寻求进展期可切除胃癌的最佳手术方案

　　Seeking the Best Surgery for Resectable Advanced Gastric Cancer

　　Takeshi Sano Cancer Institute Hospital， Japan

　　Oncology Frontier:Relative to colorectal cancer， the prognosis of stomach cancer patients is poorer. What kind of treatment we should adopt to improve the survival of advanced gastric cancer patients with peritoneal metastasis?

　　《肿瘤瞭望》：胃癌患者相对结直肠癌患者预后较差，针对发生腹膜转移的晚期胃癌患者，我们该采用怎样的治疗措施提高患者的生存率？

　　Prof Sano: Colorectal cancer is an intestinal-type cancer which may metastasize to the liver and lymph nodes but rarely to the peritoneum. Liver and lymph node metastases can be controlled either by surgery or chemotherapy， but peritoneal disease is very difficult to treat. Therefore， one of the reasons gastric cancer has a poorer prognosis is that they can easily metastasize to the peritoneum with diffuse histology. So for these tumors， treatment is difficult and early detection is the most important factor. In colorectal cancer， the disease is localized and more easily cured. But for gastric cancer， particularly if detection is delayed， it may have already spread to the peritoneum and it is too late. In order to improve treatment outcomes and survival rates， we need to detect disease early， particularly in the diffuse-type tumors. For early detection， ready access to endoscopy is important.

　　Prof Sano：结直肠肿瘤是一种肠型肿瘤，比较容易发生肝脏和淋巴结转移但是很少发生腹膜转移。肝脏和淋巴结的转移可以通过手术或者化疗控制，但是腹膜转移很难治疗。所以，胃癌预后较差的一个原因就是胃癌很容易发生腹膜种植性转移。对于这样的肿瘤，治疗是很困难的，所以早期诊断显得尤为重要。对于结直肠癌患者，这个病灶相对较局限，而且比较容易治愈。但是对于胃癌患者，一旦没办法早期发现病灶，很有可能就会发生腹膜转移，错失最好的治疗时机。为了提高治疗质量和生存率，我们需要更早地发现胃癌病灶，尤其对于那些弥漫型的胃癌患者。内镜检查对于早期发现胃癌患者尤其重要。

　　Oncology Frontier: It is controversial for the surgical treatment of advanced gastric cancer. There are some countries such as China， Japan and South Korea carry out prospective randomized controlled study about laparoscopic surgery in treatment of advanced gastric cancer. These RCTs may give an answer to this question of the surgical treatment of advanced gastric cancer. How do you think about this question?

　　《肿瘤瞭望》：针对晚期胃癌的手术治疗一直存在着很大的争议，中日韩等国也在开展腹腔镜手术治疗晚期胃癌的前瞻性随机对照研究，可能会对这个问题给出答案。您是如何看待这个问题？

　　Prof Sano: Laparoscopic surgery for advanced disease is feasible. We can treat advanced gastric cancer by laparoscopy but it will not provide better results than open surgery. In terms of quality of life， it may be better for patients but will not increase survival. So this will not solve any controversies. The important point is， that for advanced disease， a good combination of chemotherapy and surgery is very important. Timing is essential. When should we give chemotherapy? When should we perform surgery? These are the important considerations.

　　Prof Sano：腹腔镜手术治疗晚期肿瘤是可行的。我们可以通过腹腔镜手术治疗进展期胃癌，但是这并没有较开腹手术带来更好的生存结果。腹腔镜手术可以更好地提高患者的生活质量，但是却没办法提高生存时间。所以这些结果没办法解决现在的争论。但是对于晚期胃癌很重要的一个观点就是化疗和手术相结合的重要性。治疗时机也是必需的。什么时候我们应该给患者化疗？什么时候应该安排患者手术？这些都是很重要的需要考虑的问题。

　　Oncology Frontier:For advanced gastric cancer， neoadjuvant chemoradiotherapy and continous hyperthermic peritonealperfusion chemotherapy are meaningful treatments. What do you think these two kinds of treatment method?

　　《肿瘤瞭望》：针对晚期胃癌，新辅助化放疗还有热灌注腹腔化疗都是具有一定治疗意义的，您是如何看待这两种治疗方法呢？

　　Prof Sano: Neoadjuvant chemoradiotherapy is now being tested but for GE-junction tumors， it will probably be helpful in the same way it is for rectal cancer due to the similar nature of the disease. But for distal gastric cancer， the role of chemoradiotherapy is still controversial. Hyperthermic peritoneal perfusion is， so far， the only possible strategy for peritoneal carcinomatosis but in Japan we are seeing some trials with non-hyperthermic (normothermic) peritoneal chemotherapy and this approach is less toxic and equally effective. So it depends less on the method and more on the development of chemotherapeutic agents. Surgeons act aggressively with localized disease and medical oncologists act aggressively with systemic disease， but peritoneal disease is a target for both surgeons and oncologists and we have to work together. A good collaboration between surgeons and medical oncologists is important.

　　Prof Sano：新辅助化放疗正在胃食管结合部肿瘤患者身上尝试，因为这种治疗方案在结直肠癌患者中是非常有帮助的，而胃食管结合部肿瘤和结直肠癌具有一些相似的特征。但是对于胃癌患者，这种新辅助治疗方案是受争议的。腹腔热灌注被认为是治疗胃癌腹膜转移的唯一治疗途径，但是在日本我们看到一些临床试验是用常温腹腔化疗，而这种化疗途径毒性反应更小，有效性和腹腔热灌注相当。所以化疗疗效更少地依赖于化疗方式，更多地依赖于化疗方案的组成。外科医生主治局限性疾病，内科肿瘤医生主治系统性疾病，而对于腹膜转移的疾病则需要外科医生和内科肿瘤医生共同合作。外科医生和内科肿瘤医生之间好的合作是非常重要的！