Poston Graeme J, Adam René, Alberts Steven, Curley Steven, Figueras Juan, Haller Daniel, Kunstlinger Francis, Mentha Gilles, Nordlinger Bernard, Patt Yehuda, Primrose John, Roh Mark, Rougier Philippe, Ruers Theo, Schmoll Hans Joachim, Valls Carlos, Vauthey Nick Jean-Nicolas, Cornelis Marleen, Kahan James P
Department of Surgery, Royal Liverpool University Hospital, Liverpool L7 8XP, UK.
J Clin Oncol. 2005 Oct 1;23(28):7125-34. doi: 10.1200/JCO.2005.08.722.
Most patients with colorectal liver metastases present to general surgeons and oncologists without a specialist interest in their management. Since treatment strategy is frequently dependent on the response to earlier treatments, our aim was to create a therapeutic decision model identifying appropriate procedure sequences.
We used the RAND Corporation/University of California, Los Angeles Appropriateness Method (RAM) assessing strategies of resection, local ablation and chemotherapy. After a comprehensive literature review, an expert panel rated appropriateness of each treatment option for a total of 1,872 ratings decisions in 252 cases. A decision model was constructed, consensus measured and results validated using 48 virtual cases, and 34 real cases with known outcomes.
Consensus was achieved with overall agreement rates of 93.4 to 99.1%. Absolute resection contraindications included unresectable extrahepatic disease, more than 70% liver involvement, liver failure, and being surgically unfit. Factors not influencing treatment strategy were age, primary tumor stage, timing of metastases detection, past blood transfusion, liver resection type, pre-resection carcinoembryonic antigen (CEA), and previous hepatectomy. Immediate resection was appropriate with adequate radiologically-defined resection margins and no portal adenopathy; other factors included presence of < or = 4 or > 4 metastases and unilobar or bilobar involvement. Resection was appropriate postchemotherapy, independent of tumor response in the case of < or = 4 metastases and unilobar liver involvement. Resection was appropriate only for > 4 metastases or bilobar liver involvement, after tumor shrinkage with chemotherapy. When possible, resection was preferred to local ablation.
The results were incorporated into a decision matrix, creating a computer program (OncoSurge). This model identifies individual patient resectability, recommending optimal treatment strategies. It may also be used for medical education.
大多数结直肠癌肝转移患者就诊于普通外科医生和肿瘤内科医生，这些医生对其治疗并无专业兴趣。由于治疗策略常常取决于对早期治疗的反应，我们的目标是创建一个治疗决策模型，以确定合适的治疗程序顺序。
我们采用兰德公司/加利福尼亚大学洛杉矶分校适宜性方法（RAM）来评估切除、局部消融和化疗策略。在全面的文献综述之后，一个专家小组对252例病例中总共1872个评级决策的每种治疗选择的适宜性进行了评分。构建了一个决策模型，通过48个虚拟病例和34个已知结果的真实病例来衡量共识并验证结果。
总体一致率达到93.4%至99.1%，达成了共识。绝对的手术切除禁忌证包括无法切除的肝外疾病、肝脏受累超过70%、肝功能衰竭以及手术不耐受。不影响治疗策略的因素包括年龄、原发肿瘤分期、转移灶检测时间、既往输血史、肝切除类型、术前癌胚抗原（CEA）以及既往肝切除术。当有足够的影像学界定的切缘且无门静脉淋巴结病时，立即切除是合适的；其他因素包括转移灶数量≤4个或＞4个以及单叶或双叶受累。化疗后切除是合适的，对于转移灶数量≤4个且单叶肝脏受累的情况，与肿瘤反应无关。仅对于转移灶＞4个或双叶肝脏受累的情况，在化疗使肿瘤缩小后切除是合适的。如果可能，切除优于局部消融。
结果被纳入一个决策矩阵，创建了一个计算机程序（OncoSurge）。该模型可确定个体患者的可切除性，推荐最佳治疗策略。它也可用于医学教育。
