Ann Surg：结直肠癌肝转移可行肝移植

2013-02-19 ecoliDH5 DXY

影响患者存活率的术前因素　　无法通过手术切除的结直肠癌肝转移(CLM)患者预后较差，其存活时间很少超过5年。尽管对于患有原发性及部分继发性恶性肿瘤的患者，经过筛选后进行肝脏移植术可获得较佳的预后，但是目前普遍认为，结直肠癌肝转移仍为肝脏移植的绝对禁忌症。在1995年之前，曾针对结直肠癌肝转移患者进行过数例肝脏移植术，但其预后很差(5年存活率:18%)，因此最终放弃了针对结直肠癌肝转移患者进行的

影响患者存活率的术前因素

　　无法通过手术切除的结直肠癌肝转移(CLM)患者预后较差，其存活时间很少超过5年。尽管对于患有原发性及部分继发性恶性肿瘤的患者，经过筛选后进行肝脏移植术可获得较佳的预后，但是目前普遍认为，结直肠癌肝转移仍为肝脏移植的绝对禁忌症。在1995年之前，曾针对结直肠癌肝转移患者进行过数例肝脏移植术，但其预后很差(5年存活率:18%)，因此最终放弃了针对结直肠癌肝转移患者进行的肝脏移植术。与那时相比，目前患者在接受肝脏移植后的存活率总体约提高了30%。在此基础上，结直肠癌肝转移患者有望通过肝脏移植术达到约50%的5年存活率。为此，挪威奥斯陆大学医院的Aksel Foss博士等人进行了一项初步研究，该研究目的为，考察结直肠癌肝转移(CLM)患者在接受肝脏移植后的潜在长期整体存活率(OS)。该项研究结果发表于2013年1月28日在线出版的《外科学年鉴》(Annals of Surgery)杂志上。

　　在此项前瞻性初步研究中，无法通过手术切除的结直肠癌肝转移患者(n = 21)接受了肝脏移植术治疗。该研究主要的患者入选标准为，仅出现肝脏转移的结直肠癌肝转移患者、其原发性肿瘤经手术切除，并接受了至少6周的化疗。

　　研究人员通过Kaplan-Meier方法，估算得到患者1年、3年及5年整体存活率分别为95%、68%及60%。病情转移复发现象较为普遍(主要为肺转移)。然而，较大比例的复发可通过手术治疗，经过随访(中位随访时间为27个月；范围8-60个月)后发现，33%的患者未出现疾病征象。此外，肝脏移植术前肝脏肿瘤负荷、初次手术至肝脏移植术间的时间跨度以及化疗后的病情进展均被认定为显著预后因素。

该项研究表明，患者的整体存活率高于既往报道中的化疗方案，而后者为该患者群体现有唯一治疗方式。此外，无法通过手术切除的结直肠癌肝转移患者整体存活率与可通过手术切除的结直肠癌肝转移患者，以及经反复肝脏移植的良性肿瘤患者的存活状况相当。研究人员认为，基于预后因素对手术策略进行筛选后，可进一步改善患者的预后情况(该临床研究编号为ClinicalTrials.gov: NCT01311453)。

与肝移植相关的拓展阅读：

Liver Transplantation for Nonresectable Liver Metastases From Colorectal Cancer

Objective: The objective of this pilot study was to investigate the potential for long-term overall survival (OS) after liver transplantation for colorectal liver metastases (CLMs).

Background: Patients with nonresectable CLMs have poor prognosis, and few survive beyond 5 years. CLMs are currently considered an absolute contraindication for liver transplantation, although liver transplantation for primary and some secondary liver malignancies shows excellent outcome in selected patients. Before 1995, several liver transplantations for CLMs were performed, but outcome was poor (5-year survival rate: 18%) and liver transplantation for CLMs was abandoned. Since then, the survival rate after liver transplantation in general has improved by almost 30%. On the basis of this, a 5-year survival rate of about 50% after liver transplantation for CLMs could be anticipated.

Methods: In a prospective pilot study, liver transplantation for nonresectable CLMs was performed (n = 21). Main inclusion criteria were liver-only CLMs, excised primary tumors, and at least 6 weeks of chemotherapy.

Results: Kaplan-Meier estimates of the OS rate at 1, 3, and 5 years were 95%, 68%, and 60%, respectively. Metastatic recurrence of disease was common (mainly pulmonary). However, a significant proportion of the recurrences were accessible for surgery, and at follow-up (after median of 27 months; range, 8-60), 33% had no evidence of disease. Hepatic tumor load before liver transplantation, time from primary surgery to liver transplantation, and progressive disease on chemotherapy were identified as significant prognostic factors.

Conclusions: OS exceeds by far reported outcome for chemotherapy, which is the only treatment option available for this patient group. Furthermore, OS is comparable with liver resection for resectable CLMs and survival after repeat liver transplantation for nonmalignant diseases. Selection strategies based on prognostic factors may further improve the outcome (ClinicalTrials.gov: NCT01311453).

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2013-02-21 ms6747015003810650

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2013-02-21 crystal0564

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