[复发性结直肠癌肝转移：谁能从二次肝切除中获益？]

Konopke R, Volk A, Gastmeier J, Ehehalt F, Distler M, Saeger H-D, Kersting S

Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der , Technischen Universität Dresden, Deutschland.

Zentralbl Chir. 2014 Apr;139(2):226-34. doi: 10.1055/s-0032-1328565. Epub 2013 Jul 11.

BACKGROUND

Hepatic recurrence is seen in approximately 40 % of patients undergoing hepatectomy for colorectal metastases. The authors assessed the benefit and the main prognostic factors for a second liver resection of recurrent colorectal metastases.

METHODS

This study reports the experience with second liver resections for recurrent liver metastases at a German University Hospital. A total of 39 parameters from 60 patients were identified from a prospective database and analysed as to their influence on recurrence-free survival and overall survival.

RESULTS

At a median follow-up of 26 months (range: 2-173 months) after second hepatic resection, recurrence-free survival at 3 and 5 years were 50 % and 37 %, respectively. The overall survival at three and five years were 61 % and 52 %, respectively. Recurrence was identified in 58.3 % of the patients. Recurrences involved exclusively the liver in 19 patients (31.6 %). By multivariate analysis (Cox proportional hazard model), a time interval between diagnosis of the liver metastases of less than 24 months after operation for colorectal primary carcinoma (HR: 6.47, p = 0.002), a CEA level of 4.0 ng/mL or more (HR: 3.48, p = 0.004) at the time of first liver metastases and a size of second liver metastases of 80 mm or more (HR: 4.73, p = 0.007) were independent prognostic factors for a reduced recurrence-free survival. A repeat recurrence of liver metastases without the option of curative resection was the only risk factor for overall survival after second hepatic resection (p = 0.009). In these cases, mortality risk was 4.51-fold, however, when the second liver recurrence was resectable, the mortality risk increased only 1.4-fold.

CONCLUSIONS

Technically resectable recurrent colorectal hepatic metastases should be resected the same as the first metastases. Characteristics of the primary metastasis as well as parameters of the hepatic recurrence are shown to influence the prognosis of patients after resection of recurrent liver metastases. Repeat resection of colorectal liver metastases allows for improved survival in patients even after two previous liver operations.

背景

在接受肝切除术治疗结直肠癌肝转移的患者中，约40%会出现肝复发。作者评估了复发性结直肠癌肝转移患者进行二次肝切除的益处及主要预后因素。

方法

本研究报告了德国一家大学医院复发性肝转移患者二次肝切除的经验。从一个前瞻性数据库中确定了60例患者的39项参数，并分析了它们对无复发生存期和总生存期的影响。

结果

二次肝切除术后的中位随访时间为26个月（范围：2 - 173个月），3年和5年的无复发生存率分别为50%和37%。3年和5年的总生存率分别为61%和52%。58.3%的患者出现复发。19例患者（31.6%）的复发仅累及肝脏。通过多因素分析（Cox比例风险模型），结直肠癌原发癌手术后肝转移诊断时间间隔小于24个月（HR：6.47，p = 0.002）、首次肝转移时癌胚抗原（CEA）水平≥4.0 ng/mL（HR：3.48，p = 0.004）以及二次肝转移瘤大小≥80 mm（HR：4.73，p = 0.007）是无复发生存期缩短的独立预后因素。肝转移瘤再次复发且无法进行根治性切除是二次肝切除术后总生存期的唯一危险因素（p = 0.009）。在这些情况下，死亡风险增加4.51倍，然而，当二次肝复发可切除时，死亡风险仅增加1.4倍。