局部晚期胃食管癌怎么治疗？

　　在 “上消化道肿瘤疑难病例的管理” 这个模块， Catenacci博士和两位放射科和外科肿瘤医生一起探讨一个病例。专家们对 “局部晚期胃食管癌合并有主动脉瓣狭窄”的病例进行交流，提出了自己的意见，探讨如何多学科地治疗该患者，但没有达成共识。Catenacci博士指出，即使该患者没有主动脉瓣狭窄的合并症，在治疗方法上也缺乏国际共识。这是由该疾病的性质和解决方法多样性造成的。既然没有共识，所以用临床试验来证明哪种方法更好是关键。该模块还有一个问答环节，三位医生征询了台下观众的意见。

　　不同的国家有不同的治疗方法。例如，在亚洲一般是先手术，再进行后续治疗；美国和欧洲更倾向先行新辅助治疗。是手术前还是手术后行新辅助化疗/放化疗，西方世界分为两个阵营，这两个做法都不算错，都有Ⅲ期临床试验数据来支持，但这些试验仅仅是把两种方案与单纯手术治疗做对照。目前已有国际性临床试验比较这两种方案孰优孰劣，但试验结果还要等好几年，在此之前争论还会继续。

　　改善上消化道癌症治疗预后的关键所在？

　　要改善癌症治疗效果，提高诊断分期的准确性更加重要。诊断患者除了需要CT、PET、超声内镜等检测手段，有些患者还需要腹腔镜诊断。可对一部分胃癌/胃食管连接部癌做腹腔镜检查（Ⅱ期以上淋巴结受累患者）。超过30%胃癌隐匿转移用PET或CT扫描检测不到，但是用腹腔镜可检查到，可行根治性手术治疗。胃食管连接部癌/食管癌也会出现10%的隐匿腹膜转移，印戒细胞癌或高级别癌症更会如此。所以，要提高上消化道癌症的预后，首先是分期准确，然后是分子分型准确。目前的试验设计已经这样做了，这也是Catenacci博士的研究重点之一。

　　上消化道癌症多学科综合管理？

　　多学科综合管理第一步是肿瘤分期，需要放射科、消化科、肿瘤内科和外科医生以及腹腔镜外科介入。肿瘤多学科治疗涉及化疗、手术和/或放疗等综合治疗。在多学科会议上多个领域的专家一起讨论同一个病例，把各个因素（包括并发症）考虑在内以提出最佳治疗方案，这种形式的讨论值得提倡。 医生们对治疗方案可能没有达成共识 ，但是如果把并发症考虑在内，可能某位医生能为患者提供合适的治疗方案。

访谈原文

　　Oncology Frontier:  “Management of Challenging Cases of Upper Gastrointestinal Cancers” was a feature talk here at the meeting. Can you give us a brief introduction to what it was you were discussing in that talk?

　　《肿瘤瞭望》：“上消化道肿瘤疑难病例的管理”本次会议一个特殊部分，您能否简单介绍一下您的讲题吗？

　　Dr Catenacci: That session was a panel of clinical experts including a medical oncologist (me)， a radiation oncologist and a surgical oncologist discussing a couple of cases. One was a locally advanced gastro-esophageal cancer that had some comorbidities of aortic stenosis amongst others and we were talking through the case and how we would best manage that patient from the perspective of each of those multidisciplinary fields. In the background of that， even without the comorbidity of aortic stenosis， there is a lack of consensus in the field internationally in terms of how to approach these patients. So we discussed that and provided our own opinions and there was a lack of consensus even on our panel， just due to the nature of the disease and the number of options there are to approaching it. I provided my opinions and why I would do what I would do. There was also a Q&A with the audience and we were able to poll everyone in the room to see how they felt. You could see from the response that there was a lack of consensus. As an international meeting， that highlights how the ongoing trials will be pivotal in how we answer these questions and which of the approaches is better.

　　Catenacci博士：这个部分是一个临床医生小组讨论几个患者案例，其中包括肿瘤内科医生（我）、肿瘤放射科医生和外科肿瘤医生。案例中的患者是局部晚期胃食管癌合并有主动脉瓣狭窄的等合并症，我们几个人围绕这个案例进行了交流，探讨如何多学科管理患者。而且这种情况下，即使没有主动脉瓣狭窄的合并症，如何处理这类患者也缺乏国际共识。我们一起讨论，并提供了自己的意见，但我们小组也没有达成共识。这是由该疾病的性质和解决方法多样造成的。既然没有共识，以临床试验证明哪种方法更好是关键。还有一个问答环节，我们征询了台下观众对这个的病例想法。

　　Oncology Frontier:  Does that lack of consensus cross international borders or is it about those who believe in this trial or that trial?

　　《肿瘤瞭望》：是缺乏国际共识还是相关试验研究结果不同造成的？

　　Dr Catenacci: A bit of both. There are different approaches in different countries. Basically， for a perioperative setting， you can do surgery first and then deal with the consequences after in terms of adjuvant therapy， whether that be chemotherapy or chemo-radiation therapy and what chemotherapy regimens， as opposed to doing something preoperatively (neoadjuvantly) or pre- and post. Some of those strategies have just been adopted geographically. For example， in Asia they do surgery first and then deal with it after. Here in the US and in Europe， we prefer a neoadjuvant approach. In terms of neoadjuvant chemo-RT or chemo before and after surgery， which is where there is the real lack of consensus， these are the most common ones in the Western world and basically there are two camps， even inter-institutionally between different physicians. Depending on which physician you may see， you may be following a different route. That is because neither option is considered wrong (they both have phase III clinical trial data to support them) but they were compared to just surgery alone so which one of the two is optimal is open to debate. There are international trials currently investigating this question but they won’t be available for a few years yet. In the meantime， this debate will continue.

　　Catenacci博士：二者皆有。不同的国家有不同的治疗方法。例如，在亚洲一般是先手术，再进行后续治疗；美国和欧洲更倾向先行新辅助治疗。是手术前还是手术后行新辅助化疗/放化疗，西方世界分为两个阵营，这两个做法都不算错，都有Ⅲ期临床试验数据来支持，但这些试验仅仅是把两种方案与单纯手术治疗做对照。目前已有国际性临床试验比较这两种方案孰优孰劣，但试验结果还要等好几年，在此之前争论还会继续。