Конверсионное лечение при раке желудка IV стадии: обзор факторов прогноза и критериев отбора пациентов по литературным данным
Обоснование. При диссеминированном раке желудка (РЖ) основным методом лечения является противоопухолевая лекарственная терапия. Однако прогноз при РЖ IV стадии остается неблагоприятным, в связи с чем возродился интерес к комбинации химиотерапии с хирургическим лечением. Влияние паллиативной гастрэктомии на выживаемость больных РЖ IV стадии. Роль паллиативной гастрэктомии при РЖ IV стадии оценена в ряде ретроспективных анализов, давших противоречивые результаты. Результаты исследования REGATTA показали, что паллиативная гастрэктомия с последующей химиотерапией не увеличивает выживаемости больных. В литературе продолжается дискуссия по поводу влияния паллиативной гастрэктомии на выживаемость. Влияние конверсионного лечения на выживаемость больных РЖ IV стадии. Термин «conversion therapy» – конверсионное лечение, отражает лечебную концепцию, при которой в результате эффекта противоопухолевой терапии исходно неоперабель-ный диссеминированный процесс переводится в резектабельное состояние с возможностью полного хирургического удаления опухолевых проявлений. В статье представлен тематический обзор исследований, почти все из которых ретроспективные. По данным проспективного исследования III фазы Neo-REGATTA, выживаемость больных, получивших конверсионное лечение, значимо (p<0,0001) выше, чем в группе химиотерапии. Согласно результатам мета-анализов, оптимальной стратегией лечения больных РЖ IV стадии является комбинация химиотерапии с последующим оперативным лечением. Конверсионное лечение: факторы прогноза. В результате многофакторных Cox-анализов, проведенных разными авторами, выделены следующие факторы прогноза: 1) удовлетворительный функциональный статус пациента ECOG 0-1; 2) выполнение хирургического лечения в объеме R0; 3) наличие только 1-й зоны отдаленного метастазирования; 4) химиотерапия на первом этапе лечения; 5) достижение объективного эффекта химиотерапии к моменту операции; 6) проведение перед операцией не менее 6–8 курсов химиотерапии. Критерии отбора пациентов для конверсионного лечения. С учетом гетерогенности, различной биологии и распространенности опухоли предложено разделение больных РЖ IV стадии на четыре категории: 1) пациенты c потенциально операбельным процессом без метастазов по брюшине; 2) пациенты с погранично операбельным процессом без метастазов по брюшине; 3) пациенты с макроскопически определяемой диссеминацией по брюшине, но без других отдаленных метастазов; 4) пациенты с макроскопически определяемыми метастазами по брюшине и другими отдаленными метастазами. Кандидатами на конверсионное будут пациенты 1-й и 2-й категорий, реже – 3-й и единичные больные 4-й категории. Представлены критический анализ классификации и результаты ее практического применения. Заключение. Для определения роли хирургического метода в лечении больных РЖ IV стадии необходимы рандомизированные проспективные исследования.Бесова Н.С.
Ключевые слова
рак желудка
конверсионное лечение
химиотерапия
конверсионная хирургия
олигометастатическая болезнь
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Об авторах / Для корреспонденции
Автор для связи: Наталия Сергеевна Бесова, к.м.н., ведущий науч. сотр. отделения противоопухолевой лекарственной терапии № 2 отдела лекарственного лечения, Национальный медицинский исследовательский центр онкологии им. Н.Н. Блохина, Москва, Россия; besovans@mail.ru; ORCID: http://orcid.com/0000-0002-1693-0523
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