肝胆外科胆囊

胆管癌辅助治疗现状与进展,2013年美国肿瘤发病率与死亡率,所有癌总数的1%左右,intrahepatic CCA (iCCA),perihilar CCA(pCCA),distal CCA (dCCA),NATALIYA RAZUMILAVA.Classification, Diagnosis, and Management of Cholangiocarcinoma,CCA Risk Factors,肝硬化,胆管结石，胆管感染囊性病变 carolis 疾病 胆总管囊肿胆肠引流乙肝、丙肝hepatobilithiasis原发性硬化性胆管炎（psc）氧化钍胶体暴露炎症性肠病,Serum tumour markers,CA199.sensitivity of 4070%, specificity of 5080%,positive predictive value of 1640%CA-125 is detectable in up to 65% of patients with CC.prognostic for survivalMac-2BPmatrix metalloproteinase-7 insulin-like growth factor 1,Diagnosis of Imaging,Ultrasonography：sensitivity:96%Contrast CT:sensitivity3.393.8%;specificity47.8100.0%Cholangiography胆管照影术 (MRCP, ERCP, PTC)MRI:localising site and cause of biliary obstruction 100% and 95%Endoscopic ultrasound:sensitivity 89%,specificity100%Positron emission tomography PET-CT not yet reportedCholangioscopy胆道镜检查,Shahid A Khan,et al.Guidelines for the diagnosis and treatment ofcholangiocarcinoma: an update,Bismuthe-Corlette classification of biliary strictures.Guidelines Gut,Staging of TNM system,Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th editionof the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol2010;17:1471e4.,Junichi Shindoh, Staging of Biliary Tract and Primary Liver Tumors,Surgery,J. R. A. Skipworth.Review article: surgical, neo-adjuvant and adjuvantmanagement strategies in biliary tract cancer.Alimentary Pharmacology and Therapeutics,根治性手术切除是唯一治愈胆管癌的方法诊断时仅有13%-55%的患者能手术切除,Prognosis,R0 or R1 statusvascular invasion lymph node involvement (occurring in 50% at presentation) is associated with OSTNM stage and multiplicity of lesion,studies of surgery alone reporting data on survival,Patterns of Recurrence Resection of Biliary Tract Cancer,Se Jin Jung.Patterns of Initial Disease Recurrenceafter Resection of Biliary Tract Cancer.Oncology 2012;83:8390,135 ps210 sites,Pattern of recurrence according to primary tumor origin; patients (n) with recurrence,unresectable extrahepatic and hilar cholangiocarcinoma or at high risk for disease recurrence after resection,Multidisciplinary Management,Adjuvant radiotherapyAdjuvant chemotherapyAdjuvant chemoradiation therapyNeoadjuvant chemoradiation therapyMetastatic disease:palliative radiochemtherapyTargeted therapy,META-POSTOPERATION35 TRAILS,survival of the selected studies of ART,adjuvant RT have a significant lower risk of dying compared to patients treated with surgery alone,P = .23,Twenty studies involving 6,712 patients were analyzed,Efficacy outcomes for overallpopulation,Efficacy outcomes for node positivedisease,Efficacy outcomes for marginpositive disease,Neo-adjuvant therapy,Aims to down-stage disease,rendering it suitable for surgical resection and reducing the implantability of malignant cells during surgery. Both radio- and chemotherapy can be more effective in the neo-adjuvant setting is to combine both modalities to achieve a synergistic effect.,Conclusions,RT in combination with gemcitabine and oxaliplatin is feasible in patients with locally advanced pancreaticobiliary cancerThe reported time to progression underlines the potential activity of this regimen. gemcitabine 1000mg/m2The dose of 60mg/m2 of oxaliplatin can be considered as the recommended dose.,The CORGI-U study,Conclusions,XELOX-RT (30 mg/m2 oxaliplatin/675 mg/m2 capecitabine in combination with 50.4 Gy/28 fractions) was well tolerated and effective for locally advanced pancreatic and biliary tract cancer,Overall survival and Progression-free survival,ABC-02 randomly phase 2 studyClinicalT number, NCT00262769,Conclusion,cisplatin plus gemcitabine was associatedwith a significant survival advantage without the addition of substantial toxicity.Cisplatin plus gemcitabine is an appropriate option for thetreatment of patientswith advanced biliary cancer,Targeted therapy,Phase II and Phase III clinical trials investigating targeted agents in BTC,结 论,根治性手术切除是治愈胆管癌的主要手段；局部晚期病变新辅助放化疗能明显降期，增加R0切除率，显示生存优势，有望成为标准治疗方法；术后辅助化疗和辅助放化疗未能明显增加局部控制率，延长PFS和OS；亚组表明，对R1切除和淋巴结转移能增加局控率、延长PFS和OS；R1,R2手术切除，或淋巴结转移者术后同步放化疗是标准治疗。,不能手术切除的局部晚期病变同步放化疗是标准治疗，50Gy/25-28f，每周同步XILOX或GP方案；转移性胆管癌姑息化疗较BSC延长OS和PFS；GP较单药gemcitabine延长PFS3个月，是标准一线方案；初步研究表明西妥昔单抗联合GP能获得较好的控制率，但需多中心，随机III期临床试验进一步证实。,肝癌属于放射敏感肿瘤敏感性相当于低分化鳞癌,早期肝癌放疗结果,不能手术肝癌放疗结果,肝癌伴门静脉/下腔静脉癌栓的放疗,1年生存率:外照射组34.8% 未接受外照射组11.4%,Int J Radiat Oncol Biol Phys 2005;61(2)432-443,肝癌腹腔淋巴结转移的放疗,中位生存时间 外照射组:9.4月 未接受外照射组:3.3月(P0.001),Int J Radiat Oncol Biol Phys 2005;63(4)1067-1076,Phase III SHARP Trial: OS,*OBrien-Fleming threshold for statistical significance was P=0.0077. Llovet JM, et al. J Clin Oncol. 2007;25(suppl 18):LBA1. Updated from oral presentation.,Survival Probability,Weeks,0,80,8,16,24,32,40,48,56,64,72,SorafenibMedian: 46.3 weeks (10.7 mo)95% CI: 40.9-57.9,HR (95% CI): 0.69 (0.55-0.88)P=0.00058*,PlaceboMedian: 34.4 weeks (7.9 mo)95% CI: 29.4-39.4,No. of Patients,肝癌放疗的价值,大肝癌放疗后中位生存期提高8个月（12-20个月）淋巴结转移者中位生存期提高6个月（4-10个月）静脉癌栓患者中位生存期提高4个月（4-8个月）骨骼转移能明显有效止痛，增加生活质量不能手术的肝内胆管细胞癌中位生存期提高5个月（3-11个月）,不能手术切除肝癌，选择放疗同步化疗（证据2B）需要大样本，前瞻性随机对照研究期待更高级别证据,局限无远地转移可手术切除 5年生存率 20% 中位生存期 12-20个月 局部进展无远地转移 中位生存期 6-10个月 已远地转移中位生存期 3-6个月,手术治疗结果,American Joint Committee on Cancer 2010,中国2340例胰腺癌手术病例分析结果,手术根治切除率约20 胰头癌中位生存期17.1个月，5年生存率8.5% 胰体尾癌中位生存期7.2个月， 5年生存率0,2004 CACA,提高剂量可提高疗效,作者例数 剂量 有效率（%） 1年（%） 2年（%）,于金明 13 5-7Gy(70-90%) 10092.3 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 23 20-40Gy 81.2 26 4-7Gy