Tannapfel A, Reinacher-Schick A
Institut für Pathologie, Ruhr-Universität Bochum.
Z Gastroenterol. 2008 May;46(5):435-40. doi: 10.1055/s-2008-1027151.
Modern combination chemotherapies, mainly including oxaliplatin or irinotecan, have demonstrated a significant increase in response rates. This led to the concept of down-sizing irresectable liver metastases from colorectal cancer, thereby achieving secondary resectability and possibly cure. However, these benefits of preoperative chemotherapy must be weighed against potential side effects to the surrounding normal liver tissue. In particular, in patients with pre-existing liver disease combination therapy can cause liver damage which may exceed mere steatosis of hepatocytes and lead to inflammation, cholestasis and bleeding. In correspondence to the "non-alcoholic steatohepatitis" (NASH) the term "chemotherapy associated steatohepatitis" (CASH) has been proposed in the literature. Platinum derivatives, in particular, can lead to damage of the hepatic microcirculation and the so-called sinusoidal obstruction syndrome (SOS). Few reports mention an increase in perioperative morbidity after combination chemotherapy. However, there are no comprehensive data on the individual risk of a patient for postoperative complications. If elevated liver enzymes are detected before chemotherapy and cannot readily be explained through liver involvement by the tumor, then close monitoring of enzymes should be performed and a biopsy may be considered in unclear cases. We recommend that the histological changes observed in the liver be quantified and classified by a unifying scoring system and propose, in correspondence to the hepatitis activity scores, a modified scoring system.
现代联合化疗，主要包括奥沙利铂或伊立替康，已显示出缓解率显著提高。这催生了缩小无法切除的结直肠癌肝转移灶的概念，从而实现二次可切除性并有可能治愈。然而，术前化疗的这些益处必须与对周围正常肝组织的潜在副作用相权衡。特别是，在已有肝脏疾病的患者中，联合治疗可能导致肝损伤，这种损伤可能不仅仅是肝细胞脂肪变性，还会引发炎症、胆汁淤积和出血。与“非酒精性脂肪性肝炎”（NASH）相对应，文献中提出了“化疗相关性脂肪性肝炎”（CASH）这一术语。特别是铂类衍生物，可导致肝微循环损伤和所谓的窦性阻塞综合征（SOS）。很少有报告提及联合化疗后围手术期发病率增加。然而，对于患者术后并发症的个体风险，尚无全面的数据。如果在化疗前检测到肝酶升高，且无法通过肿瘤累及肝脏轻易解释，那么应密切监测酶水平，在情况不明时可考虑进行活检。我们建议对肝脏中观察到的组织学变化通过统一的评分系统进行量化和分类，并对应于肝炎活动评分，提出一种改良的评分系统。
