Онкология-

А.М.Гарин, И.С.Базин

источник RosOncoWeb.Ru

01 0203 0405 0607
ЗАКЛЮЧЕНИЕ

Рак поджелудочной железы - трагичная глава клинической онкологиипо исходам болезни.

В стандартизованных показателях заболеваемость РПЖ в России соответствуетзаболеваемости в других Европейских странах. Поражают отдаленныерезультаты . Медиана выживаемости больных по американским данным- 4,1 месяца, пять лет выживают менее 5% заболевших. Соотношениепоказателей смертности к заболеваемости по данным ВОЗ равняется0,99.

Из результатов эпидемиологических исследований наиболее важныфакты о зловещей роли курения в этиологии РПЖ, однозначны сужденияо значении диеты, в частности, повышенного потребления белкови 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. Основныесимптомы, с которыми приходят больные РПЖ к онкологу - боли мучительногохарактера, желтуха, потеря веса.

Среди методов диагностики наибольшее значение имеют ретрограднаяэндоскопическая холангиопанкреатография, компъютерная томография,ультразонография.

Среди маркеров основное значение придается уровню Са-19-9.

Единственно радикальный метод лечения хирургический. Но всеголишь 5% больных, обращающихся к онкологу, резектабильны. 46% невозможновыполнить панкреатодуоденальную резекцию из-за местной инвазиисоседних органов и лимфоузлов. 49% не производится операция из-заотдаленных метастазов.

Окончательное решение о резектабильности принимается на операционномстоле.

До выполнения радикальных операций целесообразно проведение желчеразгрузочныхопераций, если у больных есть желтуха.

Панкреатодуоденальные резекции технически очень сложны, операциидлятся более 6,5 часов. Удаленный препарат обычно состоит из общегожелчного протока, желчного пузыря, головки, шейки и секреторнойчасти поджелудочной железы, двенадцатиперстной кишки, проксимальнойчасти тощей кишки, дистальной половины желудка. Но кроме удаленияорганов хирурги выполняют также серию восстановительных манипуляций(не менее 4 анастомозов).

До настоящего времени продолжаются споры - нужны ли эти операциииз-за высокой послеоперационной летальности и плохих отдаленныхрезультатов?

В девяностых годах сократилось число послеоперационных осложненийи повысились отдаленные результаты до 16%.

Большое значение имеют паллиативные хирургические вмешательствадля контроля желтухи и при сдавлении опухолью двенадцатиперстнойкишки.

Клетки РПЖ радиочувствительны. Наружное облучение (60 gy) приводитк выживаемости к течение года около 20% больных с неректабильнымРПЖ. Медиана выживаемости составила 29 недель. Для интерстициальнойлучевой терапии применяют иод-125 и другие препараты. Средняявыживаемость при этом - 11,6 месяцев.

Используется методика интраоперационного облучения (20-25 gy),как компонент комплексного лечения. Медиана выживаемости такихбольных - 14 месяцев.

Начаты работы по неоадъювантной лучевой терапии.

Химиотерапия нерезектабильного рака в восьмидесятых годах опираласьна использование фторурацила, стрептозотоцина, митомицина , доксорубицина,эпирубицина, ифосфамида, нитрозомочевины. Эти препараты сохранилисвое значение и в наше время. Эффективность монотерапии не превышает20% , при средней выживаемости - 20 недель.

В девяностых годах для характеристики эффекта при РПЖ приняттакой параметр, как клиническое улучшение. При этом во вниманиепринималось качество жизни, снижение потребления наркотиков, ослаблениеболей, прибавка веса, улучшение статуса Карновского.

Среди препаратов, подающих особые надежды при лечении РПЖ, гемцитабин(вышел на 1-ую линию терапии) приводит к клиническому улучшениюв диапазоне 48-66% больных. Перспективны также новые ингибиторытимидилат синтетазы (Томудекс), таксаны, комптотецины.

Комбинирование химиопрепаратов имеет в качестве основной задачипродление жизни больных и улучшение ее качества. Перспективныкомбинации 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, геннойтерапии, появление новых лекарственных и иммунологических препаратовприближают к решению проблемы.

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СПИСОК СОКРАЩЕНИЙ

РПЖ - рак поджелудочной железы
TNM - классификация опухолей (Т- первичная опухоль, N -регионарныелимфоузлы, 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