Snady Harry
Pancreatobiliary Treatment Group, EUS Imaging, 22 East 88th Street, New York, NY 10128, USA. www.eusimaging.com
Hematol Oncol Clin North Am. 2002 Feb;16(1):53-79. doi: 10.1016/s0889-8588(01)00010-7.
With current treatment, survival of greater than 1 year should be anticipated for many patients with pancreatic cancer. Cure rates (5-year survival) of greater than 10% have been achieved even for unresectable disease. Obstructive jaundice is managed successfully with endoscopic placement of a plastic stent early in the evaluation of a patient with suspected regional pancreatic cancer, and a metal wall stent is reserved for patients with known 1997 AJCC stage IVB carcinoma or nonoperative patients. Relief of biliary obstruction allows improvement in liver function and more time to evaluate tumor stage accurately to determine initial treatment (see Fig. 1). A cost-effective algorithm to determine accurate stage and treatment can start with the size of the mass on initial imaging studies. EUS-guided FNA represents a significant improvement over CT scan-guided FNA to make a tissue diagnosis. Small pancreatic masses that would be resected regardless of whether an FNA is positive or negative require only an EUS evaluation to establish an early resectable stage. Tumors reliably staged as unresectable by nonoperative imaging methods including EUS are treated with chemotherapy with or without concurrent radiotherapy because median survival of these patients is 2 years in some series. Tumors can be resected after neoadjuvant chemoradiotherapy. For chronic pain or gastric outlet obstruction not responding or treatable by chemoradiotherapy, endoscopically guided celiac plexus nerve block and stenting improve the quality of life for patients with pancreatic cancer. A team approach is required to achieve the objectives of improved quality of life, prolonged survival, and possible cure for pancreatic cancer. The optimal combination and sequencing of staging methods, including EUS, specialized CT scan, MR imaging, intraoperative findings, and pathologic evaluations, would improve selection of patients for potential curative resection. Interpretations of disease stage based on each of these methods may overlap but are not identical and are operator dependent. Rather than reliance on any single standard, clinical judgment and communication among the team are paramount to providing optimal care for patients with a pancreatic neoplasm.
采用当前的治疗方法，许多胰腺癌患者的生存期有望超过1年。即使是无法切除的疾病，治愈率（5年生存率）也已超过10%。对于疑似局部胰腺癌的患者，在评估早期通过内镜放置塑料支架可成功处理梗阻性黄疸，而金属壁支架则用于已知为1997年美国癌症联合委员会（AJCC）IVB期癌的患者或非手术患者。解除胆道梗阻可改善肝功能，并争取更多时间准确评估肿瘤分期以确定初始治疗方案（见图1）。一种具有成本效益的确定准确分期和治疗方案的算法可以从初始影像学检查中肿块的大小开始。与CT扫描引导下的细针穿刺抽吸活检（FNA）相比，超声内镜引导下的FNA在进行组织诊断方面有显著改进。无论FNA结果是阳性还是阴性都将被切除的小胰腺肿块，仅需进行超声内镜评估以确定早期可切除阶段。通过包括超声内镜在内的非手术成像方法可靠地分期为无法切除的肿瘤，可接受化疗，可联合或不联合同期放疗，因为在某些系列研究中这些患者的中位生存期为2年。肿瘤可在新辅助放化疗后进行切除。对于化疗放疗无效或无法治疗的慢性疼痛或胃出口梗阻，内镜引导下的腹腔神经丛神经阻滞和支架置入可改善胰腺癌患者的生活质量。需要团队协作来实现改善生活质量、延长生存期以及可能治愈胰腺癌的目标。分期方法的最佳组合和顺序，包括超声内镜、专门的CT扫描、磁共振成像、术中发现和病理评估，将改善对可能进行根治性切除的患者的选择。基于这些方法中每一种对疾病分期的解读可能会有重叠但并不相同，并且依赖于操作人员。与其依赖任何单一标准，团队之间的临床判断和沟通对于为胰腺肿瘤患者提供最佳治疗至关重要。
