Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Ann Surg Oncol. 2017 Dec;24(13):3857-3864. doi: 10.1245/s10434-017-6089-7. Epub 2017 Sep 19.
The optimal treatment sequence for patients with advanced rectal cancer and synchronous resectable liver metastases is controversial. We examined the outcomes associated with an individualized selection of classic, reversed, or combined approaches.
Between 1999 and 2014, 268 patients with rectal cancer and synchronous liver-only metastases underwent curative-intent multimodality therapy. Demographics and tumor and treatment details were reviewed. Survival outcomes were examined across treatment sequences and time periods (1999-2003, 2004-2008, and 2009-2014).
Overall, 150 (56.0%) patients underwent primary tumor resection first ('classic' approach), 44 (16.4%) patients underwent simultaneous resection of the primary and liver metastases ('combined' approach), and 74 (27.6%) patients underwent liver resection first ('reversed' approach). Patients who underwent the reversed approach had more liver metastases (3 [2-5]) at presentation (vs. 1 [1-2.5] in the combined approach or 1 [1-3] in the classic approach; p < 0.001). Over time (from 1999 to 2003, to 2009 to 2014), both patients undergoing curative-intent treatment (62-122 patients) and the relative proportion of patients undergoing the reversed approach (6.4-37.7%) significantly increased. Despite higher disease burden, the 5-year overall survival (OS) was higher for patients treated in 2009-2014 versus those treated in 1999-2003 (76% vs. 45%; p < 0.002). Two hundred and ten patients (78%) were rendered free of disease; however, 58 were not due to disease progression or treatment complications, and their 5-year OS was poor at 6%.
Individualized selection of treatment sequence based on the liver metastases and primary tumor disease burden allowed most patients to complete resection of all gross disease, and is associated with a 5-year OS rate approaching that for stage III rectal cancer in the most recent era.
对于同时患有局部晚期直肠癌和可切除肝转移的患者，最佳的治疗顺序仍存在争议。我们通过分析经典、反转或联合治疗方法的治疗效果，来确定个体化选择的优势。
1999 年至 2014 年间，268 例局部晚期直肠癌合并单纯肝转移患者接受了根治性多模态治疗。我们对患者的一般资料、肿瘤和治疗相关细节进行了回顾性分析。同时，我们还对不同治疗序列和时间点（1999-2003 年、2004-2008 年和 2009-2014 年）的生存结局进行了评估。
总的来说，150 例（56.0%）患者首先接受了原发肿瘤切除术（经典治疗方法），44 例（16.4%）患者同时接受了原发肿瘤和肝脏转移灶切除术（联合治疗方法），74 例（27.6%）患者首先接受了肝脏切除术（反转治疗方法）。反转治疗方法的患者，肝脏转移灶更多（3 个[2-5 个]）（相比之下，联合治疗方法为 1 个[1-2.5 个]，经典治疗方法为 1 个[1-3 个]；p<0.001）。随着时间的推移（从 1999 年至 2003 年，到 2009 年至 2014 年），接受根治性治疗的患者数量（62-122 例）和反转治疗方法的相对比例（6.4-37.7%）均显著增加。尽管疾病负担较高，但 2009-2014 年治疗的患者 5 年总生存率（OS）高于 1999-2003 年治疗的患者（76% vs. 45%；p<0.002）。210 例（78%）患者达到无疾病状态，但其中 58 例因疾病进展或治疗相关并发症而未达到无疾病状态，其 5 年 OS 较差，仅为 6%。
基于肝脏转移灶和原发肿瘤疾病负担，个体化选择治疗序列，使大多数患者能够完成所有肉眼可见疾病的切除，5 年 OS 率接近最新时代 III 期直肠癌的水平。
