Hughes K, Scheele J, Sugarbaker P H
Lahey Clinic Foundation, Burlington, Massachusetts.
Surg Clin North Am. 1989 Apr;69(2):339-59. doi: 10.1016/s0039-6109(16)44790-0.
Overall, hepatic resection appears to be an important means of curing patients with metastatic colorectal cancer isolated to the liver. The only absolute contraindication to surgery was the impossibility of a radical removal of tumor: if residual disease will remain after the hepatic resection, this operation is not indicated. A possible second contraindication to surgery is the presence of tumor in the hepatic or celiac lymph nodes. Such metastases from liver metastases signal a biologic grade of tumor that is almost sure to spread to other sites. However, one patient of the 25 in this group did survive long term when positive lymph node groups were dissected. Further clinical experience with this form of the disease along with trials of regional adjuvant therapies such as intraperitoneal chemotherapy may be needed. The presence of extrahepatic metastases at the time of liver resection should be considered a relative contraindication to this surgery, but if the patient can be made clinically disease free, long-term disease-free survival may result. It seems imperative that all patients with hepatic metastases be evaluated by an experienced hepatic surgeon for a curative resection. If the patient has between one and four metastases, a 25 per cent long-term disease-free survival rate can be expected. Patients who have a radical resection of more than four metastases should be considered to be in an experimental group in whom more data are needed. In our current state of knowledge, making such patients clinically disease free is their only chance for long-term survival. Other factors besides the number of metastases that will affect the prognosis of the patient include the disease-free interval between colorectal resection and liver resection, the pathologic margin of resection on the liver specimen, and the presence or absence of mesenteric lymph node metastases from the primary cancer. These factors should be considered when determining the prognosis in a given patient and should be used as stratification variables in prospective trials. However, from our analysis of available data, these factors should not be considered contraindications to hepatic resection.
总体而言，肝切除术似乎是治愈孤立性肝转移结直肠癌患者的重要手段。手术的唯一绝对禁忌证是无法根治性切除肿瘤：如果肝切除术后仍有残留病灶，则不建议进行该手术。手术的另一个可能禁忌证是肝门或腹腔淋巴结存在肿瘤。这种来自肝转移灶的转移表明肿瘤的生物学分级几乎肯定会扩散到其他部位。然而，该组25例患者中有1例在清扫阳性淋巴结组后长期存活。可能需要对这种疾病形式进行更多的临床经验积累以及开展区域辅助治疗试验，如腹腔内化疗。肝切除时存在肝外转移应被视为该手术的相对禁忌证，但如果患者能达到临床无病状态，则可能实现长期无病生存。似乎所有肝转移患者都必须由经验丰富的肝脏外科医生进行评估，以确定是否适合进行根治性切除。如果患者有1至4个转移灶，预计长期无病生存率为25%。根治性切除超过4个转移灶的患者应被视为实验组，需要更多数据。就我们目前的认知水平而言，使这些患者达到临床无病状态是他们长期生存的唯一机会。除转移灶数量外，影响患者预后的其他因素还包括结直肠癌切除与肝切除之间的无病间隔、肝脏标本的病理切缘以及原发癌肠系膜淋巴结转移的有无。在确定特定患者的预后时应考虑这些因素，并应在前瞻性试验中用作分层变量。然而，根据我们对现有数据的分析，这些因素不应被视为肝切除的禁忌证。
