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。     

�����г���ֱ������ת�Ʋ���ԭ����Ĵ���

结直肠癌肝转移发生率高,且临床就诊者大多数肝转移灶为不可切除。尽管关于不可切除结直肠癌肝转移病人原发灶的处理尚有一定争议,但随着结直肠癌原发灶处理经验的积累,多学科综合治疗团队(MDT)模式的开展,转化性治疗思维的应用,"个体化治疗"原则的实施,针对不可切除结直肠癌肝转移病人原发灶的处理逐步形成包括手术切除原发灶在内较合理的综合治疗体系。手术切除、新辅助治疗与姑息治疗的合理选择是改善不可切除结直肠癌肝转移病人生存质量及提高生存期,获得最佳治疗效果的关键。     

��ֱ������ת�Ƶ��������ƾ��ߣ�ͬ���г����Ƿ����г�

当结直肠癌确诊并发现伴有同时性肝转移时,原发灶和转移灶手术时机的选择尚存争议。学术界传统观点是首先切除结直肠癌原发灶,然后再分期切除肝转移灶,但是近年来原发灶和转移灶同期切除的理念得到迅速发展,在一些特殊病例,甚至还会选择先切除肝转移灶,再切除原发灶的"逆向策略"。因此,当前结直肠癌伴同时性肝转移的外科治疗仍缺乏统一的规范,尚需高级别循证医学证据来支持。对于每例结直肠癌肝转移病人,需经过多学科查房讨论,制定个体化的综合治疗方案。     

转化治疗在结直肠癌肝转移中的作用(附12例报告)

总结12例结直肠癌肝转移的临床治疗经验。2008年1月—2009年12月我院共收治经转化治疗后再行肝转移灶手术治疗患者12例。肝转移灶经转化治疗后完整切除1、3、5年生存率分别为70.5%、56.3%、31.8%。肝转移灶经转化治疗后完整切除是结直肠癌肝转移获得潜在治愈的唯一机会。     

个体化治疗直肠癌同时性肝转移

肝转移是影响结直肠癌预后的重要因素之一。一般认为手术切除是唯一可能治愈结直肠癌肝转移的治疗手段。而近年随着新辅助化疗与肿瘤物理消融技术以及微创技术的进展,尤其在生物一心理一社会的现代医学模式背景下,对可以手术切除的结直肠癌同时性肝转移患者如何选择更为合理的手术方式尚存在较多争议。中国医科大学附属盛京医院收治1例直肠癌同时性肝转移患者经新辅助化疗后腹腔镜下肝转移癌微波消融＋开腹结直肠癌根治性切除术的联合序贯治疗,为同类患者治疗方式的个体化选择提供参考。     

结直肠癌肝转移的规范化治疗

结直肠癌发病率逐年升高,超过50％的患者会发生肝转移.随着治疗理念的不断发展以及治疗水平的提高,结直肠癌肝转移目前被认为是潜在可治愈性疾病,其预后也有了显著改善.但是,如何选择治疗方法的问题也随之产生.对于结直肠癌肝转移的规范化治疗,应该包括影像学检查,治疗方式的选择以及多学科团队(MDT)诊断治疗等多个方面,同时应该针对患者制订个体化治疗方案.笔者就结直肠癌肝转移影像学检查方式的选择,不同治疗方法的疗效比较,肝转移灶的外科治疗以及MDT诊断治疗模式等内容进行讨论.     

结直肠癌肝转移外科治疗近况

外科治疗结直肠癌肝转移已被公认是积极有效的方法,能明显提高结直肠癌病人的生存率。近年影像学的发展,有可能较全面、准确地对肝转移灶进行定性定位诊断;对肿瘤生物学特性,认识的进一步提高,导致手术指征、术后处理及肝转移灶的治疗原则有所更新。采取综合治疗可望能进一步提高结直肠癌肝转移病人的预后。     

再谈结直肠癌肝转移外科治疗新理念

肝转移是影响结直肠癌预后的重要因素[1-2],在众多的治疗方法中仅有手术治疗术后5年生存率为34%～38%[3-4].但超过85%的结直肠癌肝转移初诊患者无法接受手术切除,其中一部分为肝转移灶潜在可切除或伴有可切除肝外转移灶的患者.随着手术观念和技术的革新以及综合治疗手段的不断完善,更多的结直肠癌肝转移患者有获得治愈的希望[5-6].现就结直肠癌肝转移手术适应证概念的更新予以阐述.     

结直肠癌肝转移的外科治疗现状

结直肠癌肝转移实施肝叶切除是有效的治疗方法 ,切除率和术后生存率均已有明显提高。对于肝切除术后复发是否再次切除 ,以及肝外转移灶及肝门淋巴结的处理尚有争论。作者复习文献并对此方面的进展加以综述。一、结直肠癌肝转移的首选治疗———肝叶切除术结直肠癌发生肝转移同期行结肠切除和肝转移灶的切除可望获得较高的肝切除后 5年存活率。原发灶切除后发现的肝转移 ,肝叶切除后同样能长期存活。切除后的 5年存活率达 16%～ 45 % ,手术死亡率在 5 %以下〔1～ 3〕。直肠癌肝转移是可治愈的 ,肝切除是安全的、也是最有效的治疗〔4～ 6〕,并…     

结直肠癌肝及肝外转移外科治疗策略

根治性切除是结直肠癌肝转移唯一有治愈希望的治疗方法。如何提高根治性切除率成为结直肠癌肝转移治疗的主要研究方向。目前认为肝转移灶能否切除不是决定于要切除的部分而是决定于拟保留的肝组织,既要全部切除所有癌灶(R0),又要保留足够的残肝功能,残肝流入、流出道与胆管良好。结直肠癌合并肝脏转移是否同期手术仍存在争议,越来越多的学者认为在不进行较大的肝切除时,同期手术对患者有利。手术切除的边界不再强调"1cm原则",而是强调切缘阴性。以奥沙利铂为基础的新辅助化疗可以使40%原本无手术机会的患者得到根治性切除。合并肝外病变(肺、肝门淋巴结,腹腔转移)时不全是手术禁忌证。肝转移术后复发的再切除长期生存率与首次切除类似。世界许多国家正在制定循证医学基础上的结直肠癌肝转移外科治疗规范。现将结直肠癌肝转移外科治疗策略作一综述。     

��ֱ������ת��������������빲ʶ

??Surgical treatment of liver metastases of colorectal cancer: agreement and controversy XU Jian-min??ZHONG Yun-shi. Zhongshan Hospital, Fudan University; Endocopic Research Institute, Fudan University, Shanghai 200032, China
Corresponding author: XU Jian-min, E-mail: xujmin@yahoo.com.cn
Abstract Surgery is the best treatment for liver metastases of colorectal cancer, but there are some controversy, such as: neoadjuvant chemotherapy for resectable cases, treatment of colorecal cancer for unresectale liver metastases cases, liver metastases of rectal cancer, microinvasive surgery and extra-hepatic metastases. The focus of the controversy is the hope that more liver metastases of colorectal cancer can be cured.     

不同阶段结直肠癌肝转移的手术策略

结直肠癌患者容易发生肝转移,手术是目前治疗结直肠癌肝转移的最佳手段。但肝转移的发生时机不同,所采取的手术策略也不同。结直肠癌确诊时发生肝转移的患者,其手术时机一直存在争议;结直肠癌根治术后发生肝转移的患者只要具有手术指征,均应再次实施手术治疗;部分暂不能手术的结直肠癌肝转移患者,多采用化疗、RFA、介入等辅助治疗可使患者重新获得手术机会,但在临床应用中也存在不少困惑。因此,针对不同阶段的结直肠癌肝转移,应采用多学科综合治疗,制订个体化的治疗方案才是改善患者预后的关键。     

大肠癌肝转移术前化疗后的最佳手术时机

化疗联合手术治疗已逐渐成为结直肠癌肝转移病人的标准治疗方式。对于可切除的大肠癌肝转移病人是否需要术前化疗仍存在争议。存在预后不良因素时应接受术前化疗,术前化疗不应＞6周期。不可切除的肝转移病人均应接受术前化疗,术前化疗后定期复查,如转化为可切除,应立即切除。一般认为,停用化疗4周后可以手术切除肝转移灶,但如果联合贝伐单抗,应在停止治疗6~8周后进行手术。     

��ֱ������ת��ͬ���г���Ӧ֤������֢����

结直肠癌肝转移手术策略的选择是结直肠癌治疗的热点和难点之一。同期肝切除手术因其具有避免多次手术打击、不会中断连续的系统化疗等优点,受到越来越多学者的青睐。对于一般状况较好,原发灶可切除,肝转移灶小且多位于周边或局限于半肝,肝切除范围较小时,肝外转移可切除的病人,可考虑同期肝切除手术。认真进行术前评估,严格筛选合适病例,提高手术操作水平并加强围术期管理有助于减少并发症的发生,改善病人预后。     

�󳦰���ת����ǰ���ƺ���������ʱ��

??The best timing of preoperative chemotherapy for liver metastases of colorectal cancer XING Bao-cai, WANG Hong-wei. Department of Hepato-bilio-pancreatic Surgery I, Peking University School of Oncology??Beijing Cancer Hospital??Beijing 100142, China
Corresponding author??XING Bao-cai, E-mail??xingbaocai88@sina.com
Abstract The combination of surgery and chemotherapy has become the standard treatment for patients with liver metastases of colorectal cancer. There is controversy that preoperative chemotherapy should be considered in patients with resectable liver metastases of colorectal cancer. The patients with prognostic factor of poor survival should be received preoperative chemotherapy. Surgery should be performed after a maximum of 6 cycles of preoperative chemotherapy. In patients with unresectable liver metastases, there is no question regarding the indication of chemotherapy. They should be carefully monitored and performed surgery as soon as the metastases become resectable. Surgery can be performed after 4 weeks from the last cycle of chemotherapy, and 6-8 weeks following chemotherapy plus bevacizumab.     

Surgical treatment for pulmonary metastases from colorectal cancer

Blalock first reported pulmonary resection for metastatic colorectal cancer in 1944. Since then, surgical resection of pulmonary metastases has been generally accepted as a standard therapeutic procedure in properly selected cases. Recently, the criteria of eligibility have been progressively expanded according to the development of radiological diagnosis using helical computed tomography (CT), widespread of minimum invasive video-assisted thoracic surgery. In this review summarized the surgical treatment of pulmonary metastases from colorectal cancer based on the recent literatures. Major areas of controversy remain with respect to the following aspects: prognostic factors (i.e., number of metastases, size of tumor, disease free interval, preoperative serum carcinoembryonic antigen level), procedure of operation (i.e., role of video-assisted thoracic surgery, lymphonode dissection), indication of surgical treatment on metastases both lung and liver, role of repeat thoracotomy for recurrence. For all above-mentioned points it appeared reasonable to try to the cooperative multicentric clinical prospective study.     

大肠癌肝转移的诊断及外科治疗

目的：总结和分析大肠癌肝转移的早期诊断和手术治疗。方法：通过对大肠癌肝转移病例进行回顾性分析,讨论大肠癌的早期诊断及外科手术切除治疗等相关问题。结果：18例中,依靠CT、B超及CEA定量检测获得诊断者10例,术中探查获得诊断者8例。手术方式分为肝段切除、肝楔形切除及肿瘤剜出术。生存5年者2例,生存4年者3例,生存3年者5例,生存2年者5例,生存1年者3例。结论：手术治疗是大肠癌肝转移最有效 的治疗方法,主流术式应为不规则肝切除,切缘距肿瘤＞1．0cm为大肠癌肝转移的根治性切除术。     

The time interval between primary colorectal carcinoma resection to occurrence of liver metastases is the most important factor for hepatic resection. Analysis of total course following primary resection of colorectal cancer

The lack of any other effective treatment for colorectal liver metastases makes hepatic resection a primary treatment consideration. Between January 1980 and December 1996, 36 patients with metachronous liver metastases who underwent hepatic resection were reviewed. The age, sex, site of primary lesion, stage, size and number of hepatic metastases, and time interval between primary colorectal carcinoma resection to occurrence of liver metastases (disease-free interval, DFI) were documented. DFI was 569 days on average. Complete removal of primary colorectal cancer and metastatic liver tumour with histologically negative resection margins was accomplished in all cases. The 5 year survival rate following the first operation for primary colorectal cancer was 43.1%. The length of DFI influenced, independently, patients' prognoses based upon not only univariate but also multivariate survival analysis (P<0.01). We conclude that the DFI is the independent prognostic factor for metachronous liver metastases after curative resection of primary tumour.     

大肠癌肝转移的早期诊断和治疗：附89例报告

总和分析大肠癌肝转移的早期诊断与治疗结果。方法对 大肠癌肝转移病人通过胚原Ｂ超,门静脉造影下ＣＴ扫描检查,提出早期诊断措施。对肝转移根治切除２１例与肝转移灶未切除４０例行放疗,插管化疗,等治疗后进行３、５年生存率的比较。结论大肠癌肝转移以早期诊为和术根治性切除肝转移灶治疗效果最好。     

Colorectal metastasis (liver and lung)

Distant metastases are the major cause of death for colorectal carcinoma patients. Depending on the primary tumor's stage, liver metastases occur in 20% to 70% of patients and lung metastases in 10% to 20%. Unlike many other cancers, the presence of distant metastases from colorectal cancer does not preclude curative treatment. Surgical resection remains the only treatment that can ensure long-term survival and cure in some patients, but only a minority of liver metastases are amenable to surgery. New treatment modalities including portal vein embolization, perioperative chemotherapy and local destruction with cryotherapy or radiofrequency ablation may make more patients suitable for surgical resection of hepatic metastases and may prolong survival in cases of nonresectabilitv. The availability of new active drugs has changed the treatment of liver metastases from colorectal cancer.