研究显示结直肠肿瘤分期手术并无必要

佛罗里达州棕榈滩——对4个国际中心1,000例以上患者的回顾性研究显示，原发性结直肠癌和相关肝脏转移病灶同时切除与分期切除的效果相同。约翰霍普金斯大学的Timothy M. Pawlik医生在南方外科学会年会上说：“同步切除结直肠和肝脏转移病灶患者的长期结局取决于肿瘤的生物学特性，而非手术策略。”

Timothy Pawlik博士

约有1/4的晚期结直肠癌患者同时伴有肝脏转移，外科医生通常采用3种不同的切除策略。经典的方法为分期切除，首先切除原发的结直肠癌病灶，之后在另一次独立的手术中切除肝脏病灶。在很少数的病例中，采用相反的分期切除方法，即首先切除肝脏病灶，之后再切除原发性肿瘤。第三种选择为在一次手术中将原发病灶和肝脏转移病灶同时切除。迄今为止，对这些方法进行比较的评估多数使用的是来自单中心的数据，一些病例回顾中仅纳入较少的患者。

Pawlik及其合作者进行的这项研究纳入了1982~2011年间在美国和欧洲的4个大型肝胆中心接受治疗的1,004例患者。其中包括647例首先切除原发性结直肠肿瘤之后在第二次手术中切除肝脏转移病灶的患者，329例在一次手术中切除上述两种病灶的患者，以及28例首先切除肝脏转移病灶之后在第二次手术中切除原发肿瘤的患者。

结果显示，使用不同切除方法的患者在任何结局指标方面均无统计学差异，包括并发症发生率、90天死亡率、局部复发率、中位生存时间或5年生存率。例如，在中位34个月的随访期间，经典分期切除组和同步切除组患者的复发率分别为57%和60%，无统计学差异。在一项对随访期间死亡率相关因素的多变量回归分析中，与经典分期切除方法相比，同步切除组的死亡率增高8%，但这一差异也不具有统计学意义。

研究者总结认为，晚期结直肠癌伴肝脏转移分期切除或一次性切除对患者结局的影响无差异，“长期生存与疾病的部位和程度相关，而与手术策略无关”。

Pawlik医生披露无相关利益冲突。

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By: MITCHEL L. ZOLER, Oncology Practice

PALM BEACH, FLA. – Simultaneous and staged removal of primary colorectal cancer and associated liver metastases worked equally well, a review of more than 1,000 cases at four international centers has shown.

"Long-term outcome of patients with synchronous colorectal liver metastases is dictated by biology, not by surgical strategy," Dr. Timothy M. Pawlik said at the annual meeting of the Southern Surgical Association.
 
About a quarter of patients with advanced colorectal cancer present with synchronous liver metastases, and surgeons have used three different resection strategies. The classic approach has been staged removal of the primary, colorectal cancer first, followed by removal of the liver disease in a separate operation at a later time. In a much smaller number of cases, the staged approach is reversed, with initial excision of the liver disease followed later by removal of the primary tumor. The third option has been to do both excisions during a single operation. Until now, assessments that compared these approaches mostly have used data from a single center, and in several cases the reviews included relatively few patients, said Dr. Pawlik, a surgical oncologist at Johns Hopkins University in Baltimore.

The review done by Dr. Pawlik and his associates involved 1,004 patients treated between 1982 and 2011 at four major hepatobiliary centers in the United States and Europe. The series included 647 patients treated by removal of their primary colorectal tumor followed by a second surgery to remove their liver metastases, 329 patients who had both excisions done during a single operation, and 28 patients who had their liver metastases removed first and then had the primary tumor removed in a second operation.

The data showed no statistically significant difference for any outcome measure, including the incidence of complications, 90-day mortality, local recurrences, median survival, or rate of 5-year survival. For example, during a median follow-up of 34 months, the recurrence rate was 57% among patients treated with a classic, staged approach and 60% among patients who had a simultaneous excision, a difference that was not statistically significant. And in a multivariate regression analysis of factors associated with mortality during follow-up, simultaneous excision linked with an 8% higher mortality rate relative to a classic staged approach, but again the difference was not statistically significant.

"Long-term survival was associated with the location and extent of disease, but not with the surgical strategy," Dr. Pawlik said.

But he also qualified these findings with a couple of caveats. First, the findings "should only be extrapolated to academic centers, major hepatobiliary centers. The findings cannot be extrapolated to the community setting," he said.

Second, he agreed with the discussants of his report that a prospective, randomized trial should be done to definitively prove that surgical strategy has no impact on outcomes.

Dr. Pawlik said he had no relevant financial disclosures.