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腹腔内化疗治疗卵巢癌

Authors
Joan L Walker, MD
Maurie Markman, MD
Section Editor
Barbara Goff, MD
Deputy Editor
Don S Dizon, MD, FACP
Translators
卢媛, 副主任医师

引言

卵巢癌播散最常见的途径是腹腔内播散。  临床前和药物代谢动力学数据支持在腹腔内直接进行化疗的益处。与静脉给药(intravenous, IV)治疗相比，腹腔内(intraperitoneal, IP)给药可使腹腔内达到的药物浓度增加至数倍。

目前有越来越多的证据显示：对于进行最佳减瘤术(至瘤体<1.0cm)的Ⅲ期上皮性卵巢癌女性患者，与静脉内给予铂类药物联合以静脉内紫杉烷为基础的化疗相比，腹腔内给予顺铂联合以紫杉烷为基础的化疗具有生存优势。 这些试验中最近的一项试验(即妇科肿瘤学组(Gynecologic Oncology Group, GOG)的172试验[1])结果的发布，使美国国立癌症研究所在2006年1月发布了一个临床警示，强烈鼓励对此亚类的患者进行腹腔内化疗[2]。对来自GOG 172试验和GOG 114试验的中与生存期有关的预后因子的一项重新评估表明：对于已经进行完全切除术，没有残留病变的Ⅲ期患者，腹腔内化疗组的中位总生存期为110个月，相比之下，静脉内给药治疗组为82.4个月[3]。GOG 172试验中腹腔内化疗组的中位生存期甚至更好，为128个月。患者的年龄和病变的组织学类型与生存期有关。有阳性淋巴结并被切除的患者，可从腹腔内化疗中获益。存在未被评估的腹膜后淋巴结的患者生存期最差，但也可获益于腹腔内化疗。妇科肿瘤学会已经将是否提供腹腔内化疗的选择以及是否进行该治疗，作为卵巢癌治疗的一个质量指标。许多肿瘤科医生不愿给予腹腔内化疗。然而，虽然使用腹腔内化疗越来越获得认可，但并未普遍使用，主要是因为该方法具有更大的毒性。支持腹腔内化疗作为静脉内化疗的一种替代方案的数据，以及关于使用腹腔内化疗的争议，将在别处讨论。  (参见“First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer”, section on ‘Women with optimally cytoreduced disease’)

接受卵巢癌腹腔内化疗的女性患者的管理，包括与放置腹腔内导管有关的问题，将总结在此。晚期卵巢癌的手术治疗和初始化疗将单独讨论。 (参见“上皮性卵巢癌：初始手术治疗”和“First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer”)

基本原理

上皮性卵巢癌是卵巢表面上皮的一种疾病。对于绝大多数患者，该病在初始诊断和复发时局限于腹腔[4]。由于该病的病史存在上述性质，卵巢癌是腹腔内(IP)化疗的一个理想靶点。随后的多项研究显示：腹腔内给予化疗，可使腹腔内药物峰浓度与血浆药物峰浓度的比值较高，这些药物包括顺铂、卡铂、紫杉醇和多西他赛[5]。在这些药物中，顺铂的研究最广泛，临床研究已经证实其在卵巢癌一线治疗中的活性。 (参见“First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer”, section on ‘Women with optimally cytoreduced disease’)

初始手术减瘤的重要性

虽然腹腔内化疗具有区域性优势，但其向肿瘤组织内的渗透仅限于腹膜表层上肿瘤的几毫米，因此，此类方法最适用于经外科减瘤术后，残余病变极小的患者。从腹腔内化疗中得到生存获益的一个重要障碍是：进行完全减瘤性手术达到没有残留病变的女性患者的比例存在很大差异。例如，针对6685例在使用铂类药物的时代进行治疗的女性的一项meta分析显示，只有42%的病例进行了最佳的手术切除[6]。 虽然由受过培训的妇科肿瘤医生进行手术时，达到最佳减瘤效果的比例明显更高(大于等于75%)，但治疗模式研究表明，仅约50%进行卵巢癌治疗的患者是由妇科肿瘤医生治疗的[7,8]。 (参见“上皮性卵巢癌：初始手术治疗”，关于‘减瘤操作’一节)

                     

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Literature review current through: 2017-06 . | This topic last updated: 2016-03-03.
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