肝切除术治疗结直肠癌肝转移的患者选择

<正>1简介结直肠癌最常见的血行转移器官为肝脏。大约有一半的患者在结直肠癌病程中发展为肝转移癌[1]。针对肝转移病灶,肝切除术仍是唯一可能的根治性治疗,其5年生存率约50%[2],10年治愈率接近20%[3]。此外,有效的系统和局部化疗结合手术切除可以达到在未治愈的情况下使患者长期存活[4]。因此,肝切除的目标和适应     

胃癌肝转移肝切除的预后分析

目的分析胃癌肝转移后实施肝切除患者的预后因素。方法对1996~2003年间实施肝切除的45例胃癌肝转移患者的临床资料进行回顾性研究,分析临床病理学指标与患者生存期之间的关系。结果45例接受肝切除的患者有2例死于术后严重并发症。获得随访的39例患者的1,3,5年的总体生存率分别为54%,32%和21%。中位生存时间为29.5月,6例患者存活时间超过5年。胃周淋巴结转移、侵袭深度、辅助化疗、肝脏转移灶数目以及胃癌患者的组织学分级均与患者生存期之间存在不同程度的相关。但年龄、性别、肝脏转移灶的最大直径以及是否进行肝脏介入治疗与患者的生存期之间未见相关性。结论无腹腔淋巴结广泛转移的胃癌肝转移后实施肝切除术可以延长患者的生存期。     

胃癌肝转移的外科治疗

目的探讨胃癌肝转移外科治疗的远期疗效。方法回顾性分析1993年1月至2001年10月间938例原发性胃癌患者中32例行胃癌肝转移灶切除者的临床资料。结果938例原发性胃癌患者中,异时性肝转移24例(2.6%),行肝转移灶切除14例(58.3%);同时性肝转移90例(9.6%),行肝转移灶切除18例(20.0%)。32例患者病理检查均证实为肝转移腺癌。术后1、3、5年生存率,异时性肝转移患者为73%、37%、25%;同时性肝转移患者为68%、24%、17%;两者差异无统计学意义(P>0.05)。结论孤立的同时及异时性肝转移患者经外科手术切除肝转移灶预后较好。     

Redo hepatic resection for metastatic colorectal carcinoma

Redo hepatic resection for recurrent colorectal metastasis was performed in eight patients. There was no operative mortality; major morbidity occurred in 25% and minor morbidity in 13% of patients. Four patients are alive and disease-free at 9, 23, 39, and 49 months, respectively, after their repeat hepatic resection. Four patients have died of recurrent disease, with a median time to recurrence of 6 months and median survival of 15 months. Patterns of failure include hepatic failure alone in two patients and pulmonary and hepatic failure in two. Repeat liver resection can be performed safely and may be beneficial in some patients with recurrent metastases confined to the liver after previous hepatic metastasectomy.

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Resumen El tratamiento quirúrgico de las metástasis hepáticas recurrentes luego de una resección inicial no ha sido considerado como opción terapeútica. Sin embargo, varios informes recientes han documentado el hecho de que la resección repetida es técnicamente factible y que puede resultar en prolongados intervalos libres de enfermedad en 38% a 50% de los pacientes. Con anterioridad al présente reporte, solo 62 pacientes sometidos a resección hepática repetida por cancer colorrectal metastásico han sido descritos en la literatura. Se requieren estudios adicionales, y nuestro grupo présenta su experiencia para complementar esta base de datos.Se describe la resección redo-hepática por metástasis colorrectales recurrentes en ocho pacientes. No hubo mortalidad operatoria, se registró morbilidad mayor en 25% y menor en 13%. Cuatro pacientes se encuentran vivos y libres de enfermedad a los 9, 23, 39 y 49 meses después de la nueva resección hepática. Cuatro pacientes han muerto por enfermedad récurrente con un tiempo medio de recurrencia de 6 meses, y un tiempo medio de sobrevida de 15 meses. Los lugares de falla incluyen sólo dos en el hígado y dos en el pulmón. La resección repetida del hígado puede ser realizada con seguridad y puede ser beneficiosa en algunos pacientes con metástasis récurrentes confinadas al hígado después de una metastasectomía previa.

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Résumé La résection itérative de métastases hépatiques d'un cancer colorectal a été pratiquée chez 8 patients. Il n'y a eu aucune mortalité opératoire. La morbidité majeure a été de 25% (2 patients), alors qu'elle a été mineure chez un patient (13%). Quatre patients sont en vie et apparement sans maladie à 9, 23, 39, et 49 mois après leur deuxième résection. Quatre patients sont morts de récidive avec une médiane d'intervalle libre avant la récidive de 6 mois, et une survie médiane de 15 mois. La récidive a été dans deux cas au niveau du foie seul et dans deux autres cas, simultanément au niveau du poumon et du foie. La résection itérative de métastases hépatiques est faisable avec sûreté et peut apporter un plus chez certains patients déjà opérés de leur métastase.

     

A nomogram for predicting disease-specific survival after hepatic resection for metastatic colorectal cancer

PURPOSE: To develop a tool for predicting survival after liver resection for patients with stage IV colorectal cancer. By using a nomogram we are trying to improve on the current practice of using prognostic scores for evaluating risks of therapeutic failure. PATIENTS AND METHODS: All patients admitted to Memorial Sloan-Kettering Cancer Center (MSKCC) for curative intent for treatment of metastatic disease from colorectal cancer between January 1986 and December 1999 were included. A nomogram was developed as a graphical representation of a Cox proportional hazards regression model. The nomogram was verified for discrimination and calibration, both employing bootstrapping to obtain relatively unbiased estimates. RESULTS: Using nodal status of the primary tumor, disease-free interval, size of the largest metastatic tumor, preoperative carcinoembryonic antigen, bilateral resection, extensive resection (lobectomy or more), gender, number of hepatic tumors, primary cancer site (colon vs. rectum), and age, the nomogram achieved a concordance index of 0.61, statistically significantly greater than chance. The nomogram also had very good calibration. CONCLUSION: This nomogram is a predictive tool, upon external validation, that can routinely be used to counsel patients in making treatment decisions. The discriminatory ability of the nomogram indicates that this population should not be considered homogeneous with respect to risk of death.     

Outcome after simultaneous colorectal and hepatic resection for colorectal cancer with synchronous metastases

BACKGROUND: Consensus has not been reached concerning the timing of hepatectomy in patients with synchronous colorectal liver metastases, specifically with respect to patient selection criteria for simultaneous resection of the colorectal primary and the liver metastasis. METHODS: Retrospectively obtained clinicopathologic data for 39 consecutive patients with synchronous colorectal cancer metastases to the liver, who underwent curative simultaneous "1-stage" hepatectomy and resection of the colorectal primary at 1 institution, were subjected to univariate and multivariate analysis concerning the safety and success of the combined procedure. RESULTS: Only the volume of the resected liver was selected as a risk factor for postoperative complications (350 g mean resected liver volume in patients with postoperative complications vs 150 g in those without complications; P <.05). Patient age of 70 years or older (P <.05) and poorly differentiated or mucinous adenocarcinoma as the primary lesion (P <.01) predicted decreased overall survival by univariate analysis. Multivariate analysis retained histologic differentiation of the colorectal primary as an independent survival predictor (P <.05). CONCLUSIONS: A 1-stage procedure appears desirable for synchronous colorectal hepatic metastases except for patients requiring resection of more than 1 hepatic section, patients aged 70 years or older, and those with poorly differentiated or mucinous adenocarcinomas as primary lesions.     

结直肠癌肝转移切除术后并发症对生存影响

目的 探讨围手术期并发症对接受根治性结直肠癌肝转移灶切除患者生存影响.方法 回顾性分析自2000年1月至2012年3月在我科接受结直肠癌肝转移灶切除患者临床病理资料及围手术期并发症,并发症按Dindo-Clavien分级分为无并发症、轻度(Ⅰ～Ⅱ级)并发症、重度(Ⅲ～Ⅳ级).并探讨不同分级并发症与总生存及无病生存关系.结果 本组173例结直肠癌肝转移患者接受根治性肝转移灶切除术,其中59例患者术后存在手术并发症.这些患者中37例为轻度并发症,22例为重度并发症.单因素(x2 =8.106,P=0.004)及多因素分析(x2=8.006,P=0.005)提示术后并发症会降低患者总生存.但进一步分析提示重度并发症显著降低患者无病生存(x2＝4.216,P =0.04)及总生存(x2=9.588,P=0.002),轻度并发症并未影响患者无病生存(x2 =1.313,P =0.252)及总生存(x2 =3.199,P=0.074).结论 围手术期并发症是结直肠癌肝转移患者独立预后因素.     

Liver resection for metastatic colorectal cancer

From 1975 to 1985, 60 patients with isolated hepatic metastases from colorectal cancer were treated by 17 right trisegmentectomies, five left trisegmentectomies, 20 right lobectomies, seven left lobectomies, eight left lateral segmentectomies, and three nonanatomic wedge resections. The 1-month operative mortality rate was 0%. One- to 5-year actuarial survival rates of the 60 patients were 95%, 72%, 53%, 45%, and 45%, respectively. The survival rate after liver resection was the same when solitary lesions were compared with multiple lesions. However, none of the seven patients with four or more lesions survived 3 years. The interval after colorectal resection did not influence the survival rate after liver resection, and survival rates did not differ statistically when synchronous metastases were compared with metachronous tumors. A significant survival advantage of patients with Dukes' B primary lesions was noted when compared with Dukes' C and D lesions. The pattern of tumor recurrence after liver resection appeared to be systemic rather than hepatic. The patients who received systemic chemotherapy before clinical evidence of tumor recurrence after liver resection survived longer than those who did not.     

Hepatic resection for metastatic cancer.

One-year survival is infrequent in patients with metastatic cancer to the liver. This report includes 21 patients who underwent hepatic resection between 1974 and 1981. Operative procedures included one trisegmentectomy, 12 right hepatic lobectomies, two left hepatic lobectomies, two left lateral segmentectomies, and four wedge resections. Operative morbidity and mortality rates were 43% and 5%, respectively. Life-table analysis revealed an overall 7-year survival rate of 34%. The subset of patients (16) with colorectal adenocarcinoma had a 7-year survival rate of 29% after hepatic resection. In three patients with colorectal adenocarcinoma, frequent CEA determinations were made after surgery in order to calculate the serum half-life of CEA. The data fitted a biexponential function yielding two half-lives for CEA disappearance, 0.8 +/- 0.5 days and 25.9 +/- 10.3 days. We conclude that hepatic resection for isolated hepatic metastases can be performed with acceptable morbidity, low mortality, and prolongation of patient survival.     

影响结直肠癌肝转移而行肝切除病人长期生存的预后因素分析

该研究回顾性分析了297例因结直肠癌肝转移而行肝切除的病例,对影响病人远期治疗效果的预后因素进行了探讨.     

胃癌肝转移的手术治疗

目的 探讨胃癌肝转移行肝切除术的适应证及疗效。方法 对1990年1月至1999年11月间施行肝切除的24例胃癌肝转移患的临床资料进行回顾性分析。结果 本组同时性肝转移19例，异时性转移5例。共施行肝段叶切除8例，肝部分切除16例；19例同时性肝转移患均在肝切除的同时加行根治性胃切除术。术后并发肝昏迷死亡l例。手术死亡率为4．2％。全组22例获得随访。术后1年、3年和5年生存率分别为45．5％、18．2％和9．1％。生存分析显示，肝切除术后的生存率不仅与胃癌原发灶的分化程度、有无浆膜面浸润和淋巴结转移有关，而且与肝转移灶的数目及其在肝脏内的分布范围有关。结论对于胃癌孤立性肝转移患，其原发病灶可根治切除的应积极采用手术治疗，部分患可获长期生存。     

Results of hepatic resection for sarcoma metastatic to liver

OBJECTIVE: To evaluate the outcome of patients with liver metastases from sarcoma who underwent hepatic resection at a single institution and were followed up prospectively. SUMMARY BACKGROUND DATA: The value of hepatic resection for metastatic sarcoma is unknown. METHODS: There were 331 patients with liver metastases from sarcoma who were admitted to Memorial Hospital from 1982 to 2000, and 56 of them underwent resection of all gross hepatic disease. Patient, tumor, and treatment variables were analyzed to assess outcome. RESULTS: Of the 56 patients who underwent complete resection, 34 (61%) had gastrointestinal stromal tumors or gastrointestinal leiomyosarcomas. Half of the patients required an hepatic lobectomy or extended lobectomy. There were no perioperative deaths in the completely resected group, although 3 of the 75 patients who underwent exploration (4%) died. The postoperative 1-, 3-, and 5-year actuarial survival rates were 88%, 50%, and 30%, respectively, with a median of 39 months. In contrast, the 5-year survival rate of patients who did not undergo complete resection was 4%. On multivariate analysis, a time interval from the primary tumor to the development of liver metastasis greater than 2 years was a significant predictor of survival after hepatectomy. CONCLUSIONS: Complete resection of liver metastases from sarcoma in selected patients is associated with prolonged survival. Hepatectomy should be considered when complete gross resection is possible, especially when the time to the development of liver metastasis exceeds 2 years.     

Subcardial resection for gastric cancer

The method of subtotal gastric resection for cancer, stipulating for lower esophageal sphincter and gastric cardia, was elaborated in the clinic. Good immediate results, low rate of postoperative complications, the absence of gastroesophageal anastomosis sutures insufficience together with significant improvement of functional results due to preservation of lower esophageal sphincter function permit to recommend subcardial gastric resection as a method of choice in a distal gastric third cancer as well as in the early gastric corpus cancer.