肠癌治疗方案的一般程序和依据

专业肿瘤医院制定肠癌治疗方案的一般程序和依据

1. 专业肿瘤医院诊治肠癌一般通过下列的手段进行确诊和做术前核磁tnm分期

肠癌一般通过肠镜确定肠内肿瘤大小和形状、通过取样活检确诊肿瘤性质,通过加强ct扫描或核磁扫描确定位置、肠壁浸润程度和肠外周边的直接侵犯情况,通过周边淋巴结的大小判断周边肿瘤通过淋巴系统的侵犯转移情况,抽血化验检查患者的肿瘤标志物,肠癌肿瘤一般会检查常规的五项肿瘤标志物,它属于血液化验检查的一种。包括AFP甲胎蛋白,CEA癌胚抗原,CA199糖类抗原,CA125糖类抗原,CA724糖类抗原,有些医院会加检查其它的肿瘤标志物,不过经验上参考意义不大,主要还是检查cea癌胚抗原指标是否超标,如;一般AFP甲胎蛋白与CEA癌胚抗原同时超标,医生会怀疑肝脏转移或肝癌,而结合影像检查肝脏有强化结节,肠癌也已经出肠侵犯周边组织和合并淋巴结肿大;医生就基本确诊肠癌合并肝转转移了。而CEA合并CA199糖类抗原超标,结合影像检查肠壁增厚,一般就可以初步确诊肠癌了,当然正式确诊肠癌需要肠镜对肿瘤取样做活检才可以正式确诊是哪种性质的肠癌。

而医生通过肠镜取样做组织病理检查确诊肠道肿瘤后,还需要做影像学配合做综合评估和判断。医生也会检查血常规和生化指标,以摸清患者的身体素质作为后续治疗方式选择的参考依据。这类常规的检查若怀疑患者有其它的器官转移时,还会做派特ct对患者进行全身扫描,怀疑骨转移还会对患者进行骨扫描。

 2. 根据六年的群经验观察全国各省肿瘤医院以上专业医院对各期肠癌诊治方式归纳分类

我通过自己的诊疗过程的经验,和术后的恶补学习,在肠癌群里根据自己的学习和理解给群友解释医生做各种检查的目的、和各种检查报告表述的意义,以及给群友科普tnm分期知识的过程中,慢慢了解到全国各省肿瘤医院以上的专业医院,大概是按照下列的几种患者类型进行分类和做初步的诊疗方案的,并在6年的群解答过程中对大部分专业医院的诊疗流程与规律进行跟踪,群友也不断的反馈医生制定这种诊疗程序的医学依据,和患者适合这种治疗疗程的患者病情和患者身体素质的影响因素,从而在建群2-3年后就基本看群友发上来的检查报告之后,大体可以预测出这些专业医院会用什么诊疗程序,并在后续的跟踪、反馈中得到八九不离十的证实。现把省肿瘤医院以上专业肿瘤医院大概的几种诊疗分类罗列如下,供患者和家属参考。

3.  肠镜、影像、肿标检查,术前tnm分期属于早中期肠癌的一般治疗方式

术前检查肿瘤标志物癌胚抗原正常、影像肝肺没有怀疑病灶、肠壁只侵犯粘膜层或浅肌层、肿瘤相对比较小,肿瘤肠段肠外脂肪间隙清晰,浆膜层没有任何被侵犯的迹象,周边见淋巴结影,并没有数量可观的淋巴结肿大,肿瘤处于肛门6公分以上的肠癌患者,专业医院医生一般会判断患者属于早中期,这类患者不需要做术前新辅助治疗就可以手术,术后再根据术后病理tnm分期,并根据术后病理做出适合患者病情的放化疗辅助治疗,治疗顺利基本就可以大概率的治愈。这类早中期的患者通常不需要做足8个三周期化疗或者12次两周期奥沙利铂+卡倍他滨片化疗;通常根据术后病理的风险高危因素的多寡,结合患者的身体耐受情况,做出口服8期的卡倍他滨片化疗方案;或4期奥沙利铂+卡倍他滨片化疗方案,或者6期奥沙利铂+卡倍他滨片化疗方案治疗。这类患者一般术后病理处于2期左右。

还有少数侵犯粘膜层的刚刚癌变的腺瘤通过肠镜把腺瘤、或刚刚癌变的腺癌与粘膜层分离,用肠镜切除的病例,而这类比较早期的腺癌却经常因为没有果断的做直肠癌根治术,而导致2-4年之后复发的案例不在少数,这里不做单独一节介绍。这类极少数病例的诊疗方式讨论,及患者家属的注意事项,会放在网站每周一个病例讨论栏目进行讨论。

  4. 肠镜、影像、肿标检查,术前tnm分期属于中期肠癌的一般治疗方式

术前检查肿瘤标志物癌胚抗原正常、或轻微超标,影像肝肺没有怀疑病灶、肠壁只侵犯深肌层、肿瘤相对比较大,肿瘤肠段肠外脂肪间隙模糊,浆膜层有毛躁或褶皱被侵犯的迹象,肠壁浸润程度约1cm左右,周边见数个淋巴结影,肿瘤处于肛门6公分以上的肠癌患者,专业医院医生一般会判断患者属于中期,这类患者一般不需要做术前新辅助治疗就可以手术,术后再根据术后病理做tnm分期,并根据术后病理报告病情做出适合患者病情的化疗辅助治疗,能够顺利完成适当的化疗疗程就大概率能够治愈。这类中期的患者,专业医院医生通常会根据淋巴结转移数量,肿瘤侵犯肠壁深度和周边侵犯程度,去综合判断患者应该做哪种强度的化疗疗程,一般肉眼看见侵犯肠壁深肌层,到达浆膜层附近,有脉管癌栓、或者有神经侵犯、或者有1-2个淋巴结转移的,专业医院的肿瘤内科医生都会做6-8个三周期化疗或者9-12次两周期奥沙利铂+卡倍他滨片化疗;人老体弱的患者医生通常根据术后病理的风险高危因素的多寡,结合患者的身体耐受情况做出平衡,做出口服8次的卡倍他滨片化疗方案或4期奥沙利铂+8期卡倍他滨片化疗方案,或者6期奥沙利铂+卡倍他滨片化疗方案治疗。这类患者一般术后病理分期会在2-3a期之间。

 5. 肠镜、影像、肿标检查,术前tnm分期属于中期、低位直肠癌的一般治疗方式。(这类患者最好到省肿瘤医院以上专业肿瘤医院诊治)

术前检查肿瘤标志物癌胚抗原正常、或轻微超标,肿瘤相对比较大,肿瘤占肠腔一般二分之一至四分之三之间,影像肝肺没有怀疑病灶、肠壁只侵犯深肌层、肿瘤肠段肠外脂肪间隙模糊,浆膜层有毛躁或褶皱被侵犯的迹象,肠壁浸润达1cm左右,周边见数个小淋巴结,肿瘤处于肛门5-8公分左右的肠癌患者,专业医院医生一般会判断患者属于中期低位直肠癌;这类患者一般要做术前新辅助治疗后才能手术,这类肠外侵犯情况复杂,肿瘤下缘低于距离肛门5公分的患者,要慎重做出保肛手术的决定。手术一定要让经验丰富的省肿瘤医院以上的外科专家手术才行。低位保肛要考虑的因素众多,情况复杂,详见讨论低位保肛章节的讨论与分享。

这类患者一般把放疗疗程做完和先做2-4期奥沙利铂+卡倍他滨片化疗,术后再根据术后病理做tnm分期,并根据术后病理报告病情做出适合患者病情的后续治疗,做完除了术前新辅助治疗已经做了的2-4个化疗疗程之外,需要做完的全部化疗疗程;这类低位直肠癌,因为肿瘤出肠就会侵犯,或者不出肠通过淋巴管侵犯盆腔两壁、或者周边相对难以切除干净的淋巴结和脂肪,需要专家级的医生做手术;专业肿瘤医院的肿瘤内科医生一般都会术前做24次左右的放疗,以清除可能的周边侵犯和转移病灶癌细胞,而化疗疗程通常术前加术后会做足8个三周期化疗疗程或者12次两周期奥沙利铂+卡倍他滨片化疗;人老体弱的患者医生通常根据术后病理的风险高危因素的多寡,结合患者的身体耐受情况做出平衡,8次卡倍他滨口服化疗,或4个奥沙利铂+8个卡倍他滨片化疗方案,或者6个奥沙利铂+8个卡倍他滨片化疗方案治疗。这类患者一般术后病理分期会在2-3a期之间。

6. 肠镜、影像、肿标检查,术前tnm分期属于中晚期肠癌的一般治疗方式。

(这类患者一定要去省肿瘤医院以上专业水平的肿瘤医院诊治)

术前检查肿瘤标志物癌胚抗原正常、或有较大的超标,影像肝肺有大于5mm的单发实性或不均匀轻度强化怀疑病灶、肿瘤侵犯肠壁全层、肿瘤环腔生长,肿瘤肠段肠外脂肪间隙模糊,肠壁浸润1.5cm左右;或有与周边器官分界不清的表述,浆膜层有毛躁或褶皱被侵犯的迹象,周边见数个淋巴结直径大于1公分,肿瘤处于肛门6公分以上的肠癌患者,专业医院医生一般会判断患者属于t4n1-2mX的中晚期,这类患者一般要做术前新辅助化疗,直至切缘阴性,观察化疗之后肝肺的怀疑强化病灶是否变大或变小去判断肝肺的单发或多发怀疑转移病灶是否确诊或排除,如2-4次化疗肝肺的轻度怀疑结节没有变化,或其它的检查远端转移排除,或者确诊寡转移,患者得到手术机会,专业医院的医生一般会做多学科会诊、以在术中确诊或术前确诊寡转移,有除了肠道之外还有肝肺或者其它的器官病灶时,在术前做多学科会诊和做多学科联合手术,以让患者一次过做完切除所有器官上的病灶手术。

术后再根据术后病理做tnm分期,并根据术后病理报告病情做出适合患者病情的化疗辅助治疗,专业医院的医生通常会根据淋巴结转移数量,肿瘤侵犯肠壁深度和周边侵犯程度,去综合判断患者应该做哪种强度的化疗疗程,一般肉眼看见侵犯肠壁深肌层,到达浆膜层附近,有脉管癌栓、或者有神经侵犯、或者有3个淋巴结转移或肠周脂肪里有癌结节,这类患者专业医院的肿瘤内科医生都会做足8个三周期化疗或者选用总药量比较大的12次两周期奥沙利铂+卡倍他滨片化疗;4个淋巴结以上转移的患者,化疗完成之后一般还会要求患者再口服卡倍他滨片3-6个月,有远端转移的患者加靶向药治疗至8个疗程;之后卡倍他滨联合靶向药继续治疗控制,这类患者一般的术后病理会是比较严重3b-3c期,而少数确诊肝肺寡转移或多发转移的患者就是晚期的4期!

7. 肠镜、影像、肿标检查,术前tnm分期属于中晚期低位肠癌的一般治疗方式

这类患者要去省肿瘤医院以上专业医院治疗,还要尊重医生的专业意见果断的切除肛门做永久造口,不科学的强烈保肛意愿,通常是以生命为代价的)

术前检查肿瘤标志物癌胚抗原正常、或有较大的超标,影像肝肺有大于5mm的单发或多发实性或不均匀强化怀疑病灶、肿瘤侵犯肠壁全层、肿瘤环腔生长,肿瘤肠段肠外脂肪间隙模糊,或有与周边器官分界不清的表述,浆膜层有毛躁或褶皱被侵犯的迹象,肠壁浸润1.5cm左右,周边见数个肿大的淋巴结直径大于1公分,肿瘤处于肛门5公分以下的肠癌患者,专业医院医生一般会判断患者属于t4n1-2mX的中晚期,这类患者一般要做术前新辅助化疗,直至切缘阴性,这类患者一般要切除肛门才能稳妥的治愈,一般先做术前放化疗,观察低位直肠肿瘤的收缩情况和周边的淋巴结缩小情况,观察与某个器官的粘连情况,评估做出化疗几期之后再手术的决定。

观察化疗之后肝肺的怀疑病灶是否变大或变小去判断肝肺的单发或多发怀疑转移病灶是否确诊或排除,如2-4次化疗肝肺的轻度怀疑结节没有变化,或其它的检查远端转移排除,或者确诊寡转移,患者低位直肠周边侵犯情况退缩之后符合手术条件,患者得到手术机会,专业医院的医生一般会做多学科会诊、以在术中确诊或术前确诊寡转移,有除了肠道之外还有肝肺或者其它的器官病灶时,在术前做多学科会诊和做多学科联合手术,以让患者一次过做完切除所有病灶的手术。这类患者不要有太强烈的保肛愿望,要坚决的听取医生的保肛复发转移风险的意见之后,果断的做出切除肛门的决策,保命比起保肛重要,个别在专业医院医生判断要切除肛门才能治愈的患者,自己再去找不专业的医院医生强行不负责任的做保肛手术的患者,根据群6年经验结果都不太好,幸运不复发转移者肛门也不能够恢复肛门控制功能正常,有很多保肛之后肛门功能缺失不能够控制大便,不堪其苦而回医院重新做永久造口手术的病例很多。

而这类肿瘤下缘低于距离肛门5公分的低位直肠癌患者手术切除肛门之后,术后再根据术后病理做tnm分期,并根据术后病理报告病情做出适合患者病情的化疗辅助治疗,专业医院的医生通常会根据术后病理淋巴结转移数量,肿瘤侵犯肠壁深度和周边侵犯程度,去综合判断患者应该做哪种强度的化疗疗程,一般肉眼看见侵犯肠壁深肌层,到达浆膜层附近,有脉管癌栓、或者有神经侵犯、或者有3个淋巴结转移或肠周脂肪里有癌结节,这类患者专业医院的肿瘤内科医生都会做足8个三周期化疗或者选用总药量比较大的12次两周期奥沙利铂+卡倍他滨片化疗;化疗完成之后有4个淋巴结转移的患者,医生还会要求患者口服卡倍他滨片3-6个月,有远端转移的患者加靶向药治疗至8个疗程;之后卡倍他滨联合靶向药继续治疗控制,这类患者一般的术后病理会是比较严重3b-3c期,而少数确诊肝肺寡转移或多发转移的患者就是晚期的4期了!

8. 肠镜、影像、肿标检查,术前tnm分期属于晚期肠癌的一般治疗方式。

(这类患者一定要去全国十大肿瘤医院做多学科联合诊疗)

术前检查肿瘤标志物癌胚抗原正常、或有较大的超标过百,肠腔狭窄肠镜通不过或勉强通过;影像检查报告肝肺有大于10mm的多发强化或不均匀强化高度怀疑病灶、肿瘤侵犯肠壁全层、肿瘤环腔生长,肿瘤肠段肠外脂肪间隙模糊,或有与周边器官分界不清的表述,浆膜层有毛躁或褶皱被侵犯的迹象,肠壁浸润1.5cm左右,周边见数个淋巴结直径大于1公分,或有下列任何一个描述的——肿瘤明显侵犯内括约肌的、侵犯肛提肌的、侵犯腹膜反折的、直肠与子宫后壁粘连或分界不清的、侵犯输精管或输卵管的、乙状结肠癌侵犯膀胱、与膀胱分界不清、膀胱壁增厚的、横结肠癌侵犯胃部的、腹膜后、腹股沟有数枚淋巴结肿大的,盆腔种植转移的、肿瘤处于肛门6公分以上的肠癌患者,专业医院医生一般会判断患者属于t4n2m1的晚期,这类患者一般要做术前新辅助化疗,肿瘤下缘距离肛门7公分以下的要做放疗,直至切缘阴性,观察化疗之后肝肺的怀疑强化病灶是否变大或变小去判断肝肺的单发或多发怀疑转移病灶是否确诊,如2-4次化疗肝肺的轻度怀疑结节没有变化,或其它的检查远端转移排除,或者确诊寡转移,患者得到手术机会,同时在术前放化疗期观察直肠周边侵犯和粘连的情况是否缓解,达到手术标准的机会;专业医院的医生一般会做多学科会诊、以确定哪种综合治疗方案患者会受益,以在术中确诊或术前确诊寡转移可以切除,或者周边侵犯缓解到具备手术指征,全国十大肿瘤医院通过多学科会诊和评估,做多学科联合诊疗或多学科手术,以让患者一次过做完切除所有病灶的手术或者分阶段段切除、或者肝肺做消融或低位患者做放疗等根治或舒缓性治疗。

能够手术的患者,术后再根据术后病理做tnm分期,并根据术后病理报告病情做出适合患者病情的放化疗辅助治疗,专业医院的医生通常会根据淋巴结转移数量,肿瘤侵犯肠壁深度和周边侵犯程度,肝肺的转移病灶的切除、消融,低位直肠癌周边侵犯的情况做放疗、骨转移做放疗、去综合判断患者应该做哪种强度的化疗疗程,一般这类晚期患者,不管侵犯肠壁深浅,是否到达浆膜层或出肠,是否有脉管癌肉栓、或者有神经侵犯、或者有3个淋巴结转移或肠周脂肪里有癌结节,这类患者专业医院的肿瘤内科医生都会做足8个三周期化疗加靶向药治疗。或者选用总药量比较大的12次两周期奥沙利铂+卡倍他滨片化疗+靶向药化疗;8个奥沙利铂+卡倍他滨片+靶向药化疗完成之后,还会要求患者继续口服卡倍他滨片和一直做靶向药治疗以控制或治愈病情。

这类患者一般的术后病理会是比较难于治愈的晚期病情,而少数确诊肝肺多发转移,原发病灶切除没有意义,癌胚抗原几百上千,甲胎蛋白严重超标,盆腔转移并积液严重的患者,特别是血常规血象已经处于崩溃的边缘,肝肾代谢功能严重缺失,或者有其它的严重并发症出现的患者,一般就处于晚晚期了!医生所做的治疗一般是舒缓式治疗,患者有时会做临时造口,甚至尿道造口,以维持患者的正常饮食和排泄,进去晚晚期的患者,一般追求的治疗目标是能吃能喝、能睡能起、能大小便、没有严重的器官功能衰竭,没有严重的疼痛,患者可以自理或者护理强度不大的生活状态,就是晚晚期患者的追求目标和舒缓治疗医生的最大努力。

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肠癌治疗方案的一般程序和依据》有68个想法

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