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论晚期卵巢癌的规范治疗手段

发布日期：2024-07-02 09:46:20编辑：秩名


之所以写晚期卵巢癌的规范治疗，是因为早期或者较早期的卵巢癌，我国的治疗水平在多数医院，与国外差距不大，绝大多数医生已经掌握了早期（I期、II期）卵巢癌的治疗方法。但是，晚期卵巢癌的治疗方法，国内医院与国外医院之差距，根本不在一个数量级上。目前，能将晚期卵巢癌手术做到与国外一样好的医生团队不多。
 
卵巢癌以上皮性癌最常见。因此，这里的卵巢癌，如果没有特别说明，都是指卵巢上皮性癌。由于起源上的原因，输卵管癌和原发性腹膜癌，也具有卵巢癌的一切生物学行为，相同的诊断和治疗原则，因此，这两个癌也包括在内。如果没有说明，谈卵巢癌的诊断和治疗，实际上是指卵巢、输卵管上皮癌和原发性腹膜癌。有的还包括子宫浆液性腺癌。
 
由于卵巢癌发现时绝大多数属于晚期，目前尚缺乏早期诊断工具，因此，晚期卵巢癌的治疗，显得尤其重要。根据流行病学调查，卵巢癌曾经是美国人癌症死亡中的第五位病因，我国虽然没有大规模的流行病学调查，但有资料表明，卵巢癌导致的死亡，在我国占癌症死因的第七位，每年大约有4万多人死于卵巢癌。
 
虽然卵巢癌在绝大多数医师眼里至今还是绝症，但并非说晚期卵巢癌患者就没有生存的希望。目前，晚期卵巢癌患者在美国MD Anderson肿瘤中心等四家顶级医院，其平均生存时间早就超过了70个月，而我国绝大多数医院的平均生存时间，很少有超过2年的。全国卵巢癌的5年生存率仅37%，这还是包括了早期卵巢癌的结果。
 
什么原因导致我国卵巢癌患者的预后与国外差距如此之大？主要原因是我国第一次手术原则与国外医院具有的差别。
 
其实，卵巢癌患者的预后，最主要的影响因子就是第一次手术后残余瘤的大小。所谓残余瘤，就是指手术完毕后没有切干净或者无法切干净的肿瘤。目前公认的观点是：当残余瘤直径大于或等于2厘米时，患者的预后是很差的。差到做手术与不做手术一样。当残余瘤小于2厘米但大于1厘米时，患者的预后明显好于不做手术或者残余瘤大于2厘米的患者，但其平均生存期大概在21个月左右，也就是说，不足两年。当残余瘤小于1厘米，且接受了规则的化疗后，患者的预后会明显改善，这也是目前国际学术界界定的满意的细胞减灭术。其5年生存率大约在30-40%左右。之所以又有这么大的差距，主要是残余瘤大小并非是用尺子量出来的，而是医生凭主观感觉，用眼睛估计出来的。目前，美国有89家医院对妇科肿瘤的标准制定了标准化治疗方案，每年都要根据前一年的研究结果发表一个指南，这就是所谓的NCCN指南。
 
美国顶尖级的四大医院虽然是这个指南的牵头者和参与者，但他们自己有自己的标准：将残余瘤标准设置为“肉眼不可见”，或者小于5毫米。虽然只是几个毫米最多一个厘米的差距，但患者的5年生存率却可以达到90%以上，患者的平均生存期限达70个月，超过了我们常用的指标“5年生存率”。
 
为什么要把肿瘤的残余瘤做得这么小？因为卵巢癌切除之后，无论做的多么彻底，体内都有残留的癌细胞。这些肉眼看不见的癌细胞，只有化疗才能杀灭。但是这些化疗药物，对肿瘤的渗透作用，仅3-5毫米。因此，残余肿瘤的直径越小，被化疗药物全部浸透的几率就越大。如果小到肉眼不可见的程度，当然最后都被杀灭了。如果残余瘤大于1厘米，总有几个癌细胞无法被化疗药物渗透进去，最后成为复发的根源。如果残余瘤小于1厘米，虽然也会有癌细胞成为化疗药物的漏网之鱼，但这个过程要长得多。这个过程越长，预示患者存活的时间越久。
 
晚期卵巢癌指III期和IV期患者。III期指患者的癌细胞转移到腹腔内的一些脏器表面或者腹膜后淋巴结有了转移，而IV期患者指转移超过了盆、腹腔。在III期患者中，能把癌细胞彻底清除，做到“肉眼不可见”这个状态的，全世界没有一个医生声称可以全部做到。顶尖高手也只声称可以对91%的患者做到彻底清除。在美国，受过专门外科手术训练的妇科肿瘤医生，手术残余瘤的标准还是限定在1厘米内， 但仅仅只有46%的患者会遇到专门的妇科肿瘤医师；其余54%的患者，其手术是普通妇科医师或者妇产科医师甚至外科医师做的。这也是卵巢癌至今为什么还是导致患者死亡的重要原因。由于晚期卵巢癌的手术需要肝胆外科医师、胃肠外科医师、血管外科医师甚至胸外科医师的参与，才能达到把肿瘤彻底清除的目的，所有很多学科不全面的专科医院，就很难把卵巢癌的手术做好。限制手术医师将肿瘤彻底清除的主要原因是，如果手术医师没有一个配合良好的团队，而自己又无法单独切除膈肌、肝表面、脾曲甚至肠管上的肿瘤，使得肿瘤在这些部位残留下来，手术效果就会大打折扣。
 
由于妇科医师没有办法把肿瘤彻底切除，有人就先对患者进行化疗3个疗程后，再进行手术。这样，的确会使患者的肿瘤切除率提高，但长期的随访观察表明，这种“化疗-手术-化疗”后的患者，其平均生存期大约在22个月左右，与手术中将肿瘤的残余瘤切到大于1厘米小于2厘米差不多。因此，这个所谓的中间手术方案，正逐步被学术界放弃。实际上，只有当手术的确无法切除时，才建议先切除大部分肿瘤，化疗2-3个疗程后，再将第一次无法切除的肿瘤，重新切除。遗憾的是，这类患者的预后也不怎么好。不如第一次将肿瘤彻底切除，达到肉眼不可见然后规范化疗的患者。
 
要彻底切除晚期卵巢癌患者体内的肿瘤很难吗？答案是否定的。一个手术团队经过与外科医生合作，经过15年左右的合作，基本上都可以达到肉眼不可见的程度。我国的医院体制多数是综合性医院，与外科医师合作做好一台手术，比个体单干为主的美国医疗体制具有更多的优越性。一般花12年左右的时间，就可以达到这个程度。
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