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结直肠癌的规范化治疗课件

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直肠癌 规范化 治疗 课件
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Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 结直肠癌的外科规范化治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 主要内容 结肠癌外科的基本治疗流程1 直肠癌外科的基本治疗流程2 结直肠癌辅助化疗的规范和进展3 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术前 评价 临床 决策 手术 治疗 辅助 治疗 结肠癌外科的基本治疗流程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术前评价 手术 血CEA 肠镜 病理 胸 腹 盆 增强CT PET CT非常规检查 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术前 评价 临床 决策 手术 治疗 辅助 治疗 结肠癌外科的基本治疗流程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床决策 适合切除 可切除 无梗阻 根治性切除 无远处转移 可切除 有梗阻 根治性切除 吻合 根治性切除 转流 转流 支架 局部 无法切除或不适合切除 化疗 根治性切除 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术前 评价 临床 决策 手术 治疗 辅助 治疗 结肠癌外科的基本治疗流程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 结肠癌的手术原则 沿壁层筋膜腹侧表面锐性解剖脏层筋膜 安全显露供血动脉和同名静脉 先结扎同名静脉 然后在动脉起始部结扎 完整切除对应的结肠系膜 切除距离胃大弯10 15cm的大网膜以及胰腺周围淋巴结 结肠系膜切除术 complete mesocolic excision CME 原则 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 结肠癌的手术原则 对于有明显的结肠癌家族史或年轻患者 50 岁 考虑行更广泛的结肠切除术 完全切除才可被认为是治愈性的 HNPCC患者的处理原则 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术前 评价 临床 决策 手术 治疗 辅助 治疗 结肠癌外科的基本治疗流程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术 前 评 价 临 床 决 策 新辅 助治 疗 手 术 治 疗 辅 助 治 疗 直肠癌外科的基本治疗流程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术 前 评 价 临 床 决 策 新辅 助治 疗 手 术 治 疗 辅 助 治 疗 直肠癌外科的基本治疗流程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 直肠癌的术前评价 提供结肿瘤的临床分期 明确与周围脏器的关系 评价肿瘤对各种治疗的反应 推荐盆腔MRI或经直肠超声 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术 前 评 价 临 床 决 策 新辅 助治 疗 手 术 治 疗 辅 助 治 疗 直肠癌外科的基本治疗流程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床决策 适宜切除 的直肠癌 活检 T1 N0经肛切除 病理评估 结肠镜检查 硬质直肠镜 检查 胸部 腹 部 盆腔CT CEA 直肠内超声或 直肠内MRI或 盆腔MRI 如有需要 术 前请造口治疗 师行造口定位 和宣教 PET CT检查不 作常规推荐 T2 N0 经腹切除 T3 N0或任何T N1 2 T4 和 或局部无法 切除 因禁忌而不能采用 综合治疗 任何T 任何N M1 转移灶可切除 任何T 任何N M1 转移灶不可切除或 患者不能耐受手术 术前放化疗后 经腹切除 放化疗 经腹切除 化疗后经腹切 除 评估病人局部 症状 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术 前 评 价 临 床 决 策 新辅 助治 疗 手 术 治 疗 辅 助 治 疗 直肠癌外科的基本治疗流程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial T3和 或N 的可切除直肠癌患者 推荐术前新辅助放化疗 T4或局部晚期不可切除的直 肠癌患者 必须行新辅助放 化疗 治疗后必须重新评价 并考虑是否可行手术 新辅助治疗原则 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 同期放化疗方案 推荐长程放疗 TD 45 50 4Gy 每次1 8 2 0Gy 共25或28次 卡培他滨825mg m2 每天2次 每周5天或7天 与放疗同步 放疗 卡培他滨 5 Fu每天225mg m2 放疗期间每天24小时每周5 7天维持 与放疗同步 放疗 5 Fu持续输注 放疗第1 5周给予5 Fu400mg m2 d LV20mg m2 d静脉推注 d1 4 共4天 放疗 5 Fu LV Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术 前 评 价 临 床 决 策 新辅 助治 疗 手 术 治 疗 辅 助 治 疗 直肠癌外科的基本治疗流程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 直肠癌的局部切除原则 仅适用于T1肿瘤 侵犯肠周径 30 肿瘤大小 3cm 活动 不固定 距肛缘8cm以内 切缘阴性 距离肿瘤 3mm 高 中分化 无血管淋巴管浸润 LVI 或神经浸润 治疗前影像学检查无淋巴结转移的证据 经肛门切除必须满足如下要求 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 经肛门内镜显微手术 Transanal Endoscopic Microsurgery TEM 应用特殊的器械经肛门切除直肠肿瘤的 手术方式 可应用于早期直肠癌的外科治疗 局部切除后标本的固定与切缘标示 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 全直肠系膜切除原则 直视下锐性分离骶前间隙 远切缘至少距肿瘤远端2cm 直肠系膜切缘至少距肿瘤远端5cm 中下段直肠癌行全系膜切除 TME Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 直肠癌的外科手术原则 尽可能把清扫范围外的可疑淋巴结切除或活检 如无临床可疑转移淋巴结 不推荐扩大的淋巴 结清扫术 淋巴结清扫原则 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 直肠癌的外科规范化治疗 对中低位直肠癌 病理科医生应评价直肠系 膜的完整性 环周切缘阳性的定义是肿瘤距切缘小于1mm 此评估应包括淋巴结内的肿瘤或原发肿瘤直 接浸润 直肠癌手术质量的评价 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 环周切缘 circumferential resection margin CRM 肿瘤或癌结节的边缘距离环周切缘 1mm者为CRM CRM 是局部复发的高危因素 J Clom Oncol 26 303 312 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 结直肠癌的外科规范化治疗 肿瘤学指 标和预后 淋巴 结检 查数 量 NS 切缘 阳性 率 NS 3y DFS NS 3y OS NS 适合结肠癌患者 直肠癌患者有争议 腹腔镜手术原则 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 行腹腔镜辅助的结肠切除术原则 1 由有经验的腹腔镜外科医师实施手术 2 小病灶应进行术前标记 3 无局部晚期病变的表现 4 无急性肠梗阻或穿孔的表现 5 保证能进行全腹腔的探查 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 结直肠癌的外科规范化治疗 准确的术前评估 合理的术前治疗 细致的手术操作 完整的术后病理 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 结肠癌辅助化疗策略的演变 1 Clin Colorectal Cancer 2014 Nov 15 pii S1533 0028 14 00128 5 doi 10 1016 j clcc 2014 11 002 2 JCO 2007 25 102 109 3 JCO 2011 29 1465 1471 4 ASCO MEETING ABSTRACTS 2012 38 5 ESMO 2014 Abstra LBA12 24 S6 vi64 vi72 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 期结肠癌辅助化疗的探讨 争议 28 2 264 271 IIaIIbIIcIIIaIIIaIIIa 第七版AJCC TNM分期 T4患者预后差 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 期结肠癌的危险度分层 临床因素 Hak Mien Quah et al Dis of Colon 51 503 507 MSKCC资料1990 2001年 448例 期结肠癌 单纯手术 未行术后化疗 甄别出三个高危因素 术前CEA升高 HR 2 1 T4病灶 HR 2 7 脉管 神经浸润 HR 2 1 预后价值 0个高危因素 5年OS 95 1个高危因素 5年0S 85 2个高危因素 5年OS 57 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 期结肠癌的危险度分层 临床因素 各机构对临床 高危 期 的定义 参数ASC0 2004 NCCN 2013 ESMO 2012 T4肿瘤 组织学分化差 3 4级 淋巴结数量不足 13 12 12 穿孔 含局部 肠梗阻 脉管或神经浸润 切缘太近 阳性或不确定 术前CEA升高 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 期结肠癌辅助化疗 NCCN指南推 荐 1 无高危因素者 不常规化疗 如化疗则单药 2 高危II期 建议化疗 可考虑加奥沙 利铂 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 期辅助化疗 ESMO指南推荐 Schmoll et al Ann Oncol 2012 23 2479 2516 期 低危 不常规推荐化疗 如化疗 则选氟尿嘧啶单药 期 高危 70岁 推荐化疗 氟尿嘧啶类 奥沙利铂 生物学年龄较年轻者 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 期的化疗获益 MOSAIC 试验最终结果 Tournigand et al JCO 2012 42 5645 85 0 vs 83 3 86 8 vs 78 8 82 3 vs 74 6 7 7 8 0 1 7 高危 期的生存结果 结论 高危II期能从奥沙利铂辅助化疗中得到获益 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 1 0 0 8 0 6 0 4 0 2 0 0 Stage II 3 8 高危 期化疗DFS获益相当于 期 Years FOLFOX4 LV5FU2 Stage II 83 7 vs 79 9 HR 0 84 p 0 258 Stage III 66 4 vs 58 9 HR 0 78 p 0 005 高危II期 82 3 vs 74 6 HR 0 72 7 7 Andr et al JCO 2009 27 3109 16 0123456 Stage III 7 5 MOSAIC 试验5年DFS Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 如何甄别那些亚群能从现有化疗 中获益 化疗疗效预测指标的研究 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial MSI H 微卫星高度不稳定 的 II期患者没有从5 FU的辅助化疗中获益 H MSI MSS L MSI Ribic et al NEJM 2003 349 247 57 MSI 微卫星不稳定 5 FU无获益 MSS 微卫星稳定 5 FU能获益 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial HR 1 08 0 44 2 68 p 0 86 Untreated 62 Treated 67 5 yr DFS 0 10 20 30 40 50 60 70 80 90 100 012345 Years Disease Free HR 2 80 0 98 8 97 p 0 05 Untreated 87 Treated 72 5 yr DFS 0 10 20 30 40 50 60 70 80 90 100 012345 Years ACCENT数据 MMR预测FU辅助化疗疗效 dMMR状态态分层层的DFS 期 N 102 N 63 Sargent et al ASCO 2008 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial HR 0 64 0 48 0 84 p 0 001 Untreated 41 Treated 58 5 yr DFS 0 10 20 30 40 50 60 70 80 90 100 012345 Years Disease Free HR 0 84 0 57 1 24 p 0 38 Untreated 72 Treated 77 5 yr DFS 0 10 20 30 40 50 60 70 80 90 100 012345 Years ACCENT数据 MMR预测FU辅助化疗疗效 pMMR状态态分层层的DFS 期 N 428 N 434 Sargent et al ASCO 2008 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 期辅助化疗的风险评估 MMR DNA错配修复基因 检测 2015年 70岁及所有 的II期的结肠 癌患者均应考 虑检测MMR 2013年 70岁 5 FU Lev LV vs 单纯手术 年龄 70岁年龄 70岁 无复发生存率 无复发生存率 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2012年一项回顾性分析探讨 75岁以上老年人辅助化疗获益情况 一项回顾性研究 数据来自4个主要数据库 SEER医保 NYSCR NCCN预后数据库 CanCORS 共有2004 2007年的5489例确诊患者纳入分析 调查目的是评估辅助化疗对75岁以上确诊的III期结肠癌患者的作用 并对奥沙利铂 亚组与非奥沙利铂亚组进行了比较 Sanoff et al JCO 2012 21 30 2624 34 四个大型随访数据库病例 the SEER program cancer registry SEER Medicare the New York State Cancer Registry NYS CR 纽约州癌症登记处 the National Comprehensive Cancer Net work NCCN Outcomes Database the Cancer Care Outcomes Research 21 30 2624 34 SEER 配对OS n 4226 NYSCR 配对OS n 998 NCCN 未配对OS n 144 术后时间 月 30天 HR 95 CI 0 84 0 69 1 04 HR 95 CI 0 82 0 51 1 33 HR 95 CI 1 25 0 43 3 68 SEER 医疗保险数据库 NYSCR 纽约州癌症登記 NCCN 美国国家综合癌症网络 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial MOSAIC最终结果 70岁者奥沙利铂 无生存获益 Tournigand et al JCO 2012 42 5645 69 1 vs 65 8 HR 0 93 p 0 71 78 8 vs 69 9 HR 0 68 p 0 089 75 8 vs 76 1 HR 1 10 p 0 663 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2013年ACCENT数据库分析 含奥铂联合方案在 70岁患者中疗效显著降低 J Clin Oncol 2013 31 2600 2606 DFS OS 对照组为5 FU iv HR 1为试验组更优 一项ACCENT协作组对结肠癌III期辅助化疗临床研究患者 个体数据做的分析 共纳入7个研究14 528名II III期结肠 癌患者 其中11 953人 70岁 2 575人 70岁 研究目 的是探讨年龄对联合方案和口服氟尿嘧啶辅助方案的影 响 此处为6 539名使用奥沙利铂联合方案的患者数据 研究显示 含奥沙利铂联合方案较5 FU LV在 70岁患者中 DFS在3 6年间 均显著获益 OS呈现时间越长获益越多 的趋势 而在 70岁的患者中 DFS及OS在3 6 年间均无显著获益 DFS的HR越来越接 近1 而OS的HR均 1 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial NCCN指南脚标警示奥沙利铂老年III期 中的应用 70岁以上老年人 在5 FU LV的基础上增加奥沙利铂 其生存获益尚未证实 注 仅申明是在5 FU LV的基础上而非所有氟尿嘧啶 NCCN Guidelines Colon Cancer V2 2015 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial ESMO同样对 老年人使用奥沙利铂联合方案持谨慎态度 Annals of Oncology 2013 24 S6 vi64 vi72 70岁以上老年人 化疗安全性与较年轻患者类似 辅助化疗疗效与普通人群类似 研究结果证实老年人无法从含奥沙 利铂联合方案中获益 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2012年ASCO讨论认为 老年患者推荐单药辅助化疗更合适 70岁III期患者 5FU LV 12周期 或8周期卡培他滨单药 卡培他滨1000 1250mg m2第一 天至第14天 每三周重复 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 谢 谢
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