1、Patient T,Female,45 years old 胡某胡某,女，女，45岁岁The gastroscope and biopsy before surgery:gastric sinus adenocarcinoma 术前胃镜及活检证实胃窦部腺癌术前胃镜及活检证实胃窦部腺癌Sep.2004 received radical resection of gastric cancer 2004年年9月接受了胃癌根治术月接受了胃癌根治术Pathological Report:Ulcerative Adenocarcinoma,low differentiation,invades seros
2、a layer,adherence with adjacent pancreas,lymph nodes metastasis 12/16 病理报告：低分化溃疡型腺癌，侵犯浆膜层，与胰腺粘连，病理报告：低分化溃疡型腺癌，侵犯浆膜层，与胰腺粘连，淋巴结转移灶淋巴结转移灶12/16Stage:T4N2M0，G3,Stage IV 分期分期IV期，期，T4N2M0，G3Patient CharacteristicsCompleted chemotherapy regimen(MMC+CF+5-FU)4cycles after surgery 手术后完成手术后完成4个周期个周期(MMC+CF+5-FU
3、)方案的辅助化疗方案的辅助化疗Physical examination at the 6th month after chemotherapy finds the left-supraclavicular lymph nodes(size:2cm).CT Scan:two lymph nodes behind posterior peritoneum involved(size:3cm and 2.5cm)术后术后6个月复诊时体检发现左侧锁骨上淋巴结肿大，个月复诊时体检发现左侧锁骨上淋巴结肿大，2cm。CT扫描发现腹膜后两个肿大淋巴结，扫描发现腹膜后两个肿大淋巴结，3 cm及及2.5cmCA1
4、99：305u/L CEA:126ng/mlPrior TreatmentWhats your Recommend Regimen?Single agent?1、Xeloda 1250mg/m2,twice daily,14days,6 cycles Combination regimens?2、DF(cisplatin+5-FU)3、Xeloda+cisplatin 4、FOLFOX(5-FU/LV+Oxaliplatin)5、Irinotecan-based regimen 6、Taxane-based regimen0%0%10.3%41.4%0%48.3%Actual Treatmen
5、t Patient received Xeloda+cisplatin regimen as first-line chemotherapy Xeloda:1000mg/m2,twice daily,14days cisplatin:75mg/m2,day1 every 3 weeks Patient complained that the adverse reaction of nause and vomiting of cisplatin was too painful for her to go on with more treatment.Only completed 2 cycles
6、.患者由于顺铂所致的恶心呕吐反应过重，只进行了患者由于顺铂所致的恶心呕吐反应过重，只进行了 两个周期的化疗。两个周期的化疗。Physical examination:left-supraclavicular lymph nodes(size:1cm).CT Scan:two lymph nodes behind posterior peritoneum involved shrink obviously,(size:2cm and 1cm)CA199:102u/L CEA:21ng/ml Partial ResponseActual Response1、Maintain Xeloda and
7、cisplatin dosage?因原方案有效维持原方案化疗？因原方案有效维持原方案化疗？2、Reduce cisplatin dosage to 75%and continue?将顺铂剂量减为原剂量的将顺铂剂量减为原剂量的75%后继续治疗？后继续治疗？3、Interrupt？中断治疗中断治疗4、Change drug？更换药物更换药物What to do next?6.3%40.6%0%53.1%Change drug Patient received XELOX Xeloda:1000mg/m2,twice daily,14days Oxaliplatin:130mg/m2,day1 ev
8、ery 3 weeks Completed 4 cyclesActual Treatment The mild symptoms of erythema and swelling on her hands and feet were be observed after 2 cycles of XELOX.She continued the other 2 cycles of XELOX without dosage reducing or treatment delaying.完成完成2周期后患者有轻微的手足部痛性红斑及肿胀。但这周期后患者有轻微的手足部痛性红斑及肿胀。但这并没有促使化疗减量或
9、延期。并没有促使化疗减量或延期。Insensible feeling of hands and feet caused by oxaliplatin also happened.But mild too.奥沙利铂导致的手足麻木感也很轻微。奥沙利铂导致的手足麻木感也很轻微。Adverse Reaction Physical examination:left-supraclavicular lymph nodes(size:0.5cm).CT Scan:two lymph nodes behind posterior peritoneum involved disappeared,(size:0c
10、m and 0cm)CA199:40u/L CEA:11ng/ml Partial ResponseActual ResponseWhat shall you do after 6 cycles?Maintain therapy?1、Xeloda 1000mg/m2,twice daily,14daysContinue with XELOX 2、Xeloda+OxaliplatinChange to other regimen?3、T+F(5-FU/LV+Taxane)4、FOLIRI(5-FU/LV+Irinotecan)5、Radiotherapy?6、Observe?37.5%21.9%
11、3.1%9.4%6.3%21.9%Patient received palliative radiotherapy the left-supraclavicular area:50GY the area of tumor bed:45GY 患者接受了姑息性放疗，左侧锁骨上区域患者接受了姑息性放疗，左侧锁骨上区域50GY，原瘤床部位原瘤床部位45GY Concurrent chemotherapy Xeloda 900mg/m2,twice daily,14days 2 cycles 希罗达同步增敏化疗希罗达同步增敏化疗2周期周期Actual TreatmentClinical Efficacy
12、 Physical examination:left-supraclavicular lymph nodes disappeared.CT Scan:two lymph nodes behind posterior peritoneum involved disappeared CA199:12u/L CEA:6ng/ml Complete Response Last follow up date:Apr.2006What shall you do next?1、Xeloda 1000mg/m2,twice daily,14days2、Xeloda(5FU)+Oxaliplatin3、othe
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