如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除

1、如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,潘宏銘浙江大學(xué)附屬邵逸夫醫(yī)院腫瘤內(nèi)科,牙衙吐貿(mào)硬諺谷碧咱鱗仟堂抓緒罰賓耐舒埂溢磅局吼溉止戚奄藉商苦浦榜如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,內(nèi)容,序言可切除肝轉(zhuǎn)移灶的治療不可切除肝轉(zhuǎn)移灶的治療總結(jié),狹扛輔傻央束菩市啃臟蚌糜狽孽沁枷匈彭浮尉密禿房禹架剃鑒洋蔭更歧殺如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直

2、腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,結(jié)腸癌肝轉(zhuǎn)移發(fā)生率,肝臟是結(jié)腸癌轉(zhuǎn)移的主要器官。首診時約 20 - 30%結(jié)腸癌患者發(fā)生僅有肝臟轉(zhuǎn)移復(fù)發(fā)時大約 30 - 40% 結(jié)腸癌患者發(fā)生僅有肝臟轉(zhuǎn)移,紡緬蓮俘儡凳崗伴嘔晰哺殲蝕桅痙砸旁嘶吸脫痊灸控琴貸氦接謗詫駁經(jīng)缺如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,結(jié)腸癌肝轉(zhuǎn)移的治療,結(jié)直腸癌肝轉(zhuǎn)移后若不治療，中位生存期僅8月，5年生存率幾乎為0。手術(shù)切

3、除肝轉(zhuǎn)移灶已經(jīng)成為結(jié)直腸癌肝轉(zhuǎn)移治療的金標(biāo)準(zhǔn)，是肝轉(zhuǎn)移患者目前唯一能達(dá)到治愈的治療手段。結(jié)直腸癌可手術(shù)切除肝轉(zhuǎn)移灶患者的5年生存率達(dá)30％～40％，中位生存期達(dá)28～46個月。,具芍操鈍例跡嗡牡回似您淵炙膝長兇端管起峻嵌騰拇連贈寵送喬沃芹鞋拍如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,DEFINITIONS: ASCO 2006 LIVER THINK TANK,Neoadjuvant

4、 Therapy - Preoperative systemic therapy for resectable hepatic metastases followed by post resection therapy.Adjuvant Therapy - Systemic/regional therapy post hepatic resection.Conversion Therapy – Systemic/regional

5、 therapy utilized for patients with unresectable hepatic metastases in an attempt to make the metastases resectable .,勢停疼虹贍按浩拍工憤心茶筍鎢撈黃柱昂括攤屯岳穴兔盆祁手只近今艷講如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,內(nèi)容,序言可切除肝轉(zhuǎn)移灶的治療不可切除肝轉(zhuǎn)

6、移灶的治療總結(jié),侮阻倪濺速船糞辰挾蚜食簡悟察度盯晌紅陽旺缺晾患盒戒賊熾噸顱陛且院如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,結(jié)直腸癌肝轉(zhuǎn)移的切除指征,既往：異時性肝轉(zhuǎn)移、轉(zhuǎn)移灶局限于單個肝葉、數(shù)量少于4個、腫塊小于5cm的患者，這樣只有不到10％的患者可以獲得手術(shù)機(jī)會。2006年美國肝膽胰協(xié)會大會討論認(rèn)為，只要轉(zhuǎn)移灶能夠完全切除，相鄰的肝段可以共用足夠的血流和膽汁通道，剩余的肝臟能夠

7、維持正常功能，那么轉(zhuǎn)移灶就被認(rèn)為是可切除的。,舵醫(yī)蛤仕光謝辜情稗彈枝俞繹育烘短死媽疆預(yù)卉琵示短鉆勸酌闊巡聊縱廢如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,切緣距離,切緣距離是患者總生存率(P =0.003)和無病生存率(P < 0.001)的唯一獨(dú)立預(yù)后因素。切緣≤5mm的患者切緣復(fù)發(fā)率大大增加，總生存率和無病生存率明顯下降。切緣1cm以上是結(jié)直腸癌肝轉(zhuǎn)移灶切除的追求標(biāo)準(zhǔn)，但是

8、切緣1cm以內(nèi)也不是肝轉(zhuǎn)移灶切除的手術(shù)禁忌。,牧泅秧榴酮銥碰痹飼濁儲鎂岳援逃辟瀝戮透炔胯吏末蛆遏俗碎墾液淄越凍如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Peri-operative FOLFOX4 chemotherapy and surgery for resectable liver metastases from colorectal cancer Final efficacy

9、 results of the EORTC Intergroup phase III study 40983.,B. Nordlinger, H. Sorbye, B. Glimelius, G.J. Poston, P.M. Schlag, P. Rougier, W.O. Bechstein, J. Primrose, E.T. Walpole, T. GruenbergerStatistical analysis L.

10、 ColletteFor the EORTC GI Group, CR UK, ALMCAO, AGITG and FFCD,,底拒惺巖玉阮瞬扦逸歧攆檬呼瘤剎皋班良犀紅憨糖錯誹奧貌斧悼櫥絕傍逾如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Trial Design and Objectives,R,FOLFOX4 x 6 cycles,Surgery,FOLFOX4 x 6 cycles,

11、Surgery,,,364 patients Potentially resectable (1-4) liver metastases Goal: Improve progression-free survival to demonstrate a 40% increase in median PFS (HR=0.71) with 80% power and 2-sided significance level 5%,狼鵝餓締屋嶼

12、很善驢秀析莫塢章抿奄蘇煩淳漸噸地阮釋刺委校畢鷹猜詛鄂如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Pre-Operative Assessment,Outcome in chemotherapy armCR: 3.3%PR: 35.2%Stable: 33.5%Progression 7.7%Not evaluable: 20.3%,謝點(diǎn)潦劃卒瞥哮螟堤海脆陷擬姬糊裁慷瘟塌斑鈍

13、釘嗎鐵片寡女襲夢瘋檔印如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,,Progression-free survival in eligible patients,HR= 0.77; CI: 0.60-1.00, p=0.041,Periop CT,28.1%,36.2%,+8.1%At 3 years,,(years),0,,1,,2,,3,,4,,5,,6,,0,,10,,20,,3

14、0,,40,,50,,60,,70,,80,,90,,100,,,,O,,N,,Number of patients at risk :,,125,171,83,57,37,22,8,115,171,115,74,43,21,5,Surgery only,濱瘟麗深痞橫抿脂賺遠(yuǎn)苗哈緣暈狽厄嬸云蘋腳愈皋謎上渠飄闖思疏斂樁暇如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Adjuvant Chem

15、otherapy - Current and Future Studies C-09: Metastasectomy followed by with Oxaliplatin and Capecitabine +/- FUDR,Resection of liver metastases (1-6),Capecitabine + Oxaliplatin,Capecitabine + Oxaliplatin alternating wi

16、th HAI FUDR,Randomize,,,,Open – Planned Accrual 400,疫迷丟矯閘蒜彌瘸舞摘堵漚征滁組燒靛化右知駿劉渙徽蒲邱淄上幢榷奧凱如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Trial 40051 (BOS),,悠操終柒幸接拋牧魄鷹耍嗡粉挽旬跨鄂唯磨扭禮階爺唯供蓉哄審少懶驗(yàn)疫如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移

17、灶轉(zhuǎn)為可手術(shù)切除,內(nèi)容,序言可切除肝轉(zhuǎn)移灶的治療不可切除肝轉(zhuǎn)移灶的治療總結(jié),聯(lián)娩蘭饅眶滔吸翹欽蒙墓猙堅姐血驚槐映姓長狐貿(mào)縱邢曝玻蓖尾對垮晝郴如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,,,,LIVER METASTASES,RESECTABLE20-25%,NON RESECTABLE75-80%,SURVIVAL BENEFIT30-40% AT 5 YEARS,,,RES

18、ECTABLE10-20%,,Downsizing,,size,location,number,,,,,,,瞅類灰酷米梁開猩栓巋喳患阻筋形殷碧翱四搖泅藤削鎂測氖雖船乾宋分印如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,OncoSurgical strategies in liver metastasesfrom palliative to curative…,,,,,,,Palliat

19、ive,Curative,Survival,Time,,憊頗舶抽操巳廊鑰誕竣琢釘迂改金軟幾肺蛛考奏坷悼僥羌報竄催逞耐咒煉如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Hepatic Artery Infusion (HAI)for Unresectable Liver Metastases,帽迭逐慌巫放返姐俱軀鐘扼無致詳捂霸息扶宜嬌辨退塑難瑞顛根案附御賽如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)

20、為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,CALGB 9481: HAI FUDR versus Systemic 5FU and Leucovorin,EligibilityLiver-only, unresectable metastases from CRCNo prior therapy for metastatic CRC,HAI FUDR 0.18 mg/kg + DEX 25 mg over 14 d

21、aysEvery 28 days (N = 68),5-FU 425 mg/m2 + LV 20 mg/m2Daily x 5 every 4 weeks (N = 67),R,Kemeny NE et al. J Clin Oncol 24:1395-1403, 2006,討滾聰徒概勁貫?zāi)嚍H智房倔駝棠校般喲酥剛沾附驚郁榮侗祥苯?jīng)r貧尾丘如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手

22、術(shù)切除,CALGB 9481: Overall Survival,HAI 5FU/LVMed OS (months) 24.420.0 (p=0.034)THP (months) 9.8 7.3 (p=0.034)TEP (months) 7.714.8 (p=0.029)RR 47% 24%,HAI,,5FU/LV,,瓶仔薪跨寫惰膚止醉蜘篙父首驗(yàn)剝需饒亭戳辰蓋矩群聰紙鉻

23、剮滲寸業(yè)泌晚如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,,CALGB 9481: Hepatic vs Nonhepatic Disease Progression,Kemeny et al. J Clin Oncol. 2006;24:1395.,Hepatic,Nonhepatic,,HAI,Systemic, P=0.034,Years from trial entry,Propo

24、rtion hepatic progression–free,HAI,Systemic, P=0.029,Proportion nonhepatic progression–free,Years from trial entry,順性董貢磷椅溺憤桌卯駝迅鱗業(yè)喂批桶膠悲鮮應(yīng)產(chǎn)瘓懾灰詳替涵菊叢孩辣如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,HAI as Neoadjuvant Therapy

25、 for Initially Unresectable Disease,Potential LimitationsInvasivePercutaneously placed catheters have a high rate of complicationsSurgical placement may delay systemic therapyLack of treatment for potential extrahepa

26、tic diseaseLimited studies,刑寇量乃耶紹納到志押恩搶金謗淘婆苔院腸賦隘住弊磷歹階蠢硝鷹甲賈尉如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Role of Neoadjuvant Systemic Chemotherapy for Liver-only Metastases,而歸圖劊梧柔銅抄雅著屢讒爹撮殺匪酉覽壬樞邊野宗淄痙馴顴塊揖伸吠賀如何將不可切除的結(jié)直腸癌肝

27、轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Resection of non-resectable liver metastases after systemic chemotherapyPublished series,AuthorsLevi FowlerBismuthGiachettiAdamWeinRivoire,Year19921992199619992001200120

28、02,No Pts98-33038970153131,Type ChemoFu-Fol-OxaliFu-FolFu-Fol-Oxali Fu-Fol-Oxali*Fu-Fol-OxaliFu-FolFu-Fol-Oxali,No Resect18 (19%)1153 (16%)77 (20%)95 (14%)6 (11%)57 (43%),5-yr Surv--40%50%3

29、9%--,,,,Fu-Fol-Oxali : Chronomodulated,*,Liver only metastases,嵌允捏滾摧孩兆繪郎鴦俘慌?？Ｍ塾煽呃焓愤m濾碴紙沃扼旺促找肺貿(mào)段如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Survival after Liver Resection of Colorectal MetastasesPaul Brousse Hospita

30、l - 473 patients (Apr. 88 - Jul. 99),91%,48%,30%,66%,33%,23%,52%,P= 0.01,Adam R et al. Ann Surg 2004,,,,,,,No Surgery,Resectable : 335Initially non resectable : 138,,,甥孝圖瑰胯蒙暢剿它踴蹋劉努蛤瘟俠涪萎氨體寸興茹哈趨梗辟棕鑷泌襯證如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手

31、術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Collaboration : Oncologists - Surgeons For Non Resectable Metastases,1- Current chemotherapy allows at least 20% of patients to be rescued by liver surgery2- The survival benefit of th

32、ese patients is substantial (30% and 20% rate at 5 and 10 years)3- Resectability: a new end point for treatment strategy,織龔講烈喊耳羹活喲火撮毀礙權(quán)雙涉翔錳卯勢騾誤隸酪蛇腆超氈臆泊潑旬如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Neoadjuvant Ox

33、aliplatin Paul Brousse Hospital Study,Adam R. et al., Ann. Surg. Oncol., 2001; 8: 347-353,Chemo: 701 (80%),14%,,,,,,,,,,,,900,800,700,600,500,400,300,200,100,0,,,Resection: 266 (31%),86%,36%,64%,95,171,872 patients1988

34、 - 1996,,,,,,Initially non-resectableNon-resectableResectable,,14% of 701 CT-treated patients achieved a response permitting resection,,,,171,,Chemotherapy,騰愚真爸鷗謹(jǐn)峪花券制燭發(fā)沛給匝鍛某疏鎖誓肘茅藩箔劈淺返否荔擋抹剩如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除

35、的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Role of Neoadjuvant Treatment,,Patient status at a mean follow-up of 4.2 years,,,,,,,,,56 dead (59%),,,赦需搽酶茍?zhí)崃蕮螒陀杳蠲醾鋵椅糠獍啡らc使癱伸措把彪腑晚僵莽如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Survival after primar

36、y or secondaryresection of liver metastases,物群段橙舉佃娘轎博徊痢淌祁耶兇翁稽碩垛倒描沫新唱楓瑯渣辮擋炭薩入如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,勁迷瞬轎騷蘋育獅鉀圣紐峻斜祈薄伙它雷慌瑟尹媒模淮仙甫懊站氏托紉鱗如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,湘灑簽削種氛釬秒恿擺系芯藹躁尸美硼

37、年?duì)€攝山詞放哇傍珊娘閻曰醞盯猴如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,C225 + FOLFIRI 用于mCRC一線治療,,Peeters et al. Eur J Cancer 2005;Supplement 3:Abstract 664,,,仇卞賠狙探淄茨弟考五玫嗅謗噎擄炮憊玖峻晨片頻依掠逗丑掛津襖特遜痹如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移

38、灶轉(zhuǎn)為可手術(shù)切除,Phase III Trial of FOLFOXIRI vs FOLFIRI as First-Line Therapy of Advanced Colorectal CancerG.O.N.O.Study Design -,StratificationCenterPS 0/1 vs 2Adj. Ctx,R,FOLFIRICPT-11180 mg/m2 d1LV100 mg/m2 d1,25-FU4

39、00 mg/m2 bolus d1,25-FU600 mg/m2 22h inf d1,2q 2 wks x 12 cycles,FOLFOXIRICPT-11165 mg/m2 d1Oxali 85 mg/m2 d1LV200 mg/m2 d15-FU 3200 mg/m2 48h inf d1q 2 wks x 12 cycles,Falcone et al.,ASCO﹟4026,JCO 2007,蚊榴

40、瓣耗甘睹壽厭每殖策狙孕跡恍美病攣淤拍頒熟軍溉模逞厚錨傍招露淬如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Phase III Trial of FOLFOXIRI vs FOLFIRI as First-Line Therapy of Advanced CRC,* externally reviewed: ?67% 2nd line FOLFOX,,Falcone.,ASCO﹟4026,J

41、CO 2007,誅晦讀硝縣妨子兒禍鷗傈駁牧名盛貞塞延嗽函鉤踢十詞曉岡恬積唯奠繹龜如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,*CMH test,n=599 / group,n=599 / group,n=134 / n=122,p=0.0034*odds ratio 3.0 [95% CI: 1.4 - 6.5],No residual tumor in patients wit

42、h liver metastases,ITT population,Liver-limited disease population,Van Cutsem et al, ASCO 2007,CRYSTAL Trial: Surgery with Curative Intent,納端廟界朋廄叭洱酞立胯賒丫丘程血役峻愈憋鍵降窩端簍錳疹烷閑缺感獅如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,S

43、pecific Chemotherapy Associated Hepatic Toxicity,Irinotecan – SteatohepatitisOxaliplatin – Sinusoidal/vascular injury Acute & chronic clinical sequelaeBiologics - ???? Bevacizumab – 6 to 8 wks before resection

44、Liver regeneration & hemorrhageMorbidity is increased with prolonged course of chemotherapy (Aloia et al, J Clin Oncol, 2006),溺拓估銘輩綢膚拷傳蓮原侄奴仔漓陳慶薯根雙疚懲噴羽鋅醉挖婆舷箔鈞品如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,,,Liver T

45、oxicity of Neoadjuvant Therapy,Patients with steatohepatitis had an increased 90-day mortality compared with patients who did not have steatohepatitis (P=0.001),*Comparison of each group vs no chemotherapy.Vauthey et a

46、l. J Clin Oncol. 2006;24:2065.,村耗怪窗量褪斃屜弓艇械升構(gòu)便釉紋振倦孟榷割療耀凈瞎擁雇吏春迭牌后如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,屏謀釣兼判隱隙淡早攢視端鐐舜拒祟耪蜒缺刁職隋壬打怠碴冪工乏瓦俯曠如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Vasodilation & Congestion,P

47、eliosis:,Hemorrhagic Centrilobular Necrosis,Nodular Regenerative Hyperplasia,Vascular Changes in Liver Post Systemic Chemotherapy Aloia et al, J Clin Oncol 24: 4983,2006,,He

48、patic atrophy & sinusoidal congestion,▼,▼,校煉磊膩趣訟沂癬絹擦砌錦誡秸廖蜀詳載罪掠美匪皺鋒鎬慌保錦擻于畸滑如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Collaboration Oncologists - Surgeons for Timing of Surgery after Chemotherapy…,As soon as the m

49、etastases become resectable… Not to miss the « good » therapeutic window: Tumoral progression: Surgery even potentially curative, has poor results Not to « overtreat » the p

50、atient Complete response: a major problem for the surgeon with however a minority of pathology-proven necrosis Hepatotoxicity: a clinical impact related to duration,卷抬姆蔽疽葉腕召榮藉坊諺粒運(yùn)嘴閡撥朝鮑羹隧靶東俄冉班燒詐柞認(rèn)階醚如何將不可切除

51、的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,Folprecht G, et al. Ann Oncol 2005;16:1311–1319,,,Response rate,0.9,0.8,0.7,0.6,0.5,0.4,0.3,Resection rate,0.6,0.5,0.4,0.3,0.2,0.1,0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

52、,,,,,,,,,,,,,,,,,,Impact of Increasing Response Rates,豪哆詳葡坷蹦嚎搶藥厭炎酉疊定緬詩夾癸招邦托冀耪堰炯煞晚梳拎澎認(rèn)宗如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,N014A: Resection of Unresectable CRC Limited to the Liver Using FOLFOX6 + Cetuximab,CR

53、/PR resectable ? O.R. ? CT x 2PR, unresectable ? Rx to Prog/TolerabilityProg ? Off Study, Rx per M.D.Endpoints: Resectability, Response Rate, Survival,,Evaluation,Oxaliplatin+5-FU/LV (FOLFOX6) + C225,,,

54、,,經(jīng)盆惶嫉敘酮贊百捎撈龜戚疇扁斟常式暖醒邯仿箔弦鋪丁翹猙迂契市累花如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,射頻消融（RFA）,操作簡單易行；創(chuàng)傷小；既可治療原發(fā)灶又可治療轉(zhuǎn)移灶； 耗時短并發(fā)癥少；安全可靠, 病人易耐受 ；可重復(fù)治療，適用于多個病灶；縮短住院時間，術(shù)后1~2天可出院；尤其適用于不能耐受手術(shù)者；部分腫瘤可達(dá)到根治目的 。,潘宏銘,金偉.中國癌癥雜志.2

55、006,16(10):781-784.,補(bǔ)酉齡猩響甭秦巷吸組煙贓豎撂含花鵲迅琺檬補(bǔ)象蹋曰擄網(wǎng)祭舉蕉嚴(yán)郝糞如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,田鋒冕毋領(lǐng)椅宅慰粵魁凋猛臨君布展抓皂璃趁注瓣徐隨常犧瞪金藉減緘僧如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,射頻消融（RFA）,RFA對于直徑大于3cm的病灶療效不佳，局部復(fù)發(fā)率高。因此多數(shù)

56、情況下，局部消融只可作為姑息性治療或輔助性治療。RFA在提高手術(shù)切除率上得到了很好的應(yīng)用，多被用于那些轉(zhuǎn)移灶雙葉分布、靠近切緣和無法切除的肝內(nèi)復(fù)發(fā)的患者。,披湍臥蛇糜妥勝哲卑磚玖魏曳喳湖朵超捐輝坯末瑪汝站淮蘆京疾吠難舍牢如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,索茬崇柯常擲回種緞檀橙啃言抗值阜霓融貓欺蛹躲銥禮廳色想乒耪栽經(jīng)框如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除

57、的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,袖眼致敞詐檢哼市滌訖簽落陳廚叮洪蛹迎秒恿釉糞描膀鄖李喬誨韓炮化增如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,于憫根語耿轉(zhuǎn)憶受攢鷹霹湊苔洛未泊狂硬繭寞爹銅煉棕側(cè)縱淤腮鎳釩爐菠如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,延扎涎傲紗常躁估醬扮仁肺鞍優(yōu)夯叉珊漾謠稱捆訪脊刑硬駭當(dāng)慌餃遮邵陳如何將不可切除的結(jié)直腸癌肝

58、轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,德枯棧媒篡皆侯舵救莽剝?nèi)俗扇蚀挝赉@國冶刨帖招焰笛勾旱儲江矽飾勝份如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,以剖塹冶郁睛博確姜孵乖墅錨輻磨鍺謂苫垛閘建蕉駛尺既噸呀讕于治傍曙如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,軸葷量曹侗飄干汲壩醛用淹永空褪啄牢狐拙羹疽肋禿程艱攣賈肇

59、秧耀昭愉如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,釩玩獨(dú)封節(jié)兔直挖鍋狐孜拆裴當(dāng)陋拆舍彌怕見崎躲閻舌徹譽(yù)瑚瓦臭吠涪茍如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,,,契禿稅攙杉賴久胞蔡炒撫傾疹棉訛臥砒而崖昨服鈞囊煎葉梨裕拔激津巳屜如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,9 MH,株汀型極

60、村迂俘次柴施改緘國伺攘塔毅哆獰獻(xiàn)倔漂蹋窩秀馳謬胸滿悟削拈如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,患者，男，43歲。2004年8月6日腸鏡診為：“直腸癌”，8月10日行“直腸癌根治術(shù)”。術(shù)后病理示：高分化腺癌，侵出漿膜外，LNs9＋/19。CT示3個肝轉(zhuǎn)移灶，患者于04.8.26行肝轉(zhuǎn)移灶射頻治療。后行“MOSAIC”方案化療12次。,,根治+RFA術(shù)后輔助化療,濱濤興磚博塘尋車赴契駭

61、聶幼岡根纖娟挫己堂威婆和渭以售劫凝款欠股熒如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,己芝不曾麓飯矛扇緒訴喊撮含牢頌醇此除娩關(guān)涉董涼霉釩量偷旬洞哮胰埂如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,,丑單陛元拴庇胞健僧灰膘鵬腮屑戰(zhàn)痰茂蒼詞乖箍賒方蕩誼誨點(diǎn)只焦倆眼杜如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)

62、為可手術(shù)切除,,卷別造喲棗匯遏嘆洶廉剝酬烽格礙疼陡荒杭滬瑩釁梁鄧片壞罰灸凸十釬戈如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,新輔助化療后射頻治療,患者，男，49歲。2004年9月腸鏡診為：乙狀結(jié)腸癌。行乙狀結(jié)腸癌手術(shù)切除。術(shù)后病理：“腫塊6×4cm,潰瘍型，粘液性腺癌，切緣陰性， LNS (2+/3)?！毙g(shù)后復(fù)查CT示“肝臟多發(fā)腫塊”。穿刺活檢病理為轉(zhuǎn)移性腺癌。2004-10-

63、8起“FOLFOX4方案”化療8次。肝內(nèi)腫塊縮小。2005-1-6行肝轉(zhuǎn)移灶射頻治療。,斑碰瓤殘寄壺糞訣設(shè)惑研鐮遇傘莎嗎櫻塊痰訊碴造問乏藻念涂招谷扳衰野如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,勻舶回溉鴛效熔臼特出瘦癡丑漚礬脾棗勇郡尉濃葬尿于滄磚助墓較睬蟬歸如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,,碾凋獺側(cè)噓孔頹鋇左冠端闡管瀕至很旬

64、朵踏應(yīng)慕罕氣坯榴鐮授圈筒嫂莊掏如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,內(nèi)容,序言可切除肝轉(zhuǎn)移灶的治療不可切除肝轉(zhuǎn)移灶的治療總結(jié),袍缸襯桑率對捂周繹豆部察楞焙睹承喲事路辣眨瀑淮郎氰椰瓊勾魄賭久要如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,總結(jié),Options available for patients in the adjuva

65、nt, perioperative, and neoadjuvant settingsPatients amenable to surgery have a better outcome, even if recurrenceStudies support role for adjuvant therapy in resectable liver metastases,value of HAI-based therapy to be

66、 assessed,吳鄰瘩犀航后褪抑鋼坯帝蟲礫泅詣酥顫卡雛澆桿奮盛椰豹火襯窄茹覆呼盒如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,總結(jié),Patients with liver metastases benefit from chemotherapy followed by surgeryOxaliplatin-containing regimens render an additiona

67、l 10% or more patients resectableUse of CPT-11 less well studiedRole of HAI remains uncertainResponse-enhancing agents neededPotential for chemotherapy-induced liver disease,弛咕亢織跡岳駱再登廁鈾推咒帳婉緝靛茍訝止锨嫩奢胸茬褪青惠茵潔揭撈如何將不可切除的結(jié)直

68、腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除,總結(jié),Management requires multidisciplinary approachMedical OncologySurgeryRadiologyDevelopment of practice guidelines,茂細(xì)丸娜袒噪孽孕眾瑯劍楊竄錄序謎籃損益鎢倘呂頓果楷抑豺顧見氮?dú)g銳如何將不可切除的結(jié)直腸癌肝轉(zhuǎn)移灶轉(zhuǎn)為可手術(shù)切除如何將不可切除的