Онкология-
РАК ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ
(значение проблемы, возможности лечения)
А.М.Гарин, И.С.Базин
источник RosOncoWeb.Ru
01 02 03 04 05 06 07ЗАКЛЮЧЕНИЕ
Рак поджелудочной железы - трагичная глава клинической онкологии по исходам болезни.
В стандартизованных показателях заболеваемость РПЖ в России соответствует заболеваемости в других Европейских странах. Поражают отдаленные результаты . Медиана выживаемости больных по американским данным - 4,1 месяца, пять лет выживают менее 5% заболевших. Соотношение показателей смертности к заболеваемости по данным ВОЗ равняется 0,99.
Из результатов эпидемиологических исследований наиболее важны факты о зловещей роли курения в этиологии РПЖ, однозначны суждения о значении диеты, в частности, повышенного потребления белков и мяса.
Среди химических агентов наибольшую ответственность несут нитрозоамины.
Предрасполагающими к РПЖ болезнями и состояниями считаются диабет, хронический панкреатит, операции на желудке.
К генетическим аномалиям при РПЖ относят мутации генов р53, К-ras, DCC.
Самой частой формой РПЖ является протоковая аденокарцинома.
Ранние симптомы РПЖ не специфичны и не выразительны. Основные симптомы, с которыми приходят больные РПЖ к онкологу - боли мучительного характера, желтуха, потеря веса.
Среди методов диагностики наибольшее значение имеют ретроградная эндоскопическая холангиопанкреатография, компъютерная томография, ультразонография.
Среди маркеров основное значение придается уровню Са-19-9.
Единственно радикальный метод лечения хирургический. Но всего лишь 5% больных, обращающихся к онкологу, резектабильны. 46% невозможно выполнить панкреатодуоденальную резекцию из-за местной инвазии соседних органов и лимфоузлов. 49% не производится операция из-за отдаленных метастазов.
Окончательное решение о резектабильности принимается на операционном столе.
До выполнения радикальных операций целесообразно проведение желчеразгрузочных операций, если у больных есть желтуха.
Панкреатодуоденальные резекции технически очень сложны, операции длятся более 6,5 часов. Удаленный препарат обычно состоит из общего желчного протока, желчного пузыря, головки, шейки и секреторной части поджелудочной железы, двенадцатиперстной кишки, проксимальной части тощей кишки, дистальной половины желудка. Но кроме удаления органов хирурги выполняют также серию восстановительных манипуляций (не менее 4 анастомозов).
До настоящего времени продолжаются споры - нужны ли эти операции из-за высокой послеоперационной летальности и плохих отдаленных результатов?
В девяностых годах сократилось число послеоперационных осложнений и повысились отдаленные результаты до 16%.
Большое значение имеют паллиативные хирургические вмешательства для контроля желтухи и при сдавлении опухолью двенадцатиперстной кишки.
Клетки РПЖ радиочувствительны. Наружное облучение (60 gy) приводит к выживаемости к течение года около 20% больных с неректабильным РПЖ. Медиана выживаемости составила 29 недель. Для интерстициальной лучевой терапии применяют иод-125 и другие препараты. Средняя выживаемость при этом - 11,6 месяцев.
Используется методика интраоперационного облучения (20-25 gy), как компонент комплексного лечения. Медиана выживаемости таких больных - 14 месяцев.
Начаты работы по неоадъювантной лучевой терапии.
Химиотерапия нерезектабильного рака в восьмидесятых годах опиралась на использование фторурацила, стрептозотоцина, митомицина , доксорубицина, эпирубицина, ифосфамида, нитрозомочевины. Эти препараты сохранили свое значение и в наше время. Эффективность монотерапии не превышает 20% , при средней выживаемости - 20 недель.
В девяностых годах для характеристики эффекта при РПЖ принят такой параметр, как клиническое улучшение. При этом во внимание принималось качество жизни, снижение потребления наркотиков, ослабление болей, прибавка веса, улучшение статуса Карновского.
Среди препаратов, подающих особые надежды при лечении РПЖ, гемцитабин (вышел на 1-ую линию терапии) приводит к клиническому улучшению в диапазоне 48-66% больных. Перспективны также новые ингибиторы тимидилат синтетазы (Томудекс), таксаны, комптотецины.
Комбинирование химиопрепаратов имеет в качестве основной задачи продление жизни больных и улучшение ее качества. Перспективны комбинации с включением фторурацила, гемзара, митомицина С и цисплатина.
Доказана целесообразность адъювантной терапии РПЖ (облучение + фторурацил, или фторурациловые комбинации).
Интенсивно разрабатываются неоадъювантные режимы химиотерапии (перед операциями или облучением).
Вызов, о котором мы писали в начале книги, принят онкологами. Интенсивное развитие молекулярно-биологических подходов, генной терапии, появление новых лекарственных и иммунологических препаратов приближают к решению проблемы.
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СПИСОК СОКРАЩЕНИЙРПЖ - рак поджелудочной железы
TNM - классификация опухолей (Т- первичная опухоль, N -регионарные
лимфоузлы, М- отдаленные метастазы)
Са-19-9 - маркер
КТ - компьютерная томография
gy- грей
СЕА - маркер
FU - фторафур
ММС - митомицин С
Szt- стрептозотоцин
ADM - доксорубицин
EPI- эпирубицин
IFO- ифосфамид
Том - томудекс
DPD- фермент дигидропиримидин деидрогеназа
CPt-11- КАМПТО
Тах- паклитаксол
Тхt- доцетаксел
Gem- гемзар