邢宝才教授:局部联合全身系统性治疗是肝癌治疗的大势所趋

2019-05-29 佚名 肿瘤资讯

过去,原发性肝癌的主要治疗手段为外科手术。随着靶向治疗、免疫治疗药物的问世,肝癌的治疗策略逐渐从单一局部治疗向联合系统治疗转变。

过去,原发性肝癌的主要治疗手段为外科手术。随着靶向治疗、免疫治疗药物的问世,肝癌的治疗策略逐渐从单一局部治疗向联合系统治疗转变。

最新研究进展:肝切除术可让部分BCLC-B期肝癌患者获益

在我国,原发性肝癌是一类较为常见的恶性肿瘤,发病率和死亡率均较高,整体疗效及预后不太理想。原发性肝癌的治疗目前以外科手术为主,但能进行手术切除的患者毕竟有限,一般国际上公认的、在初次诊断时能手术切除的患者只有15%~20%。而对于能手术的患者也仍然存在很高的术后复发风险。另外约80%的患者在初次诊断时即为不可切除肝癌,如何改善这类患者的治疗效果、延长其生存时间,是很重要的临床问题。

作为肝胆外科医生,我们应该更多地思考,对于过去我们认为不可切除的肝癌患者,是否能通过术前、术后的围手术期治疗增加手术机会,甚至延长患者的无病生存或总生存?目前,国内外专家都在开展相关的研究。过去,肝切除术是BCLC-A期患者的首选治疗选择,而TACE治疗为BCLC-B期患者的治疗推荐;近年来,也有一些研究观点认为TACE联合分子靶向治疗能显着延长BCLC-B期患者的生存。另外,今年1月,我们北京大学肿瘤医院联合北京协和医院及广西医科大学附属肿瘤医院开展的一项多中心、回顾性临床研究发表于《肠肝病学杂志》(Alimentary Pharmacology & Therapeutics)(影响因子:7.357)上,同时,杂志还邀请了英国爱丁堡皇家医院学者Stutchfield和Powell教授对本研究做专家评述。本研究对早中期肝癌的分期进行了优化,进一步证实了肝切除术在一些过去被认为不能手术的BCLC-B期患者中的治疗价值。

肝癌治疗策略:从单一局部治疗向联合系统治疗转变

作为肿瘤外科医生,结合这些年的临床体会,我认为绝大部分肿瘤是系统性疾病,采用全身系统性治疗联合局部治疗会取得比较好的疗效。20世纪70年代以前,手术切除一直是肝癌最主要的治疗手段; 1979年介入治疗被引入肝癌的治疗中,不能切除的患者采用介入治疗获得了较好的疗效; 90年代末,消融治疗又被引入肝癌治疗中,使一部分患者取得很好的获益。但是手术、介入和消融技术均属于局部治疗的范畴,直到2008年索拉非尼的出现,肝癌的治疗才迎来了真正意义上的系统治疗药物。索拉非尼的问世确实是肝癌治疗的一大里程碑,但是其应用也存在很大的局限性,主要体现在其总有效率(ORR)只有3%,患者的无病生存期(PFS)也很短,远远不能满足肝癌治疗的临床需求。2018年,仑伐替尼的上市让肝癌全身系统性治疗又登上了一个新的台阶,其ORR和PFS均有显着的提高。另外,仑伐替尼与免疫治疗PD-1/PD-L1抗体的联合应用也取得了令人鼓舞的初步结果,ORR能达到30%~40%。

因此,我们临床医生在肝癌治疗的全程管理上要重新思考如何制订整体的治疗策略,不仅从过去单纯的局部治疗引入全身系统性治疗,而且要考虑应用时机和药物选择。目前,晚期不可切除肝癌的治疗药物主要分为三大类,包括分子靶向治疗、免疫治疗和抗血管生成治疗。未来的研究方向可以考虑把三者联用,当然治疗费用、患者身体耐受程度都是需要探索和考虑的问题。而两种手段的结合可能更具可行性,例如免疫治疗联合抗血管生成药物或靶向药物(如仑伐替尼),这样的联合是否能取得更优疗效的同时不增加毒副反应?这是值得期待的探索方向。目前,仑伐替尼联合免疫治疗已得到初步的疗效结果,相信随着研究的深入,联合治疗的疗效将得到进一步肯定。

肝癌全程管理:局部联合全身系统性治疗双管齐下

目前,从治疗层面来看,原发性肝癌分为两大类,一类为可局部治疗的患者,一类为诊断时无局部治疗机会的患者。对于可局部治疗的肝癌,患者通过手术、消融等能获得显着的生存延长,但术后复发风险仍然很高,而术前的新辅助治疗和术后的辅助治疗能发挥很大的作用,一定程度上能降低术后复发率。对于无局部治疗机会的患者,其一线治疗选择应该推荐免疫治疗联合抗血管生成治疗(如仑伐替尼),这种联合治疗能让患者生存得到更好的延长,同时其有效率也更高,而治疗有效的患者,后续或许还能争取到手术的机会,进一步提高其生存获益。因此,对于不可切除的肝癌,应以全身系统性治疗为主,以创造后续的局部治疗机会。

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    2019-05-31 chg122
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    2019-05-29 留走人康

    肝癌,接下来就要细分了,对于体质好的病人,能否将PD-1类+抗血管新生+放疗等相结合,甚至有必要用TACE进行减负

    0

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