结直肠癌肝转移的治疗进展

目前,结直肠癌正逐渐成为一个越来越影响当今世界人类健康的问题.而结直肠癌肝转移是结直肠癌患者最主要的死亡原因,肝转移灶无法切除患者的中位生存期仅6.9个月,5年生存率接近0[1],而肝转移灶能根治性切除患者的中位生存期为35个月,5年生存率达30％～50％[2].故结直肠癌肝转移已成为目前结直肠癌治疗的重点和难点之一.     

手术治疗为主的综合治疗在结直肠癌肝转移中的应用体会

目的探讨以手术治疗为主的综合措施治疗结直肠癌肝转移的疗效。方法对我科2005年12月～2011年10月收治的29例结直肠癌肝转移患者的临床资料进行回顾性分析,所有患者均接受以手术治疗为主的综合治疗。结果 29例患者共行33次肝切除术,均无围手术期死亡。术后成功随访20例,16例目前仍存活,存活时间为0.5～5.5年,其中4例再次出现肝转移并再次接受手术治疗,余12例无肿瘤复发;4例死于结肠癌复发。结论以手术治疗为主的个体化综合治疗是结直肠癌肝转移的有效治疗方法,对复发性肝转移癌选择性再手术有利于提高治愈率。     

结直肠癌肝转移的外科防治

目的探讨结直肠癌肝转移的防治,对提高患者的长期生存和改善其预后具有重要意义.方法通过手术切除有可能根治的一种实体瘤的转移性病变,对于多发性、无法切除的肝转移则首先选用肝动脉滴注化疗.结果对结直肠癌肝转移的治疗,已从消极转为积极多途径的综合治疗,取得一定的效果.结论结直肠癌肝转移是可以积极预防和治疗的.     

结直肠癌肝转移不同治疗方式的预后比较

目的探讨不同治疗方式对结直肠癌肝转移生存时间和无复发生存时间的影响。方法回顾性分析2002年1月至2013年5月期间解放军总医院收治的71例结直肠癌肝转移患者的临床资料,分析干预对结直肠癌肝转移患者生存时间和无复发生存时间的影响。结果 71例结直肠癌肝转移患者的原发灶均行根治性切除。对肝转移灶,20例未予干预(未干预组);20例行肝转移灶切除,20例行射频消融,11例行肝转移灶切除+射频消融(所有接受干预的患者为干预组)。Cox比例风险模型结果显示,在控制其他因素的情况下,干预对生存(HR=1.724,P=0.043)和无复发生存(HR=0.701,P=0.048)均有影响,接受干预患者的生存情况和无复发生存情况较好。结论在对结直肠癌行根治性手术的条件下,对结直肠癌肝转移灶给予干预措施可以延长结直肠癌肝转移患者的生存时间和无复发生存时间。     

结直肠癌肝转移消融与外科切除的治疗选择与时机

结直肠癌是全球第三高发恶性肿瘤,易发生肝转移。消融治疗与外科切除是结直肠癌肝转移有效且安全的局部治疗方法,可在全身治疗有效的基础上,有效控制局部病灶,延长患者生存期。药物治疗的进步使很多既往不宜局部治疗的结直肠癌肝转移患者获得了局部转化治疗机会。然而对于不同治疗目标、不同肿瘤负荷的结直肠癌肝转移,消融治疗与外科切除干预的时机以及术式尚没有明确的界限。本文对结直肠癌肝转移消融治疗与外科切除的研究进展以及治疗时机选择进行讨论。     

结直肠癌肝转移的治疗进展

影响结直肠癌预后的因素有很多,结直肠癌肝转移就是其中的重要原因之一.肝转移是结直肠癌最常见的血道转移方式,文献报道约10%～25%的结直肠癌患者在接受原发灶的手术治疗时已经出现了肝转移,另有约25%的患者在术后随访中发现肝转移[1,2],50%以上的结直肠癌最终发生肝转移,而肝转移是结直肠癌死亡的主要原因之一.本文就近年来国内外文献对结直肠癌肝转移的诊治进行综述.     

结直肠癌肝转移的中医药防治

结直肠癌是包括自盲肠至直肠的整个肠段的癌肿,是常见的恶性肿瘤.结直肠癌由于早期临床症状不明显,早期诊断率较低,到临床症状明显时,已多属中晚期.结直肠癌的治疗,目前仍以手术切除为首选方法.结直肠癌手术切除率和治愈率有了一定的提高,但是结直肠癌合并肝转移相当常见,15%～25%的结直肠癌患者发现肿瘤诊断时即有肝转移(同时性肝转移),.在结直肠癌切除后患者随诊中20%～50%将发生肝转移(异时性转移).手术时结直肠癌同期肝转移率为15%～25%[1],20%～35%的肝唯一转移部位[2].因此,迫切需要提高结直肠癌的治疗效果,特别是延长结直肠癌术后患者的生存期,提高生存质量,防治结直肠的肝转移.近十余年来,结直肠癌诊断治疗水平快速提高,在早期结直肠癌的手术根治治疗,中晚期结直肠癌的综合治疗等方面取得了较大进展,结直肠癌患者虽经更为合理的根治性手术,但5年生存率仍徘徊在50%左右,其根本原因在于结直肠癌的转移和复发尚未得到有效控制.因此,转移是结直肠癌治疗的主要障碍,控制转移是决定结直肠癌患者预后的关键因素.中医药在结直肠癌肝转移防治方面占有重要地位.     

同时性结直肠癌肝转移的外科治疗

结直肠癌是我国常见的消化道恶性肿瘤之一.进展期结直肠癌肝转移的发生率约50%～70%,因结直肠癌死亡的患者中约50%是肝转移所致,如何处理肝转移成为延长结直肠癌患者生存期的关键[1].     

结直肠癌肝转移外科治疗的争议

肝脏是结直肠癌最常见的转移部位,肝转移是结直肠癌治疗失败的主要原因。外科切除在结直肠癌肝转移综合治疗模式中占据主导地位．也是患者获得治愈机会的重要手段。尽管如此,在结直肠癌肝转移外科治疗领域目前还存在很多困惑和争议．包括结直肠癌肝转移分期系统尚不完善、潜在可切除标准尚未统一、可切除肝转移灶是否需要新辅助化疗、根治切除后辅助化疗方案的选择以及不可切除肝转移灶患者无症状原发灶的处理等。本文依据近年来发表的研究资料,结合自身临床实践,剖析肝转移外科研究领域中不同的观点和依据。     

结直脾性癌肝转移的外科防治

目的　探讨结直肠癌肝转移的防治 ,对提高患者的长期生存和改善其预后具有重要意义。方法　通过手术切除有可能根治的一种实体瘤的转移性病变 ,对于多发性、无法切除的肝转移则首先选用肝动脉滴注化疗。结果　对结直肠癌肝转移的治疗 ,已从消极转为积极多途径的综合治疗 ,取得一定的效果。结论　结直肠癌肝转移是可以积极预防和治疗的。     

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??Risk and prognostic factors of colorectal liver metastases LIANG Li, LIU Tian-shu. Department of Medical Oncology??Zhongshan Hospital, Fudan University??Shanghai 200032, China
Corresponding author: LIU Tian-shu, E-mail: liu.tianshu@
zs-hospital.sh.cn
Abstract Liver is the most common metastasis site of colorectal cancer, and the prognosis of colorectal liver metastases (CRLM)is poor. CRLM are divided into synchronous metastasis and metachronous metastasis. Single factor and multiple factor regression analyses show that the risk factors of CRLM include the depth of invasion, lymph node metastasis, tumor node, differentiation degree, tumor antigen and carbohydrate antigen. The factors influencing the prognosis of CRLM include the size and quantity of liver metastases, primary resection, surgical resection of liver metastases, systemic drug therapy and so on. Therefore, the surgical resection of liver metastases as well as drug therapy to get the opportunity of resection can maximize the survival of patients with CRLM. For a combination of a number of factors, the scoring system can better predict the prognosis of CRLM.     

结直肠癌肝转移危险及预后因素分析

肝脏是结直肠癌最常见的远处转移器官,结直肠癌病人出现肝转移一般预后较差。结直肠癌肝转移分为同时性肝转移和异时性肝转移,对众多的临床以及病理学特征进行的单因素和多因素回归分析提示,影响结直肠癌发生肝转移的危险因素有：浸润深度、淋巴结转移、癌结节、分化程度、癌胚抗原和糖类抗原等。影响结直肠癌肝转移病人预后的因素有：肝转移灶大小及数目、肝外器官转移、原发灶手术切除、肝转移灶手术切除、全身药物治疗等。因此,手术切除肝转移灶、药物治疗获得手术切除机会等治疗模式能够最大程度地提高结直肠癌肝转移病人的存活率。由众多因素组合起来的评分系统,能够较好地预测结直肠癌肝转移病人的预后。     

Prognostic scoring in colorectal cancer liver metastases: development and validation

HYPOTHESIS: A prognostic scoring system for colorectal cancer liver metastases that is derived from unselected patients referred for hepatic resection would improve the applicability and increase the accuracy of prognostication. DESIGN: Retrospective analysis of prospectively documented data; validation against an unrelated cohort from another institution. The median follow-up was 16.4 months (95% confidence interval, 15.0-17.8 months) (original cohort). SETTING: Two tertiary referral centers at unrelated university hospitals. PATIENTS: Independent prognosticators of survival were derived from 337 patients with colorectal cancer liver metastases referred for consideration of liver resection, and prognostic scores were calculated in 269 patients (79.8%) (original cohort). Calculation of prognostic scores was also applied to 193 patients referred and treated in an unrelated institution (validation cohort). MAIN OUTCOME MEASURES: Kaplan-Meier survival curve analysis (log-rank test) between different prognostic groups in the original and the validation cohorts. RESULTS: Independent prognosticators of survival were Dukes stage, number of metastases, and serum concentrations of carcinoembryonic antigen, alkaline phosphatase, and albumin. Significant differences were found in cumulative overall survival between patients assigned to good, moderate, and poor prognoses in the original and validation cohorts (P<.05). Liver resection improved survival in all prognostic groups. However, no patient with poor prognosis and only 19.7% (13 of 66) of patients with moderate prognosis survived 5 years, compared with 62.5% (10 of 16) of patients with good prognosis (P<.001). CONCLUSIONS: This prognostic scoring system is derived from and can be applied to patients with colorectal cancer liver metastases at the time of referral for consideration of surgery. Patients with poor prognosis have no long-term benefit from curative liver resection and should therefore be considered for combined multimodal treatment.     

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目的探讨影响结直肠癌肝转移手术治疗的预后因素。方法回顾性分析中国医学科学院肿瘤医院腹部外科2000年1月至2011年1月资料完整并行手术治疗的123例结直肠癌肝转移病人的临床资料。结果全组病人1,3,5年存活率分别为87.2%,35.6%及21.1%。单因素分析显示肿瘤大小、术前癌胚抗原(CEA)水平、是否R0切除是影响预后的因素(P<0.05)。COX多因素分析显示是否R0切除是影响预后的独立危险因素。结论手术切除是结直肠癌肝转移病人获得长期生存的最佳手段,综合治疗是病人达到R0切除、改善远期疗效的关键。     

Severity Scoring Systems for Prognosis and Efficacy of Polymyxin B-Immobilized Fiber Treatment for Colonic Perforation

Purpose There is no established system for predicting prognosis and evaluating the efficacy of antiseptic treatments such as polymyxin B-immobilized fiber (PMX) according to the severity of peritonitis in patients with colonic perforation. We investigated the predictive value of various severity scoring systems for survival and for the efficacy of antiseptic treatments, to identify high-risk patients. Methods We reviewed 26 consecutive patients who underwent emergency operations between 1996 and 2003 for colorectal perforation not caused by trauma or iatrogenic disease. Several severity scores, i.e., Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), Mannheim Peritonitis Index (MPI), and Multiple Organ Failure (MOF) were calculated and analyzed as predictive scoring systems for prognosis, survival and efficacy of PMX treatment. Results An APACHE II score of 19, a SOFA score of 8, an MPI score of 30, and an MOF score of 7 or more were significantly related to a poor prognosis. With or without PMX treatment, an APACHE II score of 15 or less, a SOFA score of 7 or less, an MPI score of 27 or less, and an MOF score of 7 or less were all related to a good prognosis. Conversely, all patients died when the severity scoring points were higher than 20 in APACHE II, higher than 12 in SOFA, and higher than 39 in MPI. When PMX treatment was given to patients with an intermediate score, no correlation between survival and its efficacy was found, except in the MOF scoring system. Conclusion These severity scoring systems can assist with the prediction of prognosis. They may also be useful for determining if PMX treatment would be unnecessary or ineffective in certain patients. However, the optimal application of PMX treatment in selected patients according to the severity scoring systems needs further investigation. This study was presented at the 104th Annual Congress of the Japan Surgical Society, Osaka, Japan, April 7–9, 2004.     

肝切除治疗结直肠癌肝转移预后影响因素研究进展

结直肠癌是我国最常见的恶性肿瘤之一。临床上,结直肠癌病人首次确诊时已有15%～25%发生肝脏转移,中位生存期约为6个月,然而行手术切除肝转移灶后5年存活率可达60%。近年来,虽然在新辅助化疗和外科技术等方面取得迅速发展,使得病人获得较长的生存时间,但肝切除仍是治愈结直肠癌肝转移（CRLM）病人的主要治疗方式。肝切除术能够改善病人预后,手术应做到R0切除或者达到无疾病证据状态（NED）;若有复发应积极施行二次手术;原发病灶部位以及淋巴结转移情况对预后影响尚有待研究;结直肠癌确诊至发生肝转移时间间隔越长预后较好（＞2年）。然而,肝转移灶的大小、数目、部位情况等,并不是影响手术预后的主要因素。总之,肝切除对CRLM病人具有良好的预后,同时需要结合病人的切缘状态、残余肝体积、原发病灶及淋巴结转移等因素综合考虑。     

肝切除治疗结直肠癌肝转移预后影响因素研究进展

结直肠癌是我国最常见的恶性肿瘤之一。临床上，结直肠癌病人首次确诊时已有15%～25%发生肝脏转移，中位生存期约为6个月，然而行手术切除肝转移灶后5年存活率可达60%。近年来，虽然在新辅助化疗和外科技术等方面取得迅速发展，使得病人获得较长的生存时间，但肝切除仍是治愈结直肠癌肝转移（CRLM）病人的主要治疗方式。肝切除术能够改善病人预后，手术应做到R0切除或者达到无疾病证据状态（NED）；若有复发应积极施行二次手术；原发病灶部位以及淋巴结转移情况对预后影响尚有待研究；结直肠癌确诊至发生肝转移时间间隔越长预后较好（＞2年）。然而，肝转移灶的大小、数目、部位情况等，并不是影响手术预后的主要因素。总之，肝切除对CRLM病人具有良好的预后，同时需要结合病人的切缘状态、残余肝体积、原发病灶及淋巴结转移等因素综合考虑。     

Simple scoring system for the prediction of the prognosis of severe acute pancreatitis

BACKGROUND: In severe acute pancreatitis (SAP), it is important clinically to predict the prognosis at the time of admission. Most scoring systems for severity of acute pancreatitis consist of multiple factors and are complicated. This investigation aimed to propose a simple scoring system for the prediction of the prognosis of SAP. METHODS: Prognostic factors were evaluated by receiver operator characteristic curve analyses and multivariate analysis from data that were obtained on admission of 137 patients with SAP. A simple scoring system with 3 most useful factors was made, and its usefulness was investigated in comparison with conventional scoring systems. RESULTS: Three prognostic factors were selected: serum blood urea nitrogen > or = 25 mg/dL, serum lactate dehydrogenase > or = 900 IU/L, and contrast-enhanced computed tomography finding with pancreatic necrosis. On admission, 137 patients were classified from 0 to 3 by the number of positive items (simple prognostic score [SPS]). Mortality rates for patients whose SPS was 0, 1, 2, and 3 were 2% (1/42 patients), 18% (7/40 patients), 48% (12/25 patients), and 67% (20/30 patients), respectively. Furthermore, when usefulness of SPS was compared with conventional scoring systems, the area under the curve by receiver operator characteristic curve analyses in SPS was 0.83; the Ranson score was 0.83; the Japanese severity score was 0.83; the Acute Physiology and Chronic Health Evaluation II score was 0.81, and the Glasgow score was 0.75. After onset, SPS kept almost same levels from day 2 to day 6, and a significant difference was observed between survivors and nonsurvivors from day 1 to day 6. CONCLUSION: This scoring system that comprised 3 items is simple, is feasible for the prediction of prognosis and conventional scoring systems, and is useful for the selection of the extremely severe patients with SAP on admission.     

External validation of prognostic models among cancer patients undergoing emergency colorectal surgery

BACKGROUND: The aim of this study was to evaluate the predictive accuracy of different scoring systems on patients undergoing emergency colorectal surgery. METHODS: The Acute Physiology and Chronic Health Evaluation II or III, the Simplified Acute Physiology Score II, the Mortality Probability Model II, and the Colo-rectal POSSUM scoring systems were applied to 102 patients who underwent colorectal resection for cancer. Validation of scoring systems was tested by assessing calibration and discrimination. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic curve analysis. RESULTS: Overall, 17 deaths occurred. The Simplified Acute Physiology Score II showed good calibration (x(2) = 1.079, P = .982) and discrimination (areas under the receiver-operating characteristic curve .83). CONCLUSIONS: These data suggest that the SAPS II scoring system was accurate in predicting outcome for patients undergoing emergency colorectal surgery.     

Selection criteria related to long‐term survival following liver transplantation for colorectal liver metastasis

Patients with nonresectable colorectal cancer receiving palliative chemotherapy have a 5‐year overall survival rate of about 10%. Liver transplant provided a Kaplan‐Meier–estimated 5‐year overall survival of up to 83%. The objective of the study was to evaluate the ability of different scoring systems to predict long‐term overall survival after liver transplant. Patients with colorectal cancer with nonresectable liver‐only metastases determined by computed tomography (CT)/magnetic resonance imaging/positron emission tomography (PET)‐CT scans from 2 prospective studies (SECA‐I and ‐II) were included. All included patients had previously received chemotherapy. PET‐CT was performed within 90 days of the liver transplant. Overall survival, disease‐free survival, and survival after relapse based on the Fong Clinical Risk Score, total PET liver uptake (metabolic tumor volume), and Oslo Score were compared. At median follow‐up of 85 months for live patients, Kaplan‐Meier overall survival rates at 5 years were 100%, 78%, and 67% in patients with Fong Clinical Risk Score 0 to 2, metabolic tumor volume–low group, and Oslo Score 0 to 2, respectively. Median overall survival was 101, 68, and 65 months in patients with Fong Clinical Risk Score 0 to 2, metabolic tumor volume–low, and Oslo Score 0 to 2. These selection criteria may be used to obtain 5‐year overall survival rates comparable to other indications for liver transplant.