摘要
在我国，胃癌是第二常见的恶性肿瘤，亦为致死的主要肿瘤。尤其是Ⅳ期或不可手术切除的晚期胃癌，预后极差。近年来，对于Ⅳ期胃癌开展转化治疗已成为临床关注的重点。转化治疗的内涵，即针对因外科手术技术或肿瘤生物学行为已不可切除的晚期肿瘤，通过积极有效的化疗等，使原发癌灶降期，远处转移灶获有效控制，并争取施行R0切除术，以提高此类晚期肿瘤患者的生存率。然而，对于转化手术最佳指征仍存在争议，如何选择合适的转化治疗对象也有待进一步阐明。日本岐阜大学Yoshida等将Ⅳ期胃癌分为无腹膜转移者与有腹膜转移者两大类，又将无腹膜转移者分为可行切除的转移灶（Ⅰ亚类）和可行姑息性切除的转移灶（Ⅱ亚类）；并将有腹膜转移者分为非治愈性与不可切除的转移灶（Ⅲ亚类）和不可治愈的转移灶（Ⅳ亚类）；共4个亚类。作者认为，最佳转化治疗对象系Ⅱ亚类，以及部分Ⅲ与Ⅳ亚类患者。北京大学肿瘤医院通过术前评估，明确肿瘤能否施行R0切除而将Ⅳ期胃癌分为可切除型与不可切除型，对于不可切除的Ⅳ期胃癌可依据其转移范围再进一步分成能转化组、部分转化组与未转化组。对于未经筛选的Ⅳ期胃癌，即使切除原发灶和转移灶也未必能改善预后。REGATTA研究证实，对于患单一不可治愈因素的Ⅳ期胃癌患者，比较行单纯化疗与姑息性胃切除后再辅以术后化疗，并无生存获益之统计学差异。随着转化治疗的发展，已初见共识：若干新的联合化疗方案已表明，对伴单一不可治愈因素的Ⅳ期胃癌患者，如腹膜转移、腹主动脉旁淋巴结转移或肝转移，若选择对化疗有效的患者再施行R0胃癌根治术，可望提高术后生存率。胃癌本质上属高度异质性的肿瘤，具有多种潜能的生物学特性。根据肿瘤学原理，Ⅳ期胃�
Gastric cancer is the second most common malignancy and the one of the leading causes of cancer-related death in China. In particular, the survival rate of patients with stage IV or unresectable gastric cancer is very poor. Conversion therapy for stage IV gastric cancer has been the main subject with much attention recently. It is defined to achieve an R0 surgical resection after chemotherapy for originally unresectable cancer due to technical and/or oncological reasons. However, the optimal indications for conversion surgery are still controversial, and how to select the most appropriate candidates for conversion therapy remains to be clarified. A new biological category for stage IV gastric cancer proposed by K Yoshida from Gifu University has been tested out in some trials, from which stage IV gastric cancer can be divided into two different classifications based on the absence （category 1： potentially resectable metastasis and category 2： marginally resectable metastasis） or presence （category 3： incurable and unresectable metastasis and category 4： non-curable metastasis） of macroscopic peritoneal dissemination. The optimal indications for conversion therapy mainly include the patients with category 2, and partially for patients with categories 3 and 4. A surgery-oriented classification proposed by Peking University Cancer Hospital tried to classify the stage IV gastric cancer for conversion therapy. It would be classified as resectable and unresectable categories, depending on uhether R0 resection is available by preoperative evaluation. In this classification, unresectable cancer can be further classified as conversed, partly conversed and non-conversed types based on extent of cancer metastasis. The resection of primary and metastatic lesion in unscreened stage IV gastric cancer was not testified to improve survival. REGATTA trial has identified no significant difference in survival rate between the chemotherapy only and palliative gastrectomy with postoperative chemotherapy for stage IV g
作者
朱正纲
Zhu Zhenggang(Department of Surgery,Ruijin Hospital,Shanghai Jiaotong University School of Medicine,Shanghai Institute of Digestive Surgery,Shanghai Key Laboratory of Gastric Neoplasm,Shanghai 200025,China)
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2018年第10期1087-1092,共6页
Chinese Journal of Gastrointestinal Surgery
关键词
胃肿瘤
Ⅳ期
转化治疗
外科手术
Stomach neoplasms
Stage Ⅳ
Conversiontherapy
Surgery
