胶质瘤治疗策略

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胶质瘤治疗策略
??　　dr_weishep编译
??　　编译并展示的目的：旨在为那些患有胶质瘤病人及其家属，提供一些胶质瘤国际治疗的一般遵循原则。愿他们处乱不惊，从容应对，把病人的利益放在第一位，让病人充分享受生活，而不是长年累月的和药物和医院相伴。21世纪是人和肿瘤共存的世纪。
??　　Clinical Oncology, 3rd ed., Copyright (C) 2004 Churchill Livingstone
??　　临床肿瘤学 第三版（2004）
??　　MANAGEMENT APPROACH
??　　胶质瘤治疗策略
??　　* Grade I (pilocytic astrocytomas). Surgery is curative. If residual tumor is seen on postoperative imaging, the patient should have a second craniotomy to resect the entire tumor. Radiation therapy and chemotherapy have limited utility for these tumors.
??　　WHO一级胶质瘤（毛细胞性星形细胞瘤）：手术是可以治愈性的。如果在术后影像上有残余肿瘤，则可行第二次手术切除整个肿瘤。放疗和化疗对此类肿瘤极其有限。
??　　* Grade II (low-grade astrocytoma). Surgery is the mainstay of therapy in noneloquent brain. In patients under the age of 40 who undergo gross total resection, no additional therapy is given. Patients under the age of 40 with incomplete resections and patients over the age of 40 with or without complete resections are treated with radiation therapy (54 to 60 Gy).
??　　WHO二级胶质瘤（低度恶性胶质瘤）：手术是非功能区肿瘤的最主要的治疗手段。对于40岁以下的肉眼全切的病人，无需额外的其他治疗。对于40以下的不全切除的肿瘤病人以及病人年龄大约40岁不管是否全切都应该进行放疗。
??　　* Grade III astrocytoma (anaplastic astrocytoma). Surgery is required to establish a tissue diagnosis and debulk the mass. Patients should be treated with radiation therapy (60 Gy) and chemotherapy.
??　　WHO三级胶质瘤（间变星形细胞瘤）：需要手术来达到组织病理诊断和减小肿瘤体积。病人应当进行放疗和化疗。
??　　* Grade IV gliomas (glioblastoma multiforme). Surgery is required to establish tissue diagnosis and debulk the lesion. Surgery is followed by radiation therapy to a dose of 60 Gy. Chemotherapy consisting of carmustine, combination PCV (procarbazine, lomustine, and vincristine), or temozolomide can be used for tumor control.
??　　WHO四级胶质瘤（多形性胶质母细胞瘤）：同样需要手术来达到组织病理诊断和减小肿瘤体积。术后放疗（剂量在60Gy左右）。化疗手段包括卡莫司汀，联合方案PCV（甲基苄肼，环己亚硝脲和长春新碱），或者替莫唑胺用来对肿瘤生长进行控制。
??　　* All tumors should be sent for genetic **ysis. Advances in molecular genetic **ysis have led to improvements in predicting response to chemotherapy. Pure oligodendrogliomas are more chemosensitive than mixed tumors (related to different proportions of loss of heterozygosity of chromosomes 1p and 19q).
??　　所以的肿瘤标本都应该送检染色体检查，因为纯粹的少枝胶质瘤可能会有1p或者19q的缺乏，此种胶质瘤对化疗特别敏感。
??　　* Primary treatment is maximal feasible resection. Anaplastic tumors are treated with radiation therapy and 1 year of PCV chemotherapy. The role of preradiation chemotherapy is the subject of several ongoing clinical trials. At recurrence temozolomide is effective for anaplastic tumors; well-tolerated and probably equally effective is PCV used as adjuvant therapy.
??　　胶质瘤主要的治疗是尽最大可能的切除肿瘤。间变胶质瘤应当给以放疗和1年左右的PCV联合化疗。放疗前的化疗目前还在进行临床试验中。对于复发的病人，替莫唑胺对间变胶质瘤是有效的。作为辅助治疗，它和PCV方案有同等的效果。
??　　* Low-grade oligodendrogliomas that are progressive by MRI can be treated with PCV or temozolomide. PCV is the best-studied regimen for recurrence but is associated with cumulative myelosuppression, nausea, vomiting, and pe**heral neuropathy. Temozolomide is well tolerated and is emerging as a feasible first-line choice. Radiation therapy maybe useful for tumors that progress on chemotherapy.
??　　低度恶性的少枝胶质瘤如果在MRI上发现有进展，则给以PCV或者替莫唑胺化疗。PCV是被证实过对复发胶质瘤有效化疗方案，但有累积的骨髓抑制，恶心，呕吐和周围神经病变。替莫唑胺耐受性良好，是新兴的可行的一线化疗药物。对于化疗中仍在进展的胶质瘤，放疗可能会有效。
??　　1. 经典的PCV化疗方案
??第1天：环己亚硝脲（CCNU） 110mg/m2口服
??第8天和第29天：长春新碱1.4mg/m2静脉滴注
??从第8天到第21天：甲基苄肼60mg/m2每日口服
??　　2. 替莫唑胺150 ～200 mg/ m2 连用5天，每28天重复一次。

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