对非结直肠、非内分泌肿瘤来源的转移性肝癌的肝脏切除术

对非结直肠、非内分泌肿瘤来源的转移性肝癌(NCNELM)的肝脏切除术

――对1452例病人的分析和预后模型的建立

Hepatic resection for noncolorectal nonendocrine liver metastases: analysis of 1452 patients and development of a prognostic model.

Adam R, Chiche L, Aloia T, et al

From the Paul Brousse Hospital Villejuif, France.

OBJECTIVE: To determine the utility of hepatic resection (HR) in the treatment of patients with noncolorectal nonendocrine liver metastases (NCNELM). SUMMARY BACKGROUND

DATA: The place of HR in the treatment of NCNELM remains controversial, primarily due to the limitations of previously published reports and the heterogeneity of primary tumor sites and histologies.

METHODS: A multivariate risk model was developed by analyzing prognostic factors and long-term outcomes in 1452 patients with NCNELM treated with HR at 41 centers from 1983 to 2004.

RESULTS: Hepatic metastases were solitary in 56% and unilateral in 71% (mean diameter, 50.5 mm). Extrahepatic metastases were present in 22%. The most common primary sites were breast (32%), gastrointestinal (16%), and urologic (14%). The most common histologies were adenocarcinoma (60%), GIST/sarcoma (13.5%), and melanoma (13%). R0 resection was achieved in 83% of patients with a 60-day mortality rate of 2.3% and a major complication rate of 21.5%. Tumor recurred in 67% of patients (liver, 24%; extrahepatic, 18%; both, 25%). Overall and disease-free survivals at 5 years were 36% and 21% and at 10 years were 23% and 15%, respectively. In multivariate analysis, factors associated with poor prognosis were patient age >60 years, nonbreast origin, melanoma or squamous histology, disease-free interval <12 months, extrahepatic metastases, R2 resection, and major hepatectomy (all P </= 0.02). A prognostic model based on these factors effectively stratified patients into low-risk (0-3 points, 46% 5-year survival), mid-risk (4-6 points, 33% 5-year survival), and high-risk (>6 points, <10% 5-year survival) groups (P = 0.0001).

DISCUSSION: HR for NCNELM is safe and effective, with outcomes mainly dependent on primary tumor site and histology. For individual patients, a statistical model based on key prognostic factors could validate the indication for hepatic resection by predicting long-term survivals.

讨论:对NCNELM病人行肝脏切除是安全且有效的治疗方式,其治疗效果主要依赖于原发肿瘤的位置和组织学类型。对于病人个体而言,一个基于主要的预后因素的统计模型可以用来评估病人的长期生存情况。

Ann Surg. 2006 Oct;244(4):524-35.

PMID: 16998361 [PubMed - in process]

其最后得出一个预后模型(评分系统 Risk Model):

分数的分配情况

1. 肝外转移在术前或术中还存在:1分

2. 大块肝切除:1分

3. R2 切除:1分

4. 年龄:<30y:0分,30-60y:1分;>60y:2分

5. 无病(瘤)间隙:>24mo:0分;12-24mo:1分;<12mo:2分

6. 原发肿瘤的性质(位置和组织类型):乳腺癌:0分;鳞状细胞癌:2分;黑色素瘤:3分;其他病人均1分

相应的评分和危险情况的对应关系就不多讲了。在Abstract的RESULTS和DISCUSSION里面已经说的很清楚了。另外,法国人对转移性肝癌的研究相当独到,在Ann Surg上面我已经见过不少的报道。