壺腹部腫瘤治療進(jìn)展

壺腹部腫瘤治療進(jìn)展第1頁/共36頁概念：壺腹部：十二指腸乳頭，Vater壺腹、膽總管第4段（十二指腸壁內(nèi)段）、胰管終末段及其周圍的括約肌。壺腹部腫瘤是指膽總管第4段、Vater壺腹(膽總管末端斜行進(jìn)入十二指腸后壁內(nèi)與主胰管形成的共同通道）及十二指腸乳頭的腫瘤。第2頁/共36頁

概述（Introduction）1.壺腹部腫瘤良性少見（<10%）[1-2]；2.與遺傳性息肉病綜合征關(guān)系密切，如FAP；3.確診壺腹癌年齡一般在60-70歲；4.一些證據(jù)表明：生物學(xué)行為更接近于腸道而非胰膽管腫瘤。[1]ParkSH,KimYI,ParkYH,KimSW,KimKW,KimYT,KimWH.Clinicopathologiccorrelationofp53proteinoverexpressioninadenomaandcarcinomaoftheampullaofVater.WorldJSurg.2000Jan;24(1):54-9.[2]ParkSW,SongSY,ChungJB,LeeSK,MoonYM,KangJK,ParkIS.EndoscopicsnareresectionfortumorsoftheampullaofVater.YonseiMedJ.2000Apr;41(2):213-8第3頁/共36頁壺腹癌治療（Treatment）：局部切除胰十二指腸根治切除（PD）及改良（保留幽門）（PPPD）微創(chuàng)非手術(shù)療法（Minimally-invasivenonsurgicaltherapies）第4頁/共36頁局部切除（Localresection）自1899年Halsted開展，未廣泛接受（患者生存6個月，復(fù)發(fā)率高，療效差）發(fā)病年齡較大，并存疾病多目前此種方法的文獻(xiàn)報道較少，之間對比缺少標(biāo)準(zhǔn)（eg,"ampullectomy"versus"localresection")第5頁/共36頁解剖學(xué)依據(jù)[1]：*十二指腸內(nèi)段膽總管長1.5-2.0cm*進(jìn)入十二指腸前1-2cm緊貼腸壁*46.7%膽胰管匯合形成Vater壺腹2*50%膽胰管并行[1]、GasslerN1,

KnüchelR.Tumorsof

Vater'sampullaPathologe.

2012Feb;33(1):17-23.doi:10.1007/s00292-011-1546-82、FunabikiT1,

MatsubaraT,

MiyakawaS,

IshiharaS.Pancreaticobiliary

maljunction

and

carcinogenesis

to

biliary

and

pancreatic

malignancy.LangenbecksArchSurg.

2009Jan;394(1):159-69.doi:10.1007/s00423-008-0336-0.Epub2008May24.理論依據(jù)第6頁/共36頁解剖學(xué)依據(jù)病理依據(jù)[1-2]：*壺腹癌以腺癌多見，分化程度高，*惡性程度低1、BegerHG1,

TreitschkeF,

GansaugeF,

HaradaN,

HikiN,

MattfeldtT.

Tumor

ofthe

ampullaofVater:

experience

with

local

or

radical

resectionin171consecutivelytreatedpatients.ArchSurg.

1999May;134(5):526-322、GasslerN1,

KnüchelR.Tumorsof

Vater'sampullaPathologe.

2012Feb;33(1):17-23.doi:10.1007/s00292-011-1546-8理論依據(jù)第7頁/共36頁解剖學(xué)依據(jù)病理依據(jù)腫瘤生物學(xué)依據(jù)[1]：*生長緩慢、轉(zhuǎn)移較晚*常沿十二指腸或膽總管粘膜*少侵及腸壁外1、BegerHG1,

TreitschkeF,

GansaugeF,

HaradaN,

HikiN,

MattfeldtT.

Tumor

ofthe

ampullaofVater:

experience

with

local

or

radical

resectionin171consecutivelytreatedpatients.ArchSurg.

1999May;134(5):526-32理論依據(jù)第8頁/共36頁解剖學(xué)依據(jù)病理依據(jù)腫瘤生物學(xué)依據(jù)其他1：Whipple可以清掃淋巴結(jié)，但不能減少血行轉(zhuǎn)移1、TopalB,FieuwsS,AertsR,WeertsJ,FerynT,RoeyenG,BertrandC,HubertC,JanssensM。Pancreaticojejunostomyversuspancreaticogastro-stomyreconstructionafterpancreaticoduodenectomyforpancreaticorperiampullary

tumours:amulticentrerandomisedtrial.LancetOncol.2013Jun;14(7):655-62.理論依據(jù)第9頁/共36頁手術(shù)范圍文獻(xiàn)報道不盡相同包括：不涉及膽胰管末端的單純十二指腸黏膜切除

廣泛的乳頭區(qū)域切除：乳頭、壺腹膽胰管末端和相應(yīng)的十二指腸后壁，以及膽胰管末端再植技術(shù)難度大精細(xì)操作切緣快速冰凍第10頁/共36頁優(yōu)缺點(diǎn)并發(fā)癥少恢復(fù)快手術(shù)時間短術(shù)后生活質(zhì)量高手術(shù)死亡率低高復(fù)發(fā)率低生存率第11頁/共36頁適用范圍：高風(fēng)險病人早期高分化、不穿透肌層（Tis,T1期)超聲內(nèi)鏡下直徑<6mm（國內(nèi)文獻(xiàn)報道直徑<2.0/2.5cm）【UpToDate】：Wesuggestlocalampullaryexcisionratherthanpancreaticoduodenectomyforpatientswithnoninvasiveampullarytumors(pTis)(Grade2B).第12頁/共36頁展望1.術(shù)前病理診斷假陰性率較高2.腫瘤的組織類型區(qū)分3.術(shù)前淋巴結(jié)情況難判定總之，尚有待臨床大規(guī)模RCT研究第13頁/共36頁P(yáng)D/PPPDPD（Whippleoperation）被認(rèn)為是治療壺腹癌的標(biāo)準(zhǔn)方法PPPD(pylorus-preservingpancreaticoduodenectomy)（保留幽門）盡管有報道[1]PPPD手術(shù)時間短，術(shù)中出血少，然而，二者對術(shù)后長期生存無明顯差異，亦有報道PPPD更易產(chǎn)生胃排空延遲。[1]DienerMK,KnaebelHP,HeukauferC,AntesG,BüchlerMW,SeilerCM.Asystematicreviewandmeta-analysisofpylorus-preservingversusclassicalpancreaticoduodenectomyforsurgicaltreatmentofperiampullaryandpancreaticcarcinoma.AnnSurg.2007Feb;245(2):187-200.第14頁/共36頁優(yōu)缺點(diǎn)[1-3]根治性切除率可達(dá)到80-90%長期生存率高，即便是對于淋巴結(jié)轉(zhuǎn)移或T3期病人圍手術(shù)期死亡率較高（最近文獻(xiàn)表明，對經(jīng)驗(yàn)豐富大夫可控制在0-5%）圍手術(shù)期并發(fā)癥發(fā)生率高20-40%（肺炎、腹腔內(nèi)感染、吻合口瘺、胃排空延遲等）手術(shù)創(chuàng)傷大與術(shù)者水平和術(shù)后護(hù)理關(guān)系密切第15頁/共36頁推薦級別【UpToDate】Werecommendpancreaticoduodenectomyratherthanlocalresectionformostpatientswithinvasiveampullarycarcinomas(Grade1B)第16頁/共36頁文獻(xiàn)回顧：RogginKK等

Limitationsofampullectomyinthetreatmentofnonfamilialampullaryneoplasms.AnnSurgOncol.2005MemorialSloan-KetteringCancerCenter（紀(jì)念斯隆-凱特琳癌癥中心[美]）99例浸潤性壺腹癌患者，其中8例行AMP（ampullectomy），91例行PD(pancreaticoduodenectomy)幸存者中位隨訪期18個月比較：復(fù)發(fā)率和生存率術(shù)前病理準(zhǔn)確性結(jié)論第17頁/共36頁微創(chuàng)非手術(shù)療法包括：內(nèi)鏡下圈套切除術(shù)（Endoscopicsnareresection）射頻消融（Laserablation）光動力療法（photodynamictherapy，PDT）姑息性治療僅適用于不適合手術(shù)或拒絕手術(shù)者第18頁/共36頁P(yáng)ROGNOSISStageI–84percentStageII–70percentStageIII–27percentStageIV–0percent（oneretrospectivesingle-institutionseries）

theNationalCancerInstituteSEERdatabasebetween1988and2003

Five-yearsurvivalratesfollowingPDrangefrom64to80percentforpatientswithnode-negativedisease,andfrom17to50percentfornode-positivedisease第19頁/共36頁資料來源/contents/ampullary-carcinoma-treatment-and-prognosis?source=search_result&search=Periampullary+tumors+AND+local+resection&selectedTitle=1~150#H11/contents/treatment-of-ampullary-adenomas?source=see_link#H24/contents/ampullary-carcinoma-epidemiology-clinical-manifestations-diagnosis-and-staging?source=see_link第20頁/共36頁ThanksPEKINGUNIONMEDICALCOLLEGEHOSPITAL

PEKINGUNIONMEDICALCOLLEGEHOSPITAL第21頁/共36頁參考文獻(xiàn)

[1]AllemaJH,ReindersME,vanGulikTM,vanLeeuwenDJ,VerbeekPC,deWitLT,GoumaDJ.Resultsofancreaticoduodenectomyforampullarycarcinomaandanalysisofrognosticfactorsforsurvival.Surgery.1995Mar;117(3):247-53.[2]BettschartV,RahmanMQ,EngelkenFJ,MadhavanKK,ParksRW,GardenOJ.Presentation,treatmentandoutcomeinpatientswithampullarytumours.BrJSurg.2004Dec;91(12):1600-7.[3]SommervilleCA,Limon