Cytoreductive surgery in the treatment of ovarian cancer Comprehensive Application and prospects
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Cytoreductive surgery in the treatment of ovarian cancer Comprehensive Application and prospects
Foreign Medical Obstetrics and Gynecology volumes in 1999 Vol 26 No. 2
Tianjin Medical University General Hospital of Obstetrics and Gynecology (300,052) of the new QU (Summary) if Mi (revision)
Abstract <BR> since the 1980s, complete cytoreductive surgery to cisplatin-based combination chemotherapy for ovarian cancer as a conventional model, cytoreductive surgery is the complete impact of the prognosis of patients with one of the important factors for recurrent ovarian cancer once again cytoreductive surgery still some value , but to improve the survival rate of patients is more important to be effective after chemotherapy treatment as a necessary complement. Early ovarian cancer retroperitoneal lymph node dissection is reasonable and significance of the still controversial.
Key words: ovarian cancer cells with reduced eliminate retroperitoneal lymph node dissection
Ovarian cancer is the low rate of early diagnosis and the highest rates of a gynecologic malignancies, 70% to 80% of newly diagnosed patients with advanced clinical already. In the early 1970s, patients with advanced ovarian cancer begin cytoreductive surgery, changed the previous concept of the traditional surgery, markedly improved patient prognosis. Nearly 10 years of experience proved to be recurrent ovarian cancer again cytoreductive surgery there is still a certain value. Thorough cytoreductive surgery to cisplatin-based combination chemotherapy has become the treatment of ovarian cancer in a conventional mode, cytoreductive surgery is the complete impact of the prognosis of patients with one of the important factors.
Cytoreductive surgery progress of the application and
The so-called cytoreductive surgery refers to the original lesion and metastases, all visible lesions completely removed so that the largest residual lesion diameter <2 cm, the procedure is based on the theory: to the greatest extent reduce the tumor burden, enhance chemotherapy cytotoxicity, cell clones for resistance induced reduction Introduction resistance occurred, enhance immunity and patients.
A surgical scope and purpose
Ovarian cancer surgery is the preferred treatment indisputable, but different period, the scope and purpose of surgery can vary greatly. Early (Phase I-II α) with the range of conventional surgical hysterectomy and double Annex resection, resection of the omentum, and that should be ascites or peritoneal fluid cytology, pots and exploratory abdominal comprehensive multi-site biopsy, retroperitoneal lymph node dissection, with the aim of all the naked eye see lesions exact parallel phases. Currently in the early ovarian cancer patients is routine appendectomy in the still controversial, Bese, [1] that early ovarian cancer patients with appendectomy in without too much significance and does not affect the final stages. For advanced (b ~ II Phase IV) patients, currently there is no model to follow the norms, including pots abdominal surgery within the scope of the organ and the retroperitoneal lymph node cancer, has now gone far beyond the field of gynecologic surgery, its main purpose is to minimize residual lesions after the number and volume, more G2 phase cells into the cell cycle, improve blood supply, improve chemotherapy sensitivity.
Cytoreductive surgery involving gynecology, general surgery and urology surgery and other operations, the scope of the operation difficult, long time, blood loss and more. In recent years, with the operation of the accumulation of experience and surgical skills improve, the help of new surgical equipment to cytoreductive surgery and the success rate has greatly improve the safety of postoperative complications and mortality were lower. Eisenkop, [2] a retrospective analysis that the majority of patients with complete cytoreductive surgery is technically feasible, but individuals should follow and comprehensive consideration of the principles, if not competent physical condition of patients with prolonged surgery and anesthesia, surgery should not blindly pursue a thorough, and if considered bowel or a real visceral metastasis with cytoreductive surgery will more thoroughly, they should be resection. Ever since surgical technique and conditions of the constraints, the diaphragm surgery metastases become blind spot, as new technologies such as solidification argon, CO2 laser and Cavitron ultrasonic surgical aspirator and the succession, and some conventional cytoreductive surgery could not be involved with the site, in order to expand the scope of operations. One Cavitron ultrasonic surgical aspirator Application of the most spectacular [3,4], in the process of separation organization rich in collagen fibers may damage the organization, particularly in the superficial diaphragm 1 to 2 cm in diameter micro-resection of the lesion and give full play to its high selectivity, less bleeding, and safe advantages, but on the larger lesions involving muscle, it will be surgical excision operation should be taken to avoid pneumothorax caused by perforation. Past low rectal metastases treatment, in the resection of metastatic lesions to be permanent colostomy fistula patients to cause great mental stress and inconvenience, but the involvement of the rectum and sigmoid colon metastases after resection of rectal distal <8cm low rectal transfer rectal stapler can be used in cutting in addition to lesions of the colon rectal anastomosis without fistula, thus enhancing the quality of life of patients.
Two early peritoneal ovarian cancer patients after radical resection of lymph nodes and the need for significance
Ovarian lymphatic drainage is very complex, most of the pelvic ligaments drainage to funnel para-aortic lymph nodes, part of the natural ovarian ligament, the broad ligament upper iliac lymph nodes down. Patients with advanced retroperitoneal lymph node metastasis and prognosis for patients with recurrence and the effect of increasing attention [5,6], and whether patients in the early stages of radical lymph node dissection are different views.
Recalling the development of cancer treatment, the tumor was due to the etiology and biological understanding of the nature and extent of the impact has been considered to be local tumor lesions, and can be cured by surgical resection, the tumor was found later by the lymphatic system can be transferred to the regional lymph nodes and a relapse, then surgery the scope of the original basis of the regional lymph node resection also include, whether there had lymph node metastasis as a surgical staging, prognosis and decisions with the estimated treatment foundation. Lymph node involvement with the aim of reducing load, reduce inhibition of the production of tumor antigen [7].
With the rapid tumor immunology development, many studies confirm that the tumor-specific immune response, T cells on the molecular target MHC peptide identification is very important but not sufficient to activate T cells, it is also necessary to have one or more elements must have the co-stimulatory signal can stimulate T cells activation, in the absence of co-stimulatory signal, only part of T-cell activation and ultimately there will be inhibited. Most entities of the lack of such co-stimulation signal, and the lack of co-stimulatory signal can not be effectively activated T cells tumors evade immune attack is the important one of the mechanisms. Many scholars have different stages of tumor development of the immune status of a systematic study [8,9] showed that the tumor in regional lymph nodes in the early activation, and with tumor progression, while a specific immune tolerance. Therefore, in advanced ovarian cancer resection has no function of lymph node involvement, tumor-induced immunosuppression reduce the incidence, clinical observation has been reported in patients with stage III ovarian cancer, retroperitoneal lymph node resection, the 5-year survival rate was 53% practical, without cutting retroperitoneal lymph node in addition, the survival rate was only 13%. Visibility from the primer, retroperitoneal lymph node metastasis and prognosis in patients with close, and retroperitoneal lymph node resection patients can significantly improve the 5-year survival rate [2].
A number of clinical studies in support of early ovarian cancer should retroperitoneal lymph node dissection, because even early ovarian cancer, 10% to 20% of the retroperitoneal lymph node metastasis, and positive lymph node resection is an effective means of treatment, the five-year survival rate has increased significance accurate staging and can avoid only a rough trip will be checked for advanced ovarian cancer misdiagnosed early, and even lead to inadequate treatment. A study ascites positive cytology and bilateral ovarian and lymph node involvement were relevant [10], in patients with early ovarian cancer, especially of more than 1 c should be routine retroperitoneal lymph node detection and removal. But a negative perspective, that cancer is a complex of host - the interaction between tumor systemic disease, local treatment and the differences will not affect the survival rate of patients with lymph node metastasis only as a judgment of the best indicators of poor prognosis, and lymph node resection can improve the prognosis of patients, it would undermine the integrity of the immune system, the addition of long-term recurrence of ovarian cancer found mostly in intra-abdominal and retroperitoneal rarely appeared in, in all intra-abdominal lesions completely alone residual tumor resection and retroperitoneal lymph node lesions, the recurrence mechanism and retroperitoneal lymph node dissection significance for further in-depth study . So that right retroperitoneal lymph node involvement can not only OK biopsy as the basis for evaluation of the prognosis, and not radical lymph node dissection.
Ovarian cancer exploration of the Second
Currently, clinical follow-up of ovarian cancer and commonly used methods such as ultrasound, CT, MRI and so can not be found within the abdominal cavity pots <2 cm lesion, and the level of serum CA125 residual tumor does not reflect the changes in laparoscopic surgery because of adhesions and their impact on the basin within the abdominal part of observation, even after the peritoneal not clear, exactly offset secondary exploration of the above methods of ovarian cancer and gradually become part of comprehensive treatment. Secondary exploration should focus on understanding of abdominal and retroperitoneal residual tumor after chemotherapy whether conventional or disappear completely disappear after the recurrence or persistence of the continued development, provide for the cessation of chemotherapy on an objective basis, but can also be the focus right there again cytoreductive surgery. Right abdominal lesions were not found, in tumor metastasis and recurrence in high-incidence area such as vaginal stump broken, colon side ditch, colon and liver spleen, diaphragm, multi-site biopsy, attention should also be right pelvic and para-aortic lymph node biopsy conducted, as nearly 20% of the residual lesions in the ventral after the film, only intra-abdominal and retroperitoneal lesions were not found to be defined as complete remission. Baiocchi, [11] A retrospective study of 58 patients with complete remission, patients with normal CA125 second parallel exploration of retroperitoneal lymph node resection, lymph node metastasis was found for 25.8%, even in the original stage patients have 22.2% of lymph node metastasis, only patients in the early stage of retroperitoneal lymph node biopsy and exploration is not enough, conventional chemotherapy for lymph node metastases not sensitive to the role, in the absence of effective stop the proliferation of peritoneal lesions after treatment circumstances, in the first line systemic surgery lymph node dissection is still improve the prognosis of patients with effective methods. Recent studies after chemotherapy retroperitoneal replace intraperitoneal chemotherapy, that can enhance the effectiveness, particularly the retroperitoneal lymph node metastasis, but the long-term effect requires further observation. At the same time the study also found that, in the Second Bank of systematic exploration of lymph node dissection, and its long-term survival seems to be whether a lymph node metastasis, and peritoneal only if there were lesions exist, that is free of abdominal lesions, regardless of whether retroperitoneal lymph node metastasis, survival five years rates are the same, but significantly higher than those with large abdominal lesions are [11].
Secondary exploration of help in evaluating the prognosis of patients with ovarian cancer, and even to some extent improved the prognosis, it is reported for the second exploration of negative 40%, under 20% positive, roughly 40% positive. In three patients, with survival rates were 70%, 24%, 17%. Two of the exploration can tumor resection survival rate is better than not resection.
Patients with recurrent ovarian cancer recurrence cytoreductive surgery
Ovarian cancer recurrence and treatment resistance is the key point, again cytoreductive surgery on the prognosis of patients with recurrence of a positive significance? A view of ovarian cancer recurrence again cytoreductive surgery for the poor results, patients with poor prognosis, while another view was that again cytoreductive surgery can not only reduce the sensitivity of cancer, and resectability of the resistance, improve chemotherapy sensitivity. Again cytoreductive surgery is to increase the total of 5-year survival rate in patients with one of the important factors again after cytoreductive residual foci for micro lesions, the five-year survival rate is 51%, residual lesions <2 cm or> 2cm survival rate below 10%, the second operation will not give up easily opportunities. But that role is completely again cytoreductive surgery itself the product of the tumor or only reflects the differences in the biological behavior of their own remains to be further explored. Buller, [12] in patients with recurrent ovarian cancer treatment found that treatment after two years as a recurrence of a new tumor, right to cisplatin-based chemotherapy is very sensitive to the primary tumor and tumor recurrence p53 mutation analysis, X chromosome inactivation determination microsatellite instability testing revealed that the recurrence of advanced ovarian cancer may result from the abdominal cavity and a tumor rather than the original primary tumor re-growth. Thus, the recurrence of ovarian cancer mechanism needs further study.
Cytoreductive surgery in the treatment of ovarian cancer in the status of and prospects
Advanced ovarian cancer treatment should be individualized attention to the comprehensive treatment and the principle of complete cytoreductive surgery is the treatment of ovarian cancer foundation, years of practice that cytoreductive surgery for stage III ovarian cancer treatment sure, but right stage IV patients with cytoreductive surgery did not prolong the survival period, but Curtin and [ 13] 97 cases of stage IV ovarian cancer found in a study of 41 patients with malignant pleural effusion were 21 cases of cytoreductive surgery for a thorough, 51 cases were transferred to other sites (including 20 cases of liver metastases) in 20 patients with lesions surgery will cut the net, these operations completely in the median survival period of 40 months, stage IV patients suggested that eliminate reduction of patients can improve the prognosis. Del campo, [14] for advanced ovarian cancer by cytoreductive surgery and chemotherapy treatment after long-term follow-up observation that cytoreductive surgery for the first time the complete and patients with advanced stages is the most important prognostic factor.
Despite cytoreductive surgery in the treatment of advanced ovarian cancer at an important position, but ultimately depend on the prognosis of patients with tumors of their inherent biological characteristics, in particular tumor sensitivity to chemotherapy drugs. The application of cisplatin chemotherapy, advanced ovarian cancer survival rate is only 4 years 9%, to cisplatin-based combination chemotherapy in patients with advanced ovarian cancer because of the survival rates increased substantially. The fact that the improvement of ovarian cancer is the fundamental way to improve technical pursuit cytoreductive surgery as completely as extensive occult metastatic operation and control, and the existence of hidden metastasis and recurrence is precisely what has caused the important reasons for treatment failure. With current surgical technique and conditions again cytoreductive surgery in the past, the success rate has improved greatly, but if no effective after chemotherapy, surgery simply expand the scope for improving the prognosis of patients with limited significance. At present, except for conventional intravenous chemotherapy, there are selective regional chemotherapy, abdominal and retroperitoneal lymph chemotherapy, the effect of the increase also reduce the systemic toxicity of, and because many elevated interleukin drugs, reduce the response to chemotherapy drugs available for chemotherapy provided a guarantee for success . But there is a lack of effective second-line chemotherapy drugs, such as more research Topography Kent (TPT), II camptothecin (CPT-II), ifosfamide, although a certain effect, but still unsatisfactory, thereby seriously affecting recurrence and the treatment of patients with drug resistance.
In the integrated treatment of ovarian cancer, immune therapy is ascendant, a variety of non-specific and specific immunity of its enhanced immunity, prevent tumor growth, destruction and removal of tumor cells, reduce relapse, and enhance the effectiveness of the role and clinical application as a major auxiliary treatment . Through the support of cytokine secretion adjacent channels or through gene transduction of costimulatory molecules are promising complementary therapy. Burke, [15] on IFN-γ observed that IFN-γ induces apoptosis in ovarian cancer cells and inhibit tumor cell growth.
Summary
Currently, cytoreductive surgery in the treatment of ovarian cancer is still in an important position, the other for the foundation, improved surgical techniques, surgical method to improve the quality of life of patients has greatly improved, but the results of many years of ovarian cancer patients that the five-year survival rate still hovers at around 30% no further enhanced. This is because surgery itself is only directed against those lesions visible to the naked eye, therefore the focus is the treatment of systemic therapy combined with local treatment, in clinical practice has proven that chemotherapy and surgical treatment of increasingly equal status.
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