Prof. Maria Bencivenga

这正是我们现阶段聚焦的研究方向，我们也联合INFINITY试验牵头的内科肿瘤学家Filippo Pietrantonio教授开展相关探索。我们观察到，微卫星不稳定（MSI）肿瘤患者接受免疫治疗、部分场景下采用去化疗方案时，若在治疗后达到临床完全缓解，可考虑采取非手术管理策略。但就目前而言，非手术管理仅建议在特定临床试验或安全可控的临床条件下实施。采取非手术管理后，需要建立完备的监测随访体系，通过临床再分期、CT、PET-CT以及ctDNA检测，确认患者能够维持免疫治疗带来的疗效应答。

这代表了外科领域未来的发展方向，而机器人手术恰好为这一方向提供了有力的技术支撑。借助机器人平台，术者可以完成精细化解剖、高质量的消化道重建，同时手术学习曲线更短。我认为，机器人手术联合免疫疗法，将有可能重塑包括欧洲在内多个地区的肿瘤治疗格局。

We know you have long been engaged in research in robotic surgery and related fields. It seems the core question is shifting from “how can we perform better surgery” to “who should receive surgery”. What is your view on this paradigm shift?

Prof. Maria Bencivenga：

This is indeed the focus of our current work, which we are conducting together with Filippo Pietrantonio, the medical oncologist leading the INFINITY trial.

We have observed that for microsatellite instable tumors treated with immunotherapy, and in some scenarios with chemotherapy free strategies, non-operative management may be feasible for patients who achieve a clinical complete response following the treatment. Of course, at present, non-operative management should only be implemented within dedicated clinical trials or well?defined safe clinical contexts. A rigorous surveillance program is required after adopting non-operative management, including clinical restaging, CT, PET-CT and ctDNA detection, to confirm sustained treatment response under immunotherapy.

For microsatellite-stable (MSS) patients, perioperative strategies incorporating single-agent immunotherapy are currently applied regardless of biomarker status. This raises a key question for MSS patients: can we reduce surgical extent? Rather than performing standard D2 total or distal gastrectomy, could we consider proximal gastrectomy or even partial resection combined with sentinel?node navigation? Some MSS patients, particularly those with a high CPS score (greater than 20~25), achieve favorable treatment responses. Therefore, one major task for us is to explore whether we can adopt non?operative management for MSI patients, and for MSS patients with strong predictive markers such as high CPS, whether we can reduce surgical resection scope.This represents the future direction of surgery, and robotic surgery strongly supports this goal. Robotic systems enable precise dissection, high-quality reconstruction, and a shorter learning curve. I believe that robotic platforms combined with immunotherapy will reshape the treatment landscape, including in Europe.

肿瘤瞭望消化时讯：全身治疗的进步正在重新定义外科的角色：一部分患者可以免于手术，另一部分患者获得了手术机会。我们应当如何甄别真正需要手术、并且能从手术中获益的患者？

Prof. Maria Bencivenga

目前，非手术管理仅适用于小部分患者，目前主要为MSI人群。即便是MSI-H患者，也并非全部适用，仍需进一步筛选，甄别出可获得持久完全缓解、真正符合非手术管理条件的MSI-H人群。不可否认，这部分患者是非手术策略极具潜力的目标人群。

另一方面，部分转移性患者，特别是寡转移患者，在接受化疗、免疫、靶向联合全身治疗后，能够取得良好疗效。

在我看来，对于经全身治疗后实现应答的寡转移患者，ctDNA转阴是筛选后续局部治疗候选者的核心指标，特别是对于非腹膜病变，包括肝脏、骨骼和其他远处转移。若确认ctDNA转阴，提示全身肿瘤负荷已得到充分控制，这类患者便有望通过局部治疗实现病灶根除。因此，在转移疾病背景下筛选手术适宜人群，需要将CT、PET-CT、MRI等影像学再分期手段与ctDNA这类生物学检测相结合；针对腹膜病灶，还需完善腹腔积液DNA检测。上述检测对评估微观肿瘤的全身治疗应答至关重要。即便局部病灶存在清除的可能性，也必须确保全身的微观肿瘤负荷已被全身治疗有效控制。

针对腹膜转移，若要实现有效的外科干预，可采用双向治疗策略：全身应用化疗、免疫或靶向药物，同步联合腹腔常温化疗或腹腔内灌注化疗（PIPAC）。腹腔内治疗可引起生物标志物谱的动态变化，而该双向治疗模式有助于提升全身治疗应答，我认为这是未来重要的发展方向。

即便采用该方案，术前仍需完成最终的疗效再评估，ctDNA与腹腔积液DNA检测在这一环节必不可少。

Improved systemic therapies are redefining the role of surgery: some patients can avoid surgery, whereas others gain new opportunities for surgical intervention. How do we identify patients who truly require and will benefit from surgery?

Prof. Maria Bencivenga ：

I think that, as I mentioned, non-operative management, i.e. surgery-sparing strategies, is applicable to only a very small subset of patients, currently those with microsatellite instability. Even within this population, not all patients qualify; further patient stratification is required to better identify which MSI patients can achieve a complete and durable response. Nevertheless, this population represents a promising target for non-operative management.

On the other hand, there are metastatic patients, such as oligometastatic patients, who demonstrate substantial responses to systemic treatment consisting of chemotherapy combined with immunotherapy and targeted therapy.In my view, among oligometastatic patients who respond to systemic therapy, candidates for subsequent local-directed treatment can be identified by ctDNA negativization, particularly for non-peritoneal lesions including liver, bone and other distant metastases. ctDNA negativization should be pursued: confirmation of controlled systemic disease burden indicates that the disease can be successfully eradicated via local-directed therapy. Therefore, to select patients suitable for surgery in the metastatic setting, clinical restaging modalities including CT, PET-CT and MRI should be combined with biological information, particularly circulating ctDNA. For peritoneal lesions, peritoneal-fluid DNA testing could also be an option. It is critical to capture the systemic treatment response at the microscopic disease level. Where local residual disease may be eradicated, it must be ensured that microscopic systemic disease is controlled and eradicated by prior systemic therapy.For peritoneal metastases, an effective surgical treatment strategy may adopt a bidirectional approach: systemic therapy with chemotherapy, immunotherapy or targeted agents combined with intraperitoneal normothermic chemotherapy or PIPAC. Intraperitoneal therapy may drive dynamic shifts in biomarker profiles, and this bidirectional strategy may enhance responses to systemic treatment. I consider this to represent a future direction.Even so, definitive pre-surgical reassessment is mandatory, ideally incorporating ctDNA and peritoneal-fluid DNA testing.

Prof. Maria Bencivenga

在我看来，现有证据尚不足以证实机器人手术相较腹腔镜手术具备显著获益。其中一个主要制约因素是，绝大多数现有机器人平台并未配备可弯曲能量器械。目前机器人系统仅能使用常规非弯曲能量器械，未能充分释放机器人本身的技术潜力。只有将可弯曲能量器械整合至机器人平台，我们才有望观察到机器人手术相较于腹腔镜手术的额外获益。

第二点，胃十二指肠吻合、近端胃切除后的消化道重建等关键操作亟待实现技术标准化。倘若重建流程无法标准化，机器人手术的优势便难以充分彰显，技术标准化是其中的核心问题。

但需要强调的是，相较于腹腔镜手术，机器人平台具备一项独特优势：可搭载基于人工智能的高级计算机视觉算法。真正带来诊疗模式变革的，并非机器人硬件本身。若想让机器人手术展现出明确的临床获益，一方面有赖于可弯曲能量器械的配套应用，另一方面需要推动手术操作的标准化。而就我个人观点，机器人平台与AI辅助技术的融合，才是真正具备颠覆性的未来发展方向。

Robotic surgery is developing very quickly, but new technology does not always mean better outcomes for patients. What is the most important benefit that robotic surgery still needs to prove？

Prof. Maria Bencivenga：

To date, robotics has not demonstrated a significant benefit compared to laparoscopic surgery. This limitation largely stems from the fact that most robotic platforms lack articulated energy devices. Therefore, current systems cannot fully leverage robotic-specific technological advantages, as only non-articulated blunt or bulk energy devices are available. Once proper articulated energy devices are developed and integrated into robotic platforms, additional clinical benefits of robotic surgery relative to laparoscopy may be observed.

A second key factor is the standardization of esophagogastroduodenal anastomosis, including anastomotic reconstruction following proximal gastrectomy. Without standardized protocols for this reconstructive phase, it will be challenging for robotic systems to realize their full potential, given the critical role of technical standardization.Nevertheless, compared with laparoscopy, robotic systems offer a unique opportunity for integration with sophisticated AI-driven computer-vision algorithms. This, rather than robotic hardware per se, represents the transformative potential of the technology.Robotic surgery may deliver incremental clinical benefits with the availability of novel articulated energy devices and improved standardization of reconstructive surgical techniques. From my perspective, the most transformative advance will be the integration of robotic platforms with AI-assisted tools.

· 专家介绍 ·

Maria Bencivenga

Maria Bencivenga 教授

意大利维罗纳大学外科学系 副教授

Frontiers in Oncology（肿瘤外科方向）审稿编辑

British Journal of Surgery（BJS）编委会委员

意大利胃癌研究协作组 (GIRCG)会员

国际胃癌协会 (IGCA)会员

欧洲肿瘤内科学会 (ESMO)会员

欧洲消化肿瘤学会 (ESDO) 会员