signi?cantly lower in group 3 (49.5%). CEA group, lymph node status after CRT (ypN) stage, and histologic type were independent prognostic factors for DFS on multivariate analysis.

Conclusions

CEA reduction ratio might be an independent prognostic factor for DFS in rectal cancer patients treated with preoperative CRT and radical surgery.