Gómez Portilla A, Cendoya I, Olabarría I, Martínez de Lecea C, Gómez Martínez de Lecea C, Gil A, Martín E, Muriel J, Magrach L, Romero E, Lirola A, Guede N, Moraza N, Fernández E, Kvadatze M, Valdovinos M, Larrabide I, Ruiz de Alegría N, Fernández J L, Castillo C, Rua O, Ulibarrena M A
Department of Surgery, Hospital San José, Vitoria, Spain.
Rev Esp Enferm Dig. 2009 Feb;101(2):97-102, 103-6. doi: 10.4321/s1130-01082009000200003.
In 1981, Dr. PH Sugarbaker, challenging oncological orthodoxy, considered carcinomatosis to be a locoregional stage of the disease that was still susceptible to treatment with curative intent. To this end he developed a new therapeutic alternative based on the combined treatment. The macroscopic disease treated by maximum radical oncological cytoreductive surgery (through the peritonectomies described by him), followed by treatment of the residual microscopic disease with the direct intra-abdominal application of intraoperative chemotherapy with locoregional intensification, modulated by hyperthermia and early normothermic postoperative intra-abdominal chemotherapy. Using this new therapeutic regimen, known as "Sugarbaker s Protocol", his group has reported 45% survival rates in carcinomatosis of colorectal origin at 5 years, and, in selected groups of patients, 50% survival rates at 5 years. The scientific community, however, has criticized these results considering that: it is a personal experience, with a not homogenous treatment protocol with developmental modifications over time, that it is a retrospective non-randomized study, and finally that the cytostatics used in his protocol are obsolete. Various European groups have replied to these main criticisms confirming the good results that this new therapeutic alternative offers for patients with carcinomatosis of colorectal origin. The purpose of this article is to present these contributions.
All the articles published in the English language by European groups in the world s medical literature have been reviewed using the Pubmed-MEDLINE database to identify the relevant articles related to the treatment of carcinomatosis of colorectal origin using cytoreduction and intraperitoneal chemotherapy from January 1980 to January 2008.
The European contribution during these 25 years in favour of the "Sugarbaker s Protocol" has consisted fundamentally in: a) one multicenter retrospective study; b) two randomized prospective phase III studies; and c) the use of oxaliplatin and irinotecan as new cytostatic agents in the protocols for intraperitoneal chemotherapy. At the same time, two new transcendental European contributions have been made in which the possibility has been considered of combined simultaneous treatment for patients with hepatic metastases and carcinomatosis, and the introduction, as a selection factor, of patients responsive to intravenous induction chemotherapy within the regimen of sandwich treatment (with systemic neoadjuvant and adjuvant chemotherapy) complementary to intraperitoneal chemotherapy.
The results obtained by European groups using "Sugarbaker s protocol" and "Elias protocol" with oxaliplatin compel us to request that these treatments be considered by all professionals involved in the treatment of patients with colorectal carcinomatosis as the best treatment currently available for this condition. Furthermore a randomized, prospective, multicenter study should be carried out to clarify its value and the degree of scientific evidence. A validation of this treatment will change, in the future, the dogmatic consideration of carcinomatosis as an incurable disease stage.
1981年，PH·休格贝克博士挑战肿瘤学正统观念，认为癌性腹膜炎是该疾病的局部区域阶段，仍可进行根治性治疗。为此，他基于联合治疗开发了一种新的治疗方案。通过最大程度的根治性肿瘤细胞减灭术（通过他所描述的腹膜切除术）治疗肉眼可见的疾病，随后通过术中腹腔内直接应用化疗并结合局部强化治疗残留的微小疾病，通过热疗和术后早期常温腹腔内化疗进行调节。使用这种被称为“休格贝克方案”的新治疗方案，他的团队报告了结直肠癌源性癌性腹膜炎患者5年生存率为45%，在特定患者群体中，5年生存率为50%。然而，科学界批评这些结果，认为：这是个人经验，治疗方案不统一且随时间不断改进，这是一项回顾性非随机研究，最后他的方案中使用的细胞毒性药物已过时。多个欧洲团队回应了这些主要批评，证实了这种新治疗方案为结直肠癌源性癌性腹膜炎患者带来的良好效果。本文的目的是介绍这些贡献。
使用Pubmed-MEDLINE数据库对欧洲团队在世界医学文献中发表的所有英文文章进行了综述，以确定1980年1月至2008年1月期间与使用细胞减灭术和腹腔内化疗治疗结直肠癌源性癌性腹膜炎相关的文章。
这25年间欧洲对“休格贝克方案”的贡献主要包括：a）一项多中心回顾性研究；b）两项随机前瞻性III期研究；c）在腹腔内化疗方案中使用奥沙利铂和伊立替康作为新的细胞毒性药物。同时，欧洲还做出了两项新的重大贡献，其中考虑了对肝转移和癌性腹膜炎患者进行联合同步治疗的可能性，并引入了对静脉诱导化疗有反应的患者作为夹心治疗（包括全身新辅助化疗和辅助化疗）方案中的选择因素，该方案与腹腔内化疗互补。
欧洲团队使用“休格贝克方案”和含奥沙利铂的“埃利亚斯方案”所取得的结果促使我们要求所有参与结直肠癌性腹膜炎患者治疗的专业人员将这些治疗视为目前针对这种情况的最佳治疗方法。此外，应开展一项随机、前瞻性、多中心研究以阐明其价值和科学证据程度。这种治疗方法的验证将在未来改变将癌性腹膜炎视为不可治愈疾病阶段的教条观念。
