肝膽胰腺腫瘤綜合治療進(jìn)展

肝膽胰腺腫瘤綜合治療進(jìn)展2023/2/1中國惡性腫瘤發(fā)病率三大治療手段的作用地位2023/2/1中美主要癌癥5年相對生存率比較（%）癌癥中國美國肺癌16.117.9胃癌27.428.0肝癌10.116.0食管癌20.919.0結(jié)直腸癌47.265.0乳腺癌7390.0所有癌癥合計30.968.0肝癌屬于放射敏感腫瘤敏感性相當(dāng)于低分化鱗癌早期肝癌放療結(jié)果作者例數(shù)腫瘤大小方法生存率(%)

1年2年3年朱小東陳龍華夏廷毅28<5CMCRT100856032<3CMCRT100979752I/IIr-ray908658

不能手術(shù)肝癌放療結(jié)果作者例數(shù)方法生存率(%)

1年2年3年

5年SeongMatuumuraCheng李玉梁世雄曾紹沖王維虎158RT4220525TACE+RT563625TACE+RT544141TACE+CRT73594241TACE552713128CRT+TACE65433354TACE+RT724224149TACE60271171r-ray592424肝癌伴門靜脈/下腔靜脈癌栓的放療1年生存率:外照射組34.8%未接受外照射組11.4%IntJRadiatOncolBiolPhys2005;61(2)432-443肝癌腹腔淋巴結(jié)轉(zhuǎn)移的放療中位生存時間外照射組:9.4月

未接受外照射組:3.3月(P<0.001)IntJRadiatOncolBiolPhys2005;63(4)1067-1076PhaseIIISHARPTrial:OS*O’Brien-FlemingthresholdforstatisticalsignificancewasP=0.0077.LlovetJM,etal.JClinOncol.2007;25(suppl18):LBA1.Updatedfromoralpresentation.SurvivalProbabilityWeeks1.0000.750.500.2508081624324048566472Sorafenib

Median:46.3weeks(10.7mo)

95%CI:40.9-57.9HR(95%CI):0.69(0.55-0.88)P=0.00058*Placebo

Median:34.4weeks(7.9mo)

95%CI:29.4-39.4No.ofPatients肝癌放療的價值大肝癌放療后中位生存期提高15個月（12-20個月）淋巴結(jié)轉(zhuǎn)移者中位生存期提高7個月（4-12個月）靜脈癌栓患者中位生存期提高6個月（4-9個月）骨骼轉(zhuǎn)移能明顯有效止痛，增加生活質(zhì)量不能手術(shù)的肝內(nèi)膽管細(xì)胞癌中位生存期提高5個月（3-11個月）不能手術(shù)切除肝癌，選擇放療同步化療（證據(jù)2B）需要大樣本，前瞻性隨機(jī)對照研究期待更高級別證據(jù)intrahepaticCCA(iCCA),perihilarCCA

(pCCA)distalCCA(dCCA)NATALIYARAZUMILAVA.Classification,Diagnosis,andManagementofCholangiocarcinomaShahidAKhan,etal.Guidelinesforthediagnosisandtreatmentofcholangiocarcinoma:anupdateBismuthe-Corletteclassificationofbiliarystrictures.GuidelinesGutSurgeryJ.R.A.Skipworth.Reviewarticle:surgical,neo-adjuvantandadjuvantmanagementstrategiesinbiliarytractcancer.AlimentaryPharmacologyandTherapeutics根治性手術(shù)切除是唯一治愈膽管癌的方法診斷時僅有13%-55%的患者能手術(shù)切除5y-osintrahepaticCC22-44%distalextrahepaticCC27-37%hilartumours

11-41%studiesofsurgeryalonereportingdataonsurvivalPrognosisR0orR1statusvascularinvasionlymphnodeinvolvement(occurringin50%atpresentation)isassociatedwithOSTNMstageandmultiplicityoflesionPatternsofRecurrence

ResectionofBiliaryTractCancerSeJinJung.PatternsofInitialDiseaseRecurrenceafterResectionofBiliaryTractCancer.Oncology2012;83:83–90135ps210sites

Patternofrecurrenceaccordingtoprimarytumororigin;patients(n)withrecurrenceunresectableextrahepaticandhilarcholangiocarcinomaorathighriskfordiseaserecurrenceafterresectionMultidisciplinaryManagementAdjuvantradiotherapyAdjuvantchemotherapyAdjuvantchemoradiationtherapyNeoadjuvantchemoradiationtherapyMetastaticdisease:palliativeradiochemtherapyTargetedtherapyMETA-POSTOPERATION35TRAILSsurvivaloftheselectedstudiesofARTadjuvantRThaveasignificantlowerriskofdyingcomparedtopatientstreatedwithsurgeryaloneP=.23Twentystudiesinvolving6,712patientswereanalyzedEfficacyoutcomesforoverall

populationEfficacyoutcomesfornodepositive

diseaseEfficacyoutcomesfor

marginpositivediseaseNeo-adjuvanttherapy

Aimstodown-stagedisease,renderingitsuitableforsurgicalresectionandreducingtheimplantabilityofmalignantcellsduringsurgery.Bothradio-andchemotherapycanbemoreeffectiveintheneo-adjuvantsettingistocombinebothmodalitiestoachieveasynergisticeffect.ConclusionsRTincombinationwithgemcitabineandoxaliplatinisfeasibleinpatientswithlocallyadvancedpancreaticobiliarycancerThereportedtimetoprogressionunderlinesthepotentialactivityofthisregimen.gemcitabine1000mg/m2Thedoseof60mg/m2ofoxaliplatincanbeconsideredastherecommendeddose.TheCORGI-UstudyConclusionsXELOX-RT(30mg/m2oxaliplatin/675mg/m2capecitabineincombinationwith50.4Gy/28fractions)waswelltoleratedandeffectiveforlocallyadvancedpancreaticandbiliarytractcancerOverallsurvivalandProgression-freesurvivalABC-02randomlyphase2studyClinicalTnumber,NCT00262769Conclusioncisplatinplusgemcitabinewasassociatedwithasignificantsurvivaladvantagewithouttheadditionofsubstantialtoxicity.CisplatinplusgemcitabineisanappropriateoptionforthetreatmentofpatientswithadvancedbiliarycancerTargetedtherapyPhaseIIandPhaseIIIclinicaltrialsinvestigatingtargetedagentsinBTC結(jié)論根治性手術(shù)切除是治愈膽管癌的主要手段；局部晚期病變新輔助放化療能明顯降期，增加R0切除率，顯示生存優(yōu)勢，有望成為標(biāo)準(zhǔn)治療方法；術(shù)后輔助化療和輔助放化療未能明顯增加局部控制率，延長PFS和OS；亞組表明，對R1切除和淋巴結(jié)轉(zhuǎn)移能增加局控率、延長PFS和OS；R1,R2手術(shù)切除，或淋巴結(jié)轉(zhuǎn)移者術(shù)后同步放化療是標(biāo)準(zhǔn)治療。不能手術(shù)切除的局部晚期病變同步放化療是標(biāo)準(zhǔn)治療，50Gy/25-28f，每周同步XILOX或GP方案；轉(zhuǎn)移性膽管癌姑息化療較BSC延長OS和PFS；GP較單藥gemcitabine延長PFS3個月，是標(biāo)準(zhǔn)一線方案；初步研究表明西妥昔單抗聯(lián)合GP能獲得較好的控制率，但需多中心，隨機(jī)III期臨床試驗進(jìn)一步證實。2015年47000例50%臨床局限期，30%局部晚期，10%為局

部可切除,10%邊界可切除;50%為全身晚期局限無遠(yuǎn)地轉(zhuǎn)移可手術(shù)切除5年生存率15%-20%中位生存期12-20個月局部進(jìn)展無遠(yuǎn)地轉(zhuǎn)移中位生存期6-10個月已遠(yuǎn)地轉(zhuǎn)移中位生存期3-6個月

手術(shù)治療結(jié)果AmericanJointCommitteeonCancer2010中國2340例胰腺癌手術(shù)病例分析結(jié)果

手術(shù)根治切除率約20％

胰頭癌中位生存期17.1個月，5年生存率8.5%

胰體尾癌中位生存期7.2個月，5年生存率0％

2004CACA新輔助放化療的目的達(dá)到好的局部控制率，降期，減少手術(shù)中的局部種植降低局部復(fù)發(fā)率，增加R0切除率，增加OS可切除胰腺癌的輔助和新輔助治療

臨床研究結(jié)果中位生存期12.4m（9-16）可以切除病例22.0m（12-32），不能切除的病例9.7m（8-41）可切除病例1年生存率61%，2年生存率44%。提高劑量可提高療效作者例數(shù)劑量有效率（%）1年（%）2年（%）

于金明13

5-7Gy(70-90%)

100

92.3

70

40-48Gy/5-8次

蔡晶18

4-7Gy（90%）72.2

55.6

27.8

32-44Gy/5-9次

周桂霞2320-40Gy

81.2

26

4-7Gy/21-42Gy

夏廷毅52

3-5Gy（50%）87.5