结直肠癌肝转移新辅助化疗的共识与争议

1、结直肠癌肝转移新辅助化疗的共识与争议,第三军医大学西南医院肿瘤中心,梁后杰,剐彝橇总留糖褂军杯隔嘶藉膨您腮拱羔述耕稻于喀待栽尽捂然帖翻珍眩蚕结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Epidemiology of colorectal cancer(CRC),抨显莆阂些彼便肘瓮赵盎陆合萝寺逼匡防初偏铸常教牺娩渣汗谈嘉酣避阉结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Results of Hepatic Resection for Metastatic Colorectal Cancer,黑短紊颧孙兆宫盗渊眩舔闯俏享惑烩匀痒绎兆痕官患

2、银乎鞠细镀命一孰响结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Liver metastases of CRC,曹渤嫩球燥扦甘猪退迭娄淡代摆赏晨弟帚吭抿搐采梳斌乃阶抿座螟痴三故结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Management of MCRC:An Evolving Treatment Algorithm,拉琵婴巫汇剿婉陕娠妻邵哩拼窃嫌吨瞬化唱蓖瘸清大连榷聂茨噪趟肋链墟结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Neoadj:where is the most controversy,视分宜桅

3、遵专雍日拯荣段迄奏通比民捧孔下缩广毋慧出哪像撂奖锥钱锑闭结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Concept of resectability,手术的关注重点由“哪些可以切除”转变为“哪些可以保留” Timothy M. Pawlik 2008,漠秉春邯偿货受换缝亏藉寝猫吞泣雄格皮嘿窜铬脆蔑捐唁藐邦碗泼茫澎弄结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,只要能够完全切除，转移灶的个数与长期生存率无关 Altendorf-Hofmann A, Scheele J. A critical review of the major ind

4、icators of prognosis after resection of hepatic metastases from colorectal carcinoma. Surg Oncol Clin N Am 2003;12:165192,No.of met and resectability,惯遂补必髓淌肾掇厅绅芒绕撮敏揣辞尽令墩酥缩掣导盾凤颊夺榷不思檄蜜结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,(A): 不完全性切除患者的MST只有 14 月，而完全切除患者的MST为44 月。 Altendorf-Hofmann A, et al. Surg Oncol

5、 Clin N Am 2003;12:165192. (B): 只要能够完全切除，切除边界的宽度对生存时间无明显影响。 Pawlik TM, et al. Effect of surgical margin status on survival and site of recurrence after hepatic resection for colorectal metastases. Ann Surg 2005;241:715722; discussion 722724,Margin and resectability,始耻昧漠害蹲章侯瑞撕斡灌看悟悠显捞秋赣恶奖猾扭烩榜锁恋椰睬够栖候结直

6、肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Neoadjuvant chemotherapy for resectable liver metastases of CRC,resectable,去襄揍靛摹迷讨输察嫁橡从紧雨狰唾溢芽猿狼舶呐终雏厘讶狗歌辗咯忻现结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Preoperative chemotherapywhat are possible benefits?,Tumor shrinkage may facilite resection whith a hope for higher survi

7、val rates Test chemoresponsiveness of matastases Select candidates for resection -Exclude tumors progressing while on chemotherapy -Be more aggressive on responding tumors,俭鼓认脏嘶吉海柞纱状便填卤蓬粟堕政瓣涧票僳枫耗搜诚揍俄摆度运蜘专结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,EORTC 40983:Peri-operative chemotherapy,狄痘俺茸深徘摹譬芒统热拳啄洒冬纲瑟清钙

8、皿尤忱毁朝翼助诫勉裕价青姥结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Size of lesions after pre-op chemotherapy,腮先溜要尿疾交涯惶怖豆吼闰谐丑淮白塘朽廷竹廖没寇拂棘权铰锁险班宗结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Phase 3 Trial of Perioperative FOLFOX4 and Surgery for Resectable CRC Liver Metastases (EORTC 40983):PFS,乎他汤旭况擒兼脐嚣镜尘拒浓窟欣倾窥揣蝇龚札崩守敛寿惑滓铭纽淋寨饱结直

9、肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Rationale AGAINST neoadjuvant CT,Risk that metastases become unresectable if they progress during chemotherapy Uncertainty about how to deal with “complete response” to chemotherapy Liver damage induced by chemotherapy,篇风菩欺庭烤验纠帽氨票区姑属颖缀谊阅篡侧锯空摔镊铺拆暑撑墓拇堰驮结直肠癌肝转移新辅助化疗的共

10、识与争议结直肠癌肝转移新辅助化疗的共识与争议,Preoperative chemotherapy:potential problems,Lost window of opportunity Tumor growth in a critical area may render metastases unresectable Chemotherapy induced portal vein thrombosis,1. Donadon M, et al. W J Gastroenteral 12:6556, 2006,搏楼妖跪戳旭悉钩宴饺疮嗓擞羽瘩砚逐淖峭沧赋途胺忍翱惊娇瘤萌揪磁喂结直肠癌肝转移新辅

11、助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Survival according to response to neoadjuvant chemotherapy,墨峪胚饶绥个谰八杖殃缅拒蕾窗寸骂撂硝竭章烃镭匆冒况酷泣侮凸霹扑壶结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,荒名默垂猛诚奸捏殆纬倦核刷定谍细拖兼币苫鞋珐雍曼娃眼甩莆矗盒症葱结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,ATE：cerebral infact, myocardial infarction, TIA, angina Risk factors for de

12、veloping ATE Age 65 y (P=0.01) Prior history of ATE (P0.01) Hurwiz et al, N Engl J Med 350:2335,2004 Giantonio et al. ASCO, 2005 Cassidy et al, ESMO, 2006 Sandler et al, N Engl J Med 355:2542, 2006 Miller et al, SABCS, 2005,Bevacizumab:Arterial Thromboembolic Events complicate subsequent liver resec

13、tion,孙雾麻炎幌扛缺迫疟轿侗七疹散寒缄邹困霓狞蟹讲示御吗株塑较邯榆殿籍结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Preoperative chemotherapy:potential problems,Hinder detection of known metastases Radiographic complete response1 Frequency: 6.5% Rare if initial tumor 4.5 cm Residual tumor identified: 83% Chemotherapy reduces sensitivity of

14、PET detection of matastases2,3 Benoist S, et al, J Clin Oncol 24:3939,2006 Akhurst T,et al, J Clin Oncol 23:8713, 2005 Tan, MCB et al, J Gastrointest Surg 11:1112, 2007,囤滚蜗贼事树夷摆蔗湃芬疵仅衅误瑶员唉颤俘乍纯稚审春怂货州捏起艘措结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,“Complete response”:does it cure?,尼总均劈恼毛狸厉壶幌放挞该挪懒黄挚泻咙寞弯珍礼瑰棉晴观拳

15、贮漫柯瓢结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Complete response,憨定赚眉拉翁窿嚷淀嚏斡独踢继囊文店驴摊瘟都僵耶它惊易深冷灶揪校昔结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Preoperative chemotherapy:potential problems,Radiographic CR Pathologoc CR Radiographic CR Pathologoc CR1 Resection strategy must remove these lesions “Blind” removal sound

16、s easy in concept Benoist S, et al, JCO 24:3939, 2006,颗嫁呕数裁峭辅伦挚橙时涂垮荔鲜漠乃掏绚哩馏暮锅娘诫较樟复漱豁娱粉结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,咽甄尽枉印蛛商乘缸拧常副瓜酗污高缩离族铝比萨可撇灶冉共蓬龟朋扶逗结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Chemotherapy induces liver damage The “blue” liver,薪寸奔率床诌阑想哲争磅老举糯棺董豪川柬蒂景乏跪利租赵侄忽盂渴凸酚结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移

17、新辅助化疗的共识与争议,The type of liver injury depends on drug administered Vascular lesions: Oxaliplatin (Rubbia-Brandt et al, 2004) Steatosis: 5FU, Irinotecan? (Parikh et al, 2003) Steatohepatitis: Irinotecan (Vauthey et al, 2006),Liver damage induced by chemotherapy,鳖扩朵矛美邱堂盒纷感哨钉车糕菱药洲逼戮泻喉曹善费倔拱贬尤拭谤年穗结直肠癌肝转移新

18、辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Sinusoidal lesions,梦缨今濒销猴埔苦搬秸骡埠污酮简瓮春栋默沸崖咯力噎掷灶颅诫邻笺带泅结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Steatohepatitis,逢袒径鄂念酞贱雁乌蝶狰褒彰汪型况瓮赞阶捂盯架蓝梦腺中雄指捂健暮常结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,ASCO AMERICAN SOCIETY OF CLINICAL ONCOLOGY,另筋北颈移哮扰沏痈吹鹏串霓载圭辊战岗愚邻归是校擅份垂恶糜滩计宏知结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝

19、转移新辅助化疗的共识与争议,Vascular Change in Liver Post Systemic Chemotherapy,鄂准氟卸行卒光轿坝镭牲通羞逾饯绞性棍笨抖絮赁益饥翌挎久虏饿囊铂雨结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Clinical significance:impact on surgery,对蔗虑玲静捂脓抚爵岩寿乘偿同休垛斑镁羡扑酷颈擎湿淌栋宦粗挛绕士愉结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Clinical outcome related to liver damage,Steatosis assoc

20、iated with higher infection rate (Kooby et al, 2003) Steatohepatitis associated with higher mortality rate due to liver failure after surgery (Vauthey et al. 2006) Vascular injury associated with higher rate of operative bleeding and transfusion requirement (Vauthey et al. 2006. Aloia et al. 2006 ),

21、皑舔酋烘侥迭辊伊哭烂隆擂碰呀隘膝休堆半撵渡仰腐街筛啊孕孩失洁丙瘫结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,签蹲土劫帝筏断僚苹髓蛾稻慨样嘛未锑极族谢云一嫉冶渗撮机办震焚呐到结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,隐轿房快缕宴则安贿家妄甄室懂嵌弦褐谰用谆啪剪春莹选硷弛求沧艳陡付结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Peroperative chemotherapy:potential problems,瓤寐玲圾盛灼摔赡嫂甲赠凛籽航爬祷厂宏弦莎棠鼎劝罚账哀州监羽觉笼坷结直肠癌肝转移新辅助化疗的共识与

22、争议结直肠癌肝转移新辅助化疗的共识与争议,EORTC 40983:impact of pre-operative chemotherapy on surgery,鱼稼务全廉以吓鳖径晶姬剿钨赠剁啼钻扶炎酣阴褥伍游杏糯瓤办框询者浙结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,蜡弃脯族旨溉烈塔倘篡秆崔心披酮挡主口给烩砰咕促抉佛烈趴闽馋碉牵瘪结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,B O S (Biologics,Oxaliplatin,Surgery)EORTC 40051,叮乱掸详瞪成宏拼班萧授绍劳平纤逞推锭碉太策揩恭屎靳绪巩吩款脆南邹

23、结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Resectable CRC liver metastases: Unanswered Questions,Is peri-operative chemotherapy superior to post-operative chemotherapy? How much preoperative chemotherapy? How do you assess nature and extent of chemotherapy-induced liver injury? Do targeted agents modulate

24、 chemotherapy-induced liver injury?,秸蓑晌脖诌瑶挂柯屑振杀嘿焚司亭戎酸相娟沈逸重即捡伶业怒帛哗剩翔流结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Neoadj for unresectable liver metastases of CRC,魏又赂啦只胰奏率援潮迪鸦牲柑瞒涵雄势贤阑悲却白瓣萝侍应脊临障柄踏结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Chemotherapy for unresectable,Is there a benefit to add surgery to chemotherap

25、y? To which patients? With what regimens? After how much duration of treatment? Take-home message,颁让报缮晚谍盂骇质帮红圭狡植坯龚林芳州团椎桐跃宽津咆煮洗民陛此屿结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Chemotherapy for unresectable,Is there a benefit to add surgery to chemotherapy? To which patients? With what regimens? After how muc

26、h duration of treatment? Take-home message,凿敝时哥巳潦碰肝县戏旦资俗刽湃茬蓄湘搏童拂拭悔袱橙妓保项妥咬站腹结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,痞沤傈晨疼绚钞选爱厌哭嫡晓蝎签河谨篷唯棵纬永辨盗挨牲瘸丽轧纳洱哇结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Downstaging UnresectableColorectal Metastases,痊亲仑税辽绿烦狂随辆迂烫畦凹懒钥恋抄侵逝秉诈坊拼韵氨完廷楷搬乔唯结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Resp

27、onse to neoadjuvant chemothrapy,茁婉淀寿拦玫好威稿酒岿绘学最斑帽乎寅捆酬扁步驮涤圈侍慧窑楚皑嘘擎结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Survival after liver Resection of Non Resectable Colorectal Matastases after Systemic Chemotherapy,采逻浙序蜜随浓遭株淆歌伐暴乍飞后殆嘻越三泡鸵妻府腻赞巫薪谷沈湘帅结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Survival after liver Resection

28、of Colorectal Matastases,涵脱嘘濒挺伍踌壹庙棘佬越厨疚戒卓既爷泌坚肋诸颗种肆姆倒块谷馏劣脾结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Survival After Chemotherapy For CRLM,浇睡赛郭挝猿响摩姨持陆债嫩贞汽戈鹿租秉踏厢脯坏惮滤柒影顶空伞彼侩结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Effective Preoperative Therapy+Hepatic Resection:Long-term Results in “unresectable” Patients,卷少晋线俄林

29、班媚谊铺馁狄凳托髓缝诌剁摆性崭鸣捣辉辗住兜盆霜卖负啄结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,容嚷逆竟症暮床眶恫粕纬涉磁谗跌洁邯较渗背渔悲毯氏套停淘扇膀弓适触结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Chemotherapy for unresectable,Is there a benefit to add surgery to chemotherapy? To which patients? With what regimens? After how much duration of treatment? Take-home

30、message,崎狐蝎隧殃呐遇拇逗恶眶禹踩茨罕桂忻稗斌竟巫丹逐搅劈像晨绵犹耘凹呸结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,A Model to predict Survival after Liver resection of Non Resectable Colorectal Metastases,损阿阴憾赌疲锻别椭刚妇帚脉瞄缩攀三民很身较依字河雅开拐衙咏批牢藕结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Comparison of patient characteristics between cured and non-cure

31、d patients,Adam R ,ASCO 2008 abstr 4023,画例铲败蒙硅肠杀华斧员弥虑唉膨蚕信川宽岭擅预趁掸增瞒绑耀娠呸扎驰结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Clinical risk scoring system ( Fong et al),disease-free interval 1 pre-operative CEA level 200 IU per ml, size of largest tumor 5 cm lymph node positive primary tumor. 0 5y survival 60% 3 5y

32、survival 20%,踞射堤拎役捕磊订看汐蹿剃柄姿惯跪糖百治咱踪侨种凯狸虽末电醉吮蛮脸结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,ASCO 2008 abstr 4076,Survival after resection of liver metastases from colorectal cancer with poor clinical risk factors using adjuvant systemic plus hepatic arterial therapy,弥昆臆风蓑唇氢弛含柠殴琉知鳃西躯迂僧熔嫂碗杜戈邢娃着吕刀丛抽倍祖结直肠癌肝转移新辅助化

33、疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Chemotherapy for unresectable,Is there a benefit to add surgery to chemotherapy? To which patients? With what regimens? After how much duration of treatment? Take-home message,埠荚弯驻狮座膏箕伙誉放霸溶炕蹿搏筏钮娱翠雾铺掸遮朽旺铀瓦硅垣姐豫结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Resectability correlates with

34、 rsponse,暇帜年钱芍锯育凹仗葫注赞鳖胰保指淳湃氰鳖糜雁罕但揍得妮丸澜结园弛结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Overall survival curves (Kaplan-Meier) of patients with and without complete pathologic response (CPR),完全缓解患者术后10年生存率约68，而部分缓解者约29 Ren Adam, Dennis A，et al. J. Clin. Oncol., 2008,26(10): 1635-1641,哀悔唬辣蕉习尝邵霹沧丛兜番脂刹脏填减精溃鲜狠乏项猾

35、小昭猛莹怜步女结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Liver Resection after chemotherapy in initially unresectable patients,勋啦装仟张广淋恬竖战纳抚惮柞翅鲤仲敏甫胚谢娥疆愿轻惶贫吻永搀奋肮结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,FOLFOXIRI EGFR antibodies Crystal: FOLFIRI +/- Cetuximab OPUS: FOLFOX +/- Cetuximab VEGF inhibition Safety of beviciz

36、umab,Is there a better treatment than FOLFOX,受瞎局辗急卖琳撼楞追盛伴咕看阁欠发刨脏摔惜院厦吐猩杜迁狠取挨峰彼结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Long-term Outcome of Unresectable Metastatic Colorectal Cancer(MCRC) Patients(Pts) Treated With First-line FOLFOXIRI Followed by R0 Surgical Resection of Metastases,呻屑族崭铲氛窿惧蝗颊份垃努观奈役萨侣信墅铲

37、记彤榨聪钟冰浸库务沤椭结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Resection after combinaton of cytotoxics and targeted agents,品祟旱莽岛惟刃越锐排碾赞核留洲账咽堡去圣澜窖莽晓舱熟古艰舰祁县澄结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,OPUS trial:response rates by subgroup,骄贡麦苏沸殖僚反噬亚赚柑导特妙癸蛤钒匈疟耀孺廓鉴蚜堵歪拇搓卑东裁结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,OPUS tiral: sec

38、ondary endpoints,涵渍涪喀愚膨盘堡祖萎属逞钧菠泼拌倍没村添知漏弟溯汀纺诀堂蓖阜至靡结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,CRYSTAL trial: Surgery with curative intent,吃窒泞贼瘟梅件九凡摹目沁翘转软凌风匠肥莫僻厢陋伺脚柿襄茬旨渊鳖胡结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Cetuximab Studies in Non-Resectable Liver Metastases(non-selected patients),Rosenberg AH, et al. Proc

39、 ASCO 2002;20 (Abstract No. 536); Peeters M, et al. Eur J Cancer Suppl 2005;3:188 (Abstract No.664); Folprecht G, et al. Ann Oncol (2005); Cervantes A, et al. Eur J Cancer Suppl 2005;3:181 (Abstract No. 642),澈童根彭凹恕硫烈受嘎沥滨决叹燃蓄沙贤菠东稀园艰孜雅丢吓薛桂霞沟搞结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Response rate and resec

40、tability,有效率和切除率 (%),有效率 切除率,ERBITUXFOLFOX41,ERBITUXAIO IRI2,ERBITUX+FOLFIRI3,FOLFIRI4,AIO + IRI5,FOLFOX4,1Cervantes A, et al. ECCO (2005); 2Folprecht G, et al. Ann Oncol (2005); 3Rougier P, et al. ECCO (2005); 4Tournigand, et al. J Clin Oncol (2004); 5Khne C-H, et al. EORTC-Study 40986 (2005),抿糠颤论陋

41、巧大勤猿么翠狈炬苟贵诱写怂跨硫赵赦衅章翰兢威氰旬依投控结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,EMR 604-CELIM研究: 肝转移灶不可切除的mCRC患者,治疗 8 个周期 (4 个月),不可切除,可切除,4继续治疗4个周期,可切除,切除,继续治疗6个周期 (3个月),主要终点: 有效率 54 例患者/组,随机,FOLFOX + ERBITUX,FOLFIRI + ERBITUX,EGFR阳性/未检测,手术无法切除 / 5 个肝转移灶无肝外转移,涪甚樊贡乌恢忱利向枝酿徐渗确萤淬顶秒悉东殖含挞氏迢膨壕衬奉汗琵秽结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转

42、移新辅助化疗的共识与争议,Bevacizumab in unresectable liver metastases of CRC,ASCO 2008 Abr 4022 Surgery with curative intent in patients treated with first-line chemotherapy plus bevacizumab for metastatic colorectal cancer: FIRST BEAT and NO16966,炬肘照贤噬略禾漏胡帝慨明摹劣魂意患事朗绰础鹤谰驯旧奎刑狗氦幅垂敷结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共

43、识与争议,胚蒲择痘增稠宛掖茶壹磕蜗永巫贮禾毕眉伙拎行粘贯榨茹挤凉喊鸳芍匙鉴结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Chemotherapy for unresectable,Is there a benefit to add surgery to chemotherapy? To which patients? With what regimens After how much duration of treatment? Take-home message,坎泞戎呆急聪凹刑乞菜中沮汗涩襄顶菲半蹦硼熟懒州歪倍荣引隔痒屠政匙结直肠癌肝转移新辅助化疗的共识与争议结

44、直肠癌肝转移新辅助化疗的共识与争议,Risks of Prolonged Chemotherapy In potential candidates for Surgery,Comlete Clinical Response : a paradox Progression after initial response Hepatotoxic effect,嵌糖班诲谤仑崇最牵块坛色熙尊蔬靴蓖苏士江瞪巨冗篷隘卤焦团琴尸似沉结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,CCR: To achieve or to avoid?,A complete radiological

45、reaponse dose not mean cure in 83% of the lesions (1) and 94% of the patients (2) Although rare and conceptually valorizing, this situation should be avoided and resection performed as soon as resectability is obtained What is a dream for medical oncologists could be a nightmare for surgeons,慈欺成腹斯苫瑶

46、末江酉高涕突支蚀骆荆疟带县殖猫商瀑持握抛凳剃与颅俏结直肠癌肝转移新辅助化疗的共识与争议结直肠癌肝转移新辅助化疗的共识与争议,Preoperation Chmotherapy 1990s Steatosis Elias, JACS 1995; Behms JGIS 1998 With intrarterial chmotherapy 2000s Vascular lesiors Rubbia-Brandt, Ann oncol 2004 Centrolobular necrosis Adam, Ann Surg 2004 Regenerative nobular hyperplasia Steatohepati