Institut Bergonié, 229 Cours de L'Argonne, 33076 Bordeaux, Cedex, France.
Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Research Hospital & Humanitas University, Via A Manzoni 56, 20089 Rozzano-Milano, Italy.
Eur J Cancer. 2018 Nov;104:195-200. doi: 10.1016/j.ejca.2018.09.030. Epub 2018 Oct 28.
The treatment of advanced colorectal liver metastases (CRLMs) follows the biphasic pattern characteristic of oncological surgery. A phase of escalation-the therapeutic aggressiveness-is followed by a phase of de-escalation aimed at decreasing the morbidity, while preserving the gains in survival. From a maximum of three lesions, the rule no longer limits the number, provided the intervention does not cause lethal liver failure. Technically feasible non-anatomical resections, two-stage hepatectomies, portal vein obliteration and so forth, have pushed the boundaries of surgery far. However, the impact and the biology of metastatic processes have been long ignored. Parenchymal sparing surgery (PSS) is a de-escalation strategy that targets only metastasis by minimising the risk of stimulating tumour growth, while enabling iterative interventions. Reducing the loss of healthy parenchyma increases the tolerance of the liver to interval chemotherapy. Technically, PSS could use any type of hepatectomy, providing it is centred on the metastatic load alongside intraoperative ablation. The PSS concept sometimes wrongly comes across as a debate between minor versus major hepatectomies. Hence, we propose a clear definition, both quantitative and qualitative, of what PSS is and what it is not. Conversely, the degree of selectivity of PSS as a percentage of the volume of resected metastases versus the volume of total liver removed has not been stopped to date and should be the subject of prospective studies. Ultimately, the treatment of advanced CRLMs, of which PSS is a part, needs to be personalised by the multidisciplinary team by adapting its response to each new recurrence.
治疗晚期结直肠癌肝转移（CRLM）遵循肿瘤外科的双相模式。一个阶段是升级——治疗的激进性——然后是一个降级阶段，旨在降低发病率，同时保持生存获益。从最多三个病变开始，只要干预不导致致命性肝衰竭，就不再限制病变的数量。非解剖性切除、两阶段肝切除术、门静脉闭塞等技术上可行的方法已经极大地扩展了手术的边界。然而，转移过程的影响和生物学特性长期以来一直被忽视。保留肝实质手术（PSS）是一种降级策略，其目标仅为转移病灶，通过最小化刺激肿瘤生长的风险，同时实现反复干预。减少健康肝实质的损失增加了肝脏对间隔期化疗的耐受性。从技术上讲，PSS 可以使用任何类型的肝切除术，只要它以转移负荷为中心，并在术中进行消融。PSS 概念有时被错误地视为小肝切除术与大肝切除术之间的争论。因此，我们提出了一个明确的定义，无论是定量的还是定性的，用于定义 PSS 是什么，以及它不是什么。相反，PSS 的选择性程度（以切除的转移灶体积与总肝切除体积的百分比表示）尚未得到确定，应该是前瞻性研究的主题。最终，作为 PSS 一部分的晚期 CRLM 的治疗需要多学科团队通过适应其对每个新复发的反应来进行个体化。
