China Anti-Cancer Association guidelines for the holistic integrative management of pancreatic cancer (abridged version)
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摘要: 胰腺癌在中国男性恶性肿瘤发病率居第10位，女性居第12位，恶性肿瘤死亡率居第6位。胰腺癌恶性程度高，预后极差。在“整合医学”理念的推动下，中国抗癌协会胰腺癌专业委员会组织相关专家制订指南，旨在以“防-筛-诊-治-康”为基础，全面、全程地指导胰腺癌的整合治疗和康复管理。期望本指南可以为临床医师提供参考意见，从而提高国内胰腺癌患者的治疗效果。Abstract: Pancreatic cancer ranks 10th in the incidence rate of malignant tumors in men and 12th in women, and is the 6th leading cause of tumor-related deaths in China. It is a devastating malignancy with a poor prognosis. Inspired by the concept of “integrated medicine,” the China Anti-Cancer Association Committee of Pancreatic Cancer has organized the efforts of relevant experts to complete these guidelines for the integrative and comprehensive treatment and rehabilitation management of pancreatic cancer based on the principles of “Preventing, Screening, Diagnosing, Treating, and Rehabilitating.” We hope that these guidelines will constitute an effective reference for clinicians in achieving the best treatment outcomes for patients with pancreatic cancer in China.
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Key words:
- pancreatic cancer /
- holistic integrative management /
- guideline
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表 1 胰腺癌第8版AJCC-TNM分期和上海复旦版改良分期
项目 标准 原发肿瘤
（T）Tx 原发肿瘤无法评估 T0 无原发肿瘤证据 Tis 原位癌 T1 肿瘤最大径≤2 cm T1a 肿瘤最大径≤0.5 cm T1b 肿瘤最大径0.6～1 cm T1c 肿瘤最大径1.1 ～2 cm T2 肿瘤最大径2.1 ～4 cm T3 肿瘤最大径>4 cm T4 肿瘤不论大小，累及腹腔干、肠系膜上动脉，和（或）肝总动脉 区域淋巴结（N） Nx 区域淋巴结无法评估 N0 无区域淋巴结转移 N1 1～3枚区域淋巴结转移 N2 4枚及以上区域淋巴结转移 远处转移（M） M0 无远处转移 M1 有远处转移 第8版AJCC分期 上海复旦版改良分期 0 TisN0M0 0 TisN0M0 ⅠA T1N0M0 ⅠA T1N0M0 ⅠB T2N0M0 ⅠB T2N0M0，T1N1M0 IIA T3N0M0 ⅡA T3N0M0，T2N1M0，T1N2M0 ⅡB T1～3N1M0 ⅡB T3N1M0，T2N2M0 Ⅲ TanyN2M0, T4NanyM0 ⅢA T3N2M0 Ⅳ TanyNanyM1 ⅢB T4NanyM0 Ⅳ TanyNanyM1 
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表 2 胰腺癌可切除性的解剖学评估
可切除状态 动脉 静脉 可切除 肿瘤未触及腹腔干、肠系膜上动脉或肝总动脉 肿瘤未触及肠系膜上静脉和门静脉，或侵犯但未超过180°，且静脉轮廓规则 交界可切除 胰头和胰颈部肿瘤：肿瘤触及肝总动脉，但未累及腹腔干或左右肝动脉起始部，可以被完全切除并重建；肿瘤触及肠系膜上动脉，但未超过180°；若存在变异的动脉解剖（如副肝右动脉、替代肝右动脉、替代肝总动脉，以及替代或副动脉的起源动脉），应明确是否有肿瘤侵犯及侵犯程度，可能影响手术决策 胰头和胰颈部肿瘤：肿瘤触及肠系膜上静脉或门静脉超过180°，或触及虽未超过180°，但存在静脉轮廓
不规则；或存在静脉血栓，切除后可进行安全的静脉重建；肿瘤触及下腔静脉胰体尾部肿瘤：肿瘤触及腹腔干未超过180°；肿瘤触及腹腔干超过180°，但未触及腹主动脉，且胃十二指肠动脉完整不受侵犯 胰体尾部肿瘤：肿瘤触及脾静脉门静脉汇入处，或触及门静脉左侧未超过180°，但存在静脉轮廓不规则；有合适的近端或远端血管可用来进行安全、完整的切除和静脉重建；肿瘤触及下腔静脉 局部进展期 胰头和胰颈部肿瘤：肿瘤触及肠系膜上动脉超过180°；肿瘤侵犯腹腔干超过180°；肿瘤触及肠系膜上动脉第一空肠支 胰头和胰颈部肿瘤：肿瘤触及或因栓塞（瘤栓或血栓）导致肠系膜上静脉或门静脉不可切除重建；肿瘤侵犯大部分肠系膜上静脉的近侧端空肠引流支 胰体尾部肿瘤：肿瘤侵犯肠系膜上动脉或腹腔干超过180°；肿瘤侵犯腹腔干和腹主动脉 胰体尾部肿瘤：肿瘤侵犯或因栓塞（可能是瘤栓或血栓）导致肠系膜上静脉或门静脉不可切除重建 合并远处转移 远处转移（包括非区域淋巴结转移） 远处转移（包括非区域淋巴结转移）
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表 3 胰腺癌根治术的淋巴结清扫范围
手术方式 清扫范围 清扫淋巴结 胰十二指肠切除术 标准清扫 5、6、8a、12b、12c、13a、13b、14a、14b、17a、17b 扩大清扫 上述范围+8p、9、12a、12p、14c、14d、16a2、16b1 胰体尾联合脾脏切除术 标准清扫 10、11p、11d、18 扩大清扫 上述范围+8a、8p、9、14a、14b、14c、14d、16a2、16b1
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