Parenchymal sparing surgery brings treatment of colorectal liver metastases into the precision medicine era
Parenchymal sparing surgery brings treatment of colorectal liver metastases into the precision medicine era
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DOI：
10.1016/j.ejca.2018.09.030
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发表时间：
2018-11-01
影响因子：
8.4
通讯作者：
Bonhomme, Benjamin
中科院分区：
文献类型：
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作者：
Evrard, Serge;Torzilli, Guido;Bonhomme, Benjamin
晚期结直肠癌肝转移（CRLM）的治疗遵循肿瘤外科手术的双相模式特征。一个治疗积极性的升级阶段之后是一个旨在降低发病率的降级阶段，同时保持生存率的提高。从最多三个病灶开始，该规则不再限制数量，前提是干预不会导致致命的肝功能衰竭。技术上可行的非解剖性切除术、二期肝切除术、门静脉闭塞术等等，已经将外科的界限推得很远。然而，转移过程的影响和生物学一直被忽视。实质保留手术（PSS）是一种降级策略，通过最大限度地减少刺激肿瘤生长的风险，同时实现迭代干预，仅针对转移。减少健康肝实质的损失增加了肝脏对间隔化疗的耐受性。从技术上讲，PSS可以使用任何类型的肝切除术，只要它是集中在转移负荷与术中消融。PSS的概念有时错误地出现作为一个小与大肝切除术之间的争论。因此，我们提出了一个明确的定义，定量和定性，什么是PSS，它不是。相反，PSS的选择性程度作为切除的转移灶的体积的百分比与总肝切除的体积还没有被停止，到目前为止，应该是前瞻性研究的主题。最终，晚期CRLM的治疗，其中PSS是一部分，需要个性化的多学科团队通过调整其响应每个新的复发。(C)2018由Elsevier Ltd.出版
The treatment of advanced colorectal liver metastases (CRLMs) follows the biphasic pattern characteristic of oncological surgery. A phase of escalationdthe therapeutic aggressiveness-is followed by a phase of de-escalation aimed at decreasing the morbidity, while preserving the gains in survival. From a maximum of three lesions, the rule no longer limits the number, provided the intervention does not cause lethal liver failure. Technically feasible non-anatomical resections, two-stage hepatectomies, portal vein obliteration and so forth, have pushed the boundaries of surgery far. However, the impact and the biology of metastatic processes have been long ignored.Parenchymal sparing surgery (PSS) is a de-escalation strategy that targets only metastasis by minimising the risk of stimulating tumour growth, while enabling iterative interventions. Reducing the loss of healthy parenchyma increases the tolerance of the liver to interval chemotherapy. Technically, PSS could use any type of hepatectomy, providing it is centred on the metastatic load alongside intraoperative ablation.The PSS concept sometimes wrongly comes across as a debate between minor versus major hepatectomies. Hence, we propose a clear definition, both quantitative and qualitative, of what PSS is and what it is not. Conversely, the degree of selectivity of PSS as a percentage of the volume of resected metastases versus the volume of total liver removed has not been stopped to date and should be the subject of prospective studies.Ultimately, the treatment of advanced CRLMs, of which PSS is a part, needs to be personalised by the multidisciplinary team by adapting its response to each new recurrence. (C) 2018 Published by Elsevier Ltd.