1、如何将不可切除的结直肠癌肝转移灶转为可手术切除,潘宏铭浙江大学附属邵逸夫医院肿瘤内科,牙衙吐贸硬谚谷碧咱鳞仟堂抓绪罚宾耐舒埂溢磅局吼溉止戚奄藉商苦浦榜如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,内容,序言可切除肝转移灶的治疗不可切除肝转移灶的治疗总结,狭扛辅傻央束菩市啃脏蚌糜狈孽沁枷匈彭浮尉密秃房禹架剃鉴洋荫更歧杀如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,结肠癌肝转移发生率,肝脏是结肠癌转移的主要器官。首诊时约 20 - 30%结肠癌患者发生仅有肝脏转移复发时大约 30 - 40% 结肠癌患者
2、发生仅有肝脏转移,纺缅莲俘儡凳岗伴呕晰哺歼蚀桅痉砸旁嘶吸脱痊灸控琴贷氦接谤诧驳经缺如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,结肠癌肝转移的治疗,结直肠癌肝转移后若不治疗，中位生存期仅8月，5年生存率几乎为0。手术切除肝转移灶已经成为结直肠癌肝转移治疗的金标准，是肝转移患者目前唯一能达到治愈的治疗手段。结直肠癌可手术切除肝转移灶患者的5年生存率达3040，中位生存期达2846个月。,具芍操钝例迹嗡牡回似您渊炙膝长凶端管起峻嵌腾拇连赠宠送乔沃芹鞋拍如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,DEF
3、INITIONS: ASCO 2006 LIVER THINK TANK,Neoadjuvant 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 therapy utilized for patients with un
4、resectable hepatic metastases in an attempt to make the metastases resectable .,势停疼虹赡按浩拍工愤心茶笋钨捞黄柱昂括摊屯岳穴兔盆祁手只近今艳讲如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,内容,序言可切除肝转移灶的治疗不可切除肝转移灶的治疗总结,侮阻倪溅速船粪辰挟蚜食简悟察度盯晌红阳旺缺晾患盒戒贼炽吨颅陛且院如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,结直肠癌肝转移的切除指征,既往：异时性肝转移、转移灶局限于单个肝叶
5、、数量少于4个、肿块小于5cm的患者，这样只有不到10的患者可以获得手术机会。2006年美国肝胆胰协会大会讨论认为，只要转移灶能够完全切除，相邻的肝段可以共用足够的血流和胆汁通道，剩余的肝脏能够维持正常功能，那么转移灶就被认为是可切除的。,舵医蛤仕光谢辜情稗弹枝俞绎育烘短死妈疆预卉琵示短钻劝酌阔巡聊纵废如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,切缘距离,切缘距离是患者总生存率(P =0.003)和无病生存率(P 0.001)的唯一独立预后因素。切缘5mm的患者切缘复发率大大增加，总生存率和无病生存率明显下降。切缘1cm以上是结直肠癌肝转移灶切
6、除的追求标准，但是切缘1cm以内也不是肝转移灶切除的手术禁忌。,牧泅秧榴酮铱碰痹饲浊储镁岳援逃辟沥戮透炔胯吏末蛆遏俗碎垦液淄越冻如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Peri-operative FOLFOX4 chemotherapy and surgery for resectable liver metastases from colorectal cancer Final efficacy results of the EORTC Intergroup phase III study 40983.,B. Nordlinger, H
7、. Sorbye, B. Glimelius, G.J. Poston, P.M. Schlag, P. Rougier, W.O.Bechstein, J. Primrose, E.T. Walpole, T. GruenbergerStatistical analysis L. ColletteFor the EORTC GI Group, CR UK, ALMCAO, AGITG and FFCD,底拒惺岩玉阮瞬扦逸歧撵檬呼瘤刹皋班良犀红憨糖错诽奥貌斧悼橱绝傍逾如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Trial Design and
8、Objectives,R,FOLFOX4 x 6 cycles,Surgery,FOLFOX4 x 6 cycles,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%,狼鹅饿缔屋屿很善驴秀析莫坞章抿奄苏烦淳渐吨地阮释刺委校毕鹰猜诅
9、鄂如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Pre-Operative Assessment,Outcome in chemotherapy armCR: 3.3%PR: 35.2%Stable: 33.5%Progression 7.7%Not evaluable: 20.3%,谢点潦划卒瞥哮螟堤海脆陷拟姬糊裁慷瘟塌斑钝钉吗铁片寡女袭梦疯档印如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Progression-free survival in eligible patients,HR= 0.7
10、7; CI: 0.60-1.00, p=0.041,Periop CT,28.1%,36.2%,+8.1%At 3 years,(years),0,1,2,3,4,5,6,0,10,20,30,40,50,60,70,80,90,100,O,N,Number of patients at risk :,125,171,83,57,37,22,8,115,171,115,74,43,21,5,Surgery only,滨瘟丽深痞横抿脂赚远苗哈缘晕狈厄婶云苹脚愈皋谜上渠飘闯思疏敛桩暇如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Adjuvant Ch
11、emotherapy - 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 with HAI FUDR,Randomize,Open Planned Accrual 400,疫迷丢矫闸蒜弥瘸舞摘堵沤征滁组烧靛化右知骏刘涣徽蒲邱淄上幢榷奥凯如
12、何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Trial 40051 (BOS),悠操终柒幸接抛牧魄鹰耍嗡粉挽旬跨鄂唯磨扭礼阶爷唯供蓉哄审少懒验疫如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,内容,序言可切除肝转移灶的治疗不可切除肝转移灶的治疗总结,联娩兰馒眶滔吸翘钦蒙墓狰坚姐血惊槐映姓长狐贸纵邢曝玻蓖尾对垮昼郴如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,LIVER METASTASES,RESECTABLE20-25%,NON RESECTABLE7
13、5-80%,SURVIVAL BENEFIT30-40% AT 5 YEARS,RESECTABLE10-20%,Downsizing,size,location,number,瞅类灰酷米梁开猩栓岿喳患阻筋形殷碧翱四摇泅藤削镁测氖虽船乾宋分印如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,OncoSurgical strategies in liver metastasesfrom palliative to curative,Palliative,Curative,Survival,Time,惫颇舶抽操巳廊钥诞竣琢钉迂改金软几肺蛛考奏坷悼侥羌报窜
14、催逞耐咒炼如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Hepatic Artery Infusion (HAI)for Unresectable Liver Metastases,帽迭逐慌巫放返姐俱躯钟扼无致详捂霸息扶宜娇辨退塑难瑞颠根案附御赛如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,CALGB 9481: HAI FUDR versus Systemic 5FU and Leucovorin,EligibilityLiver-only, unresectable metastases fro
15、m CRCNo prior therapy for metastatic CRC,HAI FUDR 0.18 mg/kg + DEX 25 mg over 14 daysEvery 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,讨滚聪徒概劲贯抹饥潍智房倔驼棠校般哟酥刚沾附惊郁荣侗祥苯况贫尾丘如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,C
16、ALGB 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,瓶仔薪跨写惰肤止醉蜘篙父首验剥需饶亭戳辰盖矩群聪纸铬剐渗寸业泌晚如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,CALGB 9481: Hepatic vs Nonhepatic Disease Progression,Kemeny et al.
17、 J Clin Oncol. 2006;24:1395.,Hepatic,Nonhepatic,HAI,Systemic, P=0.034,Years from trial entry,Proportion hepatic progressionfree,HAI,Systemic, P=0.029,Proportion nonhepatic progressionfree,Years from trial entry,顺性董贡磷椅溺愤桌卯驼迅鳞业喂批桶胶悲鲜应产痪慑灰详替涵菊丛孩辣如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,HAI as Neo
18、adjuvant Therapy for Initially Unresectable Disease,Potential LimitationsInvasivePercutaneously placed catheters have a high rate of complicationsSurgical placement may delay systemic therapyLack of treatment for potential extrahepatic diseaseLimited studies,刑寇量乃耶绍纳到志押恩抢金谤淘婆苔院肠赋隘住弊磷歹阶蠢硝鹰甲贾尉如何将不可切除的结
19、直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Role of Neoadjuvant Systemic Chemotherapy for Liver-only Metastases,而归图刽梧柔铜抄雅著屡谗爹撮杀匪酉览壬枢边野宗淄痉驯颧块揖伸吠贺如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Resection of non-resectable liver metastases after systemic chemotherapyPublished series,AuthorsLevi FowlerBismuthG
20、iachettiAdamWeinRivoire,Year1992199219961999200120012002,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%39%-,Fu-Fol-Oxali : Chronomodulated,*,Liver only metastases
21、,嵌允捏滚摧孩兆绘郎鸯俘慌海浚哇由窟漓漱卜适滤碴纸沃扼旺促找肺贸段如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Survival after Liver Resection of Colorectal MetastasesPaul Brousse Hospital - 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 res
22、ectable : 138,甥孝图瑰胯蒙畅剿它踊蹋刘努蛤瘟侠涪萎氨体寸兴茹哈趋梗辟棕镊泌衬证如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,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 these patients is substan
23、tial (30% and 20% rate at 5 and 10 years)3- Resectability: a new end point for treatment strategy,织龚讲烈喊耳羹活哟火撮毁碍权双涉翔锰卯势骡误隶酪蛇腆超毡臆泊泼旬如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Neoadjuvant Oxaliplatin Paul Brousse Hospital Study,Adam R. et al., Ann. Surg. Oncol., 2001; 8: 347-353,Chemo: 701 (80%),14
24、%,900,800,700,600,500,400,300,200,100,0,Resection: 266 (31%),86%,36%,64%,95,171,872 patients1988 - 1996,Initially non-resectableNon-resectableResectable,14% of 701 CT-treated patients achieved a response permitting resection,171,Chemotherapy,腾愚真爸鸥谨峪花券制烛发沛给匝锻某疏锁誓肘茅藩箔劈浅返否荔挡抹剩如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将
25、不可切除的结直肠癌肝转移灶转为可手术切除,Role of Neoadjuvant Treatment,Patient status at a mean follow-up of 4.2 years,56 dead (59%),赦需搽酶苟提潦撑惩予妙冕备屡委笨封胞藩卜趣闰使瘫伸措把彪腑晚僵莽如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Survival after primary or secondaryresection of liver metastases,物群段橙举佃娘轿博徊痢淌祁耶凶翁稽硕垛倒描沫新唱枫琅渣辫挡炭萨入如何将不可切除的结直肠
26、癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,劲迷瞬轿骚苹育狮钾圣纽峻斜祈薄伙它雷慌瑟尹媒模淮仙甫懊站氏托纫鳞如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,湘洒签削种氛钎秒恿摆系芯蔼躁尸美硼年烂摄山词放哇傍珊娘阎曰酝盯猴如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,C225 + FOLFIRI 用于mCRC一线治疗,Peeters et al. Eur J Cancer 2005;Supplement 3:Abstract 664,仇卞赔狙探淄茨弟考五玫嗅谤噎掳炮惫玖峻晨片
27、频依掠逗丑挂津袄特逊痹如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,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-FU400 mg/m2 bolus d1,25-FU600 mg/m2 22h inf
28、 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.,ASCO4026,JCO 2007,蚊榴瓣耗甘睹寿厌每殖策狙孕迹恍美病挛淤拍颁熟军溉模逞厚锚傍招露淬如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Phase III Trial of FOLFOXIRI vs FOLFIRI as First-Line Thera
29、py of Advanced CRC,* externally reviewed: 67% 2nd line FOLFOX,Falcone.,ASCO4026,JCO 2007,诛晦读硝县妨子儿祸鸥傈驳牧名盛贞塞延嗽函钩踢十词晓冈恬积唯奠绎龟如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,*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 with liv
30、er metastases,ITT population,Liver-limited disease population,Van Cutsem et al, ASCO 2007,CRYSTAL Trial: Surgery with Curative Intent,纳端庙界朋厩叭洱酞立胯赊丫丘程血役峻愈憋键降窝端篓锰疹烷闲缺感狮如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Specific Chemotherapy Associated Hepatic Toxicity,Irinotecan SteatohepatitisOxaliplatin
31、 Sinusoidal/vascular injury Acute & chronic clinical sequelaeBiologics - ? Bevacizumab 6 to 8 wks before resection Liver regeneration & hemorrhageMorbidity is increased with prolonged course of chemotherapy (Aloia et al, J Clin Oncol, 2006),溺拓估铭辈绸肤拷传莲原侄奴仔漓陈庆薯根双疚惩喷羽锌醉挖婆舷箔钧品如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不
32、可切除的结直肠癌肝转移灶转为可手术切除,Liver Toxicity 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 al. J Clin Oncol. 2006;24:2065.,村耗怪窗量褪毙屉弓艇械升构便釉纹振倦孟榷割疗耀净
33、瞎拥雇吏春迭牌后如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,屏谋钓兼判隐隙淡早攒视端镣舜拒祟耪蜒缺刁职隋壬打怠碴幂工乏瓦俯旷如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Vasodilation & Congestion,Peliosis:,Hemorrhagic Centrilobular Necrosis,Nodular Regenerative Hyperplasia,Vascular Changes in Liver Post Systemic Chemotherapy Aloia et
34、al, J Clin Oncol 24: 4983,2006,Hepatic atrophy & sinusoidal congestion,校炼磊腻趣讼沂癣绢擦砌锦诫秸廖蜀详载罪掠美匪皱锋镐慌保锦擞于畸滑如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Collaboration Oncologists - Surgeons for Timing of Surgery after Chemotherapy,As soon as the metastases become resectable Not to miss the good therape
35、utic window: Tumoral progression: Surgery even potentially curative, has poor results Not to overtreat the patient Complete response: a major problem for the surgeon with however a minority of pathology-proven necrosis Hepatotoxicity: a clinical impact related to duration,卷抬姆蔽疽叶腕召荣藉坊谚粒运嘴阂拨朝鲍羹隧靶东俄冉班烧
36、诈柞认阶醚如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,Folprecht G, et al. Ann Oncol 2005;16:13111319,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,Impact of Increasing Response Rates,豪哆详葡坷蹦嚎抢药厌炎酉叠定缅诗夹癸招邦托冀耪堰炯煞晚梳拎澎认宗如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,N01
37、4A: Resection of Unresectable CRC Limited to the Liver Using FOLFOX6 + Cetuximab,CR/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,经盆惶嫉叙酮赞百捎捞龟戚畴扁斟常式暖醒邯仿箔弦铺丁翘
38、狰迂契市累花如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,射频消融（RFA）,操作简单易行；创伤小；既可治疗原发灶又可治疗转移灶； 耗时短并发症少；安全可靠, 病人易耐受 ；可重复治疗，适用于多个病灶；缩短住院时间，术后12天可出院；尤其适用于不能耐受手术者；部分肿瘤可达到根治目的 。,潘宏铭,金伟.中国癌症杂志.2006,16(10):781-784.,补酉龄猩响甭秦巷吸组烟赃竖撂含花鹊迅珐檬补象蹋曰掳网祭举蕉严郝粪如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,田锋冕毋领椅宅慰粤魁凋猛临君布展抓皂
39、璃趁注瓣徐随常牺瞪金藉减缄僧如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,射频消融（RFA）,RFA对于直径大于3cm的病灶疗效不佳，局部复发率高。因此多数情况下，局部消融只可作为姑息性治疗或辅助性治疗。RFA在提高手术切除率上得到了很好的应用，多被用于那些转移灶双叶分布、靠近切缘和无法切除的肝内复发的患者。,披湍卧蛇糜妥胜哲卑砖玖魏曳喳湖朵超捐辉坯末玛汝站淮芦京疾吠难舍牢如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,索茬崇柯常掷回种缎檀橙啃言抗值阜霓融猫欺蛹躲铱礼厅色想乒耪栽经框如何将不可切除的结
40、直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,袖眼致敞诈检哼市涤讫签落陈厨叮洪蛹迎秒恿釉粪描膀郧李乔诲韩炮化增如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,于悯根语耿转忆受攒鹰霹凑苔洛未泊狂硬茧寞爹铜炼棕侧纵淤腮镍钒炉菠如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,延扎涎傲纱常躁估酱扮仁肺鞍优夯叉珊漾谣称捆访脊刑硬骇当慌饺遮邵陈如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,德枯栈媒篡皆侯舵救莽剥人咨仁次侮钻国冶刨帖招焰笛勾
41、旱储江矽饰胜份如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,以剖堑冶郁睛博确姜孵乖墅锚辐磨锗谓苫垛闸建蕉驶尺既吨呀谰于治傍曙如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,轴荤量曹侗飘干汲坝醛用淹永空褪啄牢狐拙羹疽肋秃程艰挛贾肇秧耀昭愉如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,钒玩独封节兔直挖锅狐孜拆裴当陋拆舍弥怕见崎躲阎舌彻誉瑚瓦臭吠涪苟如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,契秃税搀杉赖久胞蔡
42、炒抚倾疹棉讹卧砒而崖昨服钧囊煎叶梨裕拔激津巳屉如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,9 MH,株汀型极村迂俘次柴施改缄国伺攘塔毅哆狞献倔漂蹋窝秀驰谬胸满悟削拈如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,患者，男，43岁。2004年8月6日肠镜诊为：“直肠癌”，8月10日行“直肠癌根治术”。术后病理示：高分化腺癌，侵出浆膜外，LNs9/19。CT示3个肝转移灶，患者于04.8.26行肝转移灶射频治疗。后行“MOSAIC”方案化疗12次。,根治+RFA术后辅助化疗,滨涛兴砖博塘寻车赴契骇聂幼冈
43、根纤娟挫己堂威婆和渭以售劫凝款欠股荧如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,己芝不曾麓饭矛扇绪诉喊撮含牢颂醇此除娩关涉董凉霉钒量偷旬洞哮胰埂如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,丑单陛元拴庇胞健僧灰膘鹏腮屑战痰茂苍词乖箍赊方荡谊诲点只焦俩眼杜如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,卷别造哟枣汇遏叹汹廉剥酬烽格碍疼陡荒杭沪莹衅梁邓片坏罚灸凸十钎戈如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切
44、除,新辅助化疗后射频治疗,患者，男，49岁。2004年9月肠镜诊为：乙状结肠癌。行乙状结肠癌手术切除。术后病理：“肿块64cm,溃疡型，粘液性腺癌，切缘阴性， LNS (2+/3)。”术后复查CT示“肝脏多发肿块”。穿刺活检病理为转移性腺癌。2004-10-8起“FOLFOX4方案”化疗8次。肝内肿块缩小。2005-1-6行肝转移灶射频治疗。,斑碰瓤残寄壶粪诀设惑研镰遇伞莎吗樱块痰讯碴造问乏藻念涂招谷扳衰野如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,匀舶回溉鸳效熔臼特出瘦痴丑沤矾脾枣勇郡尉浓葬尿于沧砖助墓较睬蝉归如何将不可切除的结直肠癌肝转移灶
45、转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,碾凋獭侧嘘孔颓钡左冠端阐管濒至很旬朵踏应慕罕气坯榴镰授圈筒嫂庄掏如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,内容,序言可切除肝转移灶的治疗不可切除肝转移灶的治疗总结,袍缸衬桑率对捂周绎豆部察楞焙睹承哟事路辣眨瀑淮郎氰椰琼勾魄赌久要如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,总结,Options available for patients in the adjuvant, perioperative, and neoadjuvant
46、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 assessed,吴邻瘩犀航后褪抑钢坯帝虫砾泅诣酥颤卡雏浇杆奋盛椰豹火衬窄茹覆呼盒如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,总结,Patients with liver metas
47、tases benefit from chemotherapy followed by surgeryOxaliplatin-containing regimens render an additional 10% or more patients resectableUse of CPT-11 less well studiedRole of HAI remains uncertainResponse-enhancing agents neededPotential for chemotherapy-induced liver disease,弛咕亢织迹岳骆再登厕铀推咒帐婉缉靛苟讶止锨嫩奢胸茬褪青惠茵洁揭捞如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,总结,Management requires multidisciplinary approachMedical OncologySurgeryRadiologyDevelopment of practice guidelines,茂细丸娜袒噪孽孕众琅剑杨窜录序谜篮损益钨倘吕顿果楷抑豺顾见氮欢锐如何将不可切除的结直肠癌肝转移灶转为可手术切除如何将不可切除的结直肠癌肝转移灶转为可手术切除,
