Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1484, 1400 Pressler Street, Houston, TX 77030, USA.
J Gastrointest Surg. 2013 Jan;17(1):195-201; quiz p.201-2. doi: 10.1007/s11605-012-2022-3. Epub 2012 Oct 3.
With modern multimodality therapy, patients with resected colorectal cancer (CRC) liver metastases (CLM) can experience up to 50-60 % 5-year survival. These improved outcomes have become more commonplace via achievements in multidisciplinary care, improved definition of resectability, and advances in technical skill.
Even patients with synchronous and/or extensive bilateral disease have benefited from novel surgical strategies. Treatment sequencing of synchronous CRC with CLM can be simplified into the following three paradigms: (classic colorectal-first), simultaneous (combined), or reverse approach (liver-first). The decision of whether to treat the CLM or CRC first depends on which site dominates oncologically and symptomatically. Oxaliplatin with 5-fluorouracil/leucovorin (FOLFOX) and irinotecan with 5-fluorouracil/leucovorin (FOLFIRI) are the foundations of modern chemotherapy. Although each regimen has positively impacted survivals, both have the potential for negative effects on the non-tumor liver. Oxaliplatin is associated with vascular injury (sinusoidal ballooning, microvascular injury, nodular regenerative hyperplasia, and long-term fibrosis) but not steatosis. Irinotecan has been associated with steatohepatitis, especially in patients with obesity and diabetes. Steatohepatitis from irinotecan is the only chemotherapy-associated liver injury (CALI) associated with increased mortality from postoperative hepatic insufficiency. Extended duration of preoperative chemotherapy is also associated with CALI.
To determine resectability and to prevent overtreatment with systemic therapy, all patients should receive high-quality cross-sectional imaging and be evaluated by a hepatobiliary surgeon before starting chemotherapy. Even as chemotherapy improves, liver surgeons will continue to play a central role in treatment planning by offering the best chance for prolonged survival-safe R0 resection with curative intent.
随着现代多模态治疗，接受结直肠癌（CRC）肝转移（CLM）切除术的患者 5 年生存率可达 50-60%。通过多学科治疗、可切除性定义的改善以及技术技能的进步，这些改善的结果变得更加普遍。
即使是同步和/或广泛双侧疾病的患者也受益于新的手术策略。同步 CRC 合并 CLM 的治疗顺序可简化为以下三种模式：（经典结直肠优先）、同时（联合）或逆行（肝优先）。首先治疗 CLM 还是 CRC 的决定取决于哪个部位在肿瘤学和症状上占主导地位。奥沙利铂联合 5-氟尿嘧啶/亚叶酸钙（FOLFOX）和伊立替康联合 5-氟尿嘧啶/亚叶酸钙（FOLFIRI）是现代化疗的基础。虽然每种方案都对生存产生了积极影响，但两者都有可能对非肿瘤肝脏产生负面影响。奥沙利铂与血管损伤（窦状气球样变、微血管损伤、结节性再生性增生和长期纤维化）有关，但与脂肪变性无关。伊立替康与脂肪性肝炎有关，尤其是在肥胖和糖尿病患者中。伊立替康引起的脂肪性肝炎是唯一与术后肝功能不全相关的化疗相关肝损伤（CALI）。术前化疗的持续时间延长也与 CALI 相关。
为了确定可切除性并防止过度进行全身治疗，所有患者在开始化疗前都应接受高质量的横断面成像，并由肝胆外科医生进行评估。即使化疗有所改善，肝外科医生也将继续在治疗计划中发挥核心作用，为延长生存时间提供最佳机会，即安全地进行根治性切除。
