中国实用外科杂志

中国实用外科杂志

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依据临床循证医学研究探讨晚期胃癌的转化治疗

朱正纲   

  1. 上海交通大学医学院附属瑞金医院外科  上海消化外科研究所  上海市胃肿瘤重点实验室，上海200025
  • 出版日期:2023-01-01

  • Online:2023-01-01

摘要： 尽管在化疗、放化疗与生物免疫治疗等已取得了较大发展，但是晚期胃癌的预后仍然欠佳。在多数医学中心，姑息性化疗与最佳支持治疗仍作为治疗晚期胃癌的主要手段。晚期胃癌存在着各种转移形式，其肿瘤特征与预后主要取决于转移的部位与体量。转化治疗主要针对因手术技术或肿瘤学因素等已无法切除或勉强可予切除的晚期肿瘤，通过术前治疗等，争取使肿瘤能达到R0切除。为了能进一步改善晚期胃癌转化治疗的效果，临床上应充分关注如下几个重点因素：（1）首先，应该尽可能筛选出转化治疗潜在的获益者，包括远处“寡转移”或局限性远处转移者，例如N2融合转移（Bulky N2）和（或）腹主动脉旁淋巴结转移（No.16a1或16b2）、潜在可切除的肝转移与非弥漫性腹膜转移；肿瘤内外科医生共同面临的一大挑战即如何能正确地筛选出转化治疗的适宜对象并给予合适的综合治疗。（2）转化治疗的目的是使肿瘤降期，并能达到根治性切除（R0切除），包括完全切除转移灶，尽可能减少手术并发症，使病人术后可按计划接受后续化疗等；由于肿瘤系多途径转移，因此，围手术期全身治疗十分重要，但是R0切除仍然是改善预后的关键；另一方面，对于施行姑息性切除应持非常谨慎的态度，因为手术创伤引起的手术野与全身性炎性反应可促使残留癌灶或微小转移灶的增殖，而围手术期相关因素，诸如麻醉、输血、低温等，尤其当发生手术并发症后，都有助于肿瘤早期复发。（3）以MDT模式对晚期胃癌开展诊疗至关重要，结合肿瘤影像并以分子病理诊断与肿瘤标记物为导向作综合分析，有利于为病人制定个体化的转化治疗方案。（4）胃癌在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，晚期胃癌的实质是全身性疾病，任何治疗后的痊愈十分罕见，因此，胃癌的转化治疗是一个极具挑战性的问题。迄今，大多数晚期胃癌转化治疗的报告均来自单中心或回顾性研究，若要获得更为可靠的循证医学证据，须进一步开展多中心前瞻性的随机对照研究。

关键词: 胃癌, 转化治疗, 预后

Abstract: To investigate the conversion therapy of far-advanced gastric cancer based on research of clinical evidence-based medicine        ZHU Zheng-gang. Department of Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine;Shanghai Institute of Digestive Surgery; Shanghai Key Laboratory of Stomach Neoplasm,Shanghai 200025,China 
Abstract    Despite recent advances in chemotherapy or chemoradiotherapy and Immunobiological therapy，the prognosis associated with far-advanced gastric cancer（FAGC）is still very poor，and palliative chemotherapy with best supportive care is a mainstay in the most medical centers.In FAGC，there are various modes of metastasis，the biological characteristics of tumor and prognosis differ depending on the site and volume of metastasis.Conversion therapy is defined as a surgical treatment aiming at an R0 resection after preoperative therapy for tumor that were originally unresectable or marginally resectable for technical and/or oncological reasons.To improve the efficacy of conversion therapy，several important issues should be of great concern：（1）First of all，potential beneficiaries of conversion therapy should be fully screened out，mainly include the patients with distant oligometastases or limited distant metastases，such as extra-regional lymph-node metastasis（Bulky N2 or/and PALN 16a1/16b2），potentially resectable liver metastasis and limited peritoneal metastasis，ect.And also the challenge for the surgeon and oncologist is to identify these specific patients to offer the best multimodal treatment.（2）The objective of conversion therapy is to make the tumor downstaging，so as to achieve a radical resection of the tumor（R0 surgery），which can excise all metastatic foci with low morbidity and allow the systemic treatment to be started quickly and offer a survival advantage.Due to the multi-pathway metastasis，perioperative systemic treatment is the most important in conversion therapy for FAGC，and a R0 surgical operation is the key to improve the prognosis；On the other hand，a very cautious attitude should be taken towards palliative resection，because the surgical trauma induces local and systemic inflammatory responses that can also contribute to the accelerated growth of residual and micrometastatic disease，and the role of perioperative factors including anesthesia，transfusions，hypothermia，and postoperative complications as probable deleterious factors contributing to early recurrence；（3）The multiple disciplines team（MDT）diagnosis and treatment remains the most important approach to conversion therapy，the individualized therapeutic regimen should be based on the comprehensive evaluation of imaging，molecular pathological diagnosis and tumor biomarkers；（4）Gastric cancer is a highly heterogeneous tumor in nature，consisting of varying aggressive biological characteristics；Oncologically，FAGC is a systemic disease indeed，and the complete response to any therapy is really very rare，so that conversion therapy is a great clinical challenging problem.Up to now，most reports of conversion therapy for FAGC were from single-center or retrospective study.If more reliable evidence is to be obtained，more multi-center and prospective RCT studies must be carried out.

Key words: gastric cancer, conversion therapy, prognosis