R1 Resection by Necessity for Colorectal Liver Metastases Is It Still a Contraindication to Surgery?
R1 Resection by Necessity for Colorectal Liver Metastases Is It Still a Contraindication to Surgery?
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DOI：
10.1097/sla.0b013e31818a07f1
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发表时间：
2008-10-01
影响因子：
9
通讯作者：
Adam, Rene
中科院分区：
文献类型：
--
作者：
de Haas, Robbert J.;Wicherts, Dennis A.;Adam, Rene
目的：比较结合化疗和重复手术的积极方法治疗结直肠肝转移瘤 (CLM) 的 R0（阴性切缘）和 R1（阳性切缘）肝切除的长期结果。背景数据摘要：完整的肉眼切除且切缘阴性是 CLM 手术治疗的金标准推荐。然而，由于血管邻近或多结节，有时只能通过R1切除才能进行完整的肉眼切除。越来越有效的化疗可能会改变 R1 切除后的长期结果。方法：对我们机构 1990 年至 2006 年间所有切除的 CLM 患者（R0 或 R1）进行前瞻性评估。排除标准为：肉眼不完全（R2）切除、使用局部治疗方式以及存在肝外疾病。我们的目标是切除所有已发现的边缘呈负数的转移瘤。然而，当无法获得安全边缘时，只要完全切除肉眼可见的肿瘤，仍然可以进行切除术。比较各组之间的总生存率（OS）和无病生存率，并确定预后因素。结果：在 840 名患者中，436 名（52%）符合研究资格，其中 234 名（28%）接受了 R0 切除，202 名（24%）接受了 R1 切除。 R1 组中 CLM 的数量和大小较多，且分布更常见于双侧。平均随访 40 个月后，R0 和 R1 患者的 5 年 OS 分别为 61% 和 57%（P = 0.27）。 R0 组的五年无病生存率为 29%，而 R1 组为 20%（P = 0.12）。在 R1 组中，肝内（而非手术切缘）复发的情况更为常见（28% vs. 17%；P = 0.004）。术前癌胚抗原水平 >= 10 ng/mL 和主要肝切除术（而非 R1 切除术）是 OS 不良的独立预测因素。尺寸≥30 mm、双侧分布和术中输血独立预测手术切缘阳性。结论：尽管复发率较高，但在当前有效化疗的时代，应重新审视 R1 切除的禁忌症，因为生存率与 R0 切除相似。
Objective: To compare long-term outcome of R0 (negative margins) and R1 (positive margins) liver resections for colorectal liver metastases (CLM) treated by an aggressive approach combining chemotherapy and repeat surgery.Summary Background Data: Complete macroscopic resection with negative margins is the gold standard recommendation in the surgical treatment of CLM. However, due to vascular proximity or multinodularity, complete macroscopic resection can sometimes only be performed through R1 resection. Increasingly efficient chemotherapy may have changed long-term outcome after R1 resection.Methods: All resected CLM patients (R0 or R1) at our institution between 1990 and 2006 were prospectively evaluated. Exclusion criteria were: macroscopic incomplete (R2) resection, use of local treatment modalities, and presence of extrahepatic disease. We aimed to resect all identified metastases with negative margins. However, when safe margins could not be obtained, resection was still performed provided complete macroscopic tumor removal. Overall survival (OS) and disease-free survival were compared between groups, and prognostic factors were identified.Results: Of 840 patients, 436 (52%) were eligible for the study, 234 (28%) of whom underwent R0 resection, and 202 (24%) underwent R1 resection. Number and size of CLM were higher, and distribution was more often bilateral in the R1 group. After a mean follow-up of 40 months, 5-year OS was 61% and 57% for R0 and R1 patients (P = 0.27). Five-year disease-free survival was 29% in the R0 group versus 20% in the R1 group (P = 0.12). In the R1 group, intrahepatic (but not surgical margin) recurrences were more often observed (28% vs. 17%; P = 0.004). Preoperative carcinoembryonic antigen level >= 10 ng/mL and major hepatectomy, but not R1 resection, were independent predictors of poor OS. Size >= 30 mm, bilateral distribution, and intraoperative blood transfusions independently predicted positive surgical margins.Conclusions: Despite a higher recurrence rate, the contraindication of R1 resection should be revisited in the current era of effective chemotherapy because survival is similar to that of R0 resection.