1.With the improvement of living standard and the increase of human life expectancy, the incidence rate and death rate of colorectal cancer are gradually increasing in China and the world, and there are more and more liver metastases of colorectal cancer. First of all, what is the current situation of colorectal cancer?
Colorectal cancer, including rectal cancer and colon cancer, is one of the common malignant tumors. In 2007, there were 1.2 million new cases and nearly 630,000 people died of colorectal cancer worldwide, and the incidence rate in China is 20.6/100,000, and the trend is increasing year by year. Colorectal cancer is the 3rd most prevalent tumor worldwide and the 4th most common malignant tumor in China. The incidence rate is higher in economically developed areas, higher in urban than rural areas, and higher in large cities than in medium and small cities.
2.Status of liver metastasis of colorectal cancer?
Liver is the most metastatic part of colorectal cancer, and often the only metastatic part, about 10%-25% of patients have liver metastasis at the time of diagnosis, 20%-25% of patients have liver metastasis after surgery.
About 10%-25% of patients have liver metastasis at the time of diagnosis, and 20%-25% of patients have liver metastasis after surgery. If liver metastasis of colorectal cancer is not treated, the median survival period is only 8 months, and the 5-year survival rate is almost 0.
3.What about the current treatment of liver metastasis of colorectal cancer?
There is no doubt that surgical radical resection is the best method to cure colorectal cancer liver metastasis, and the median survival of patients who can be resected is about 35 months, and the 5-year survival rate is about 30~50%. However, unfortunately, only 10%-20% of liver metastases can be completely resected at the time of initial diagnosis, and most of them are not completely resectable due to extrahepatic metastatic lesions, involvement of multiple large vessels and insufficient reserved functional liver, and the prognosis of patients with unresectable colorectal cancer liver metastases is very poor, and there are almost no reports of long-term survival. Therefore, patients with surgical conditions should actively strive for stage I or stage II surgical treatment, and patients with partial unresectable liver metastases should take active treatment measures to strive for converting unresectable liver metastases into resectable ones, so as to maximize the treatment effect. This is also the direction of our clinicians’ efforts. Among them, I believe that early diagnosis, standardized and integrated treatment with multidisciplinary teamwork is an effective way to improve the survival rate of patients with colorectal cancer liver metastases.
4. It seems that early diagnosis and early treatment of colorectal cancer liver metastasis are still crucial for patients’ prognosis and survival, so how to diagnose colorectal cancer liver metastasis early?
According to the international common classification method, liver metastasis of colorectal cancer is divided into simultaneous and heterochronic. Concurrent liver metastasis refers to liver metastasis found at the time of colorectal cancer diagnosis or occurring within 6 months after radical resection of primary colorectal cancer; liver metastasis occurring after 6 months of radical resection of colorectal cancer is called heterochronic liver metastasis.
At present, colonoscopy + biopsy is the gold standard for diagnosis of colorectal cancer, and liver ultrasound is mandatory for every patient diagnosed with colorectal cancer, which has good screening effect on liver metastasis. patients suspected of liver metastasis by ultrasound should have serum AFP (alpha-fetoprotein) and enhanced CT examination of upper abdomen, which helps to determine the nature of lesions and shows structures such as hepatic veins, portal veins and bile ducts. MRI has a significant advantage in detecting lesions smaller than 1 cm, and the sensitivity of enhanced MRI examination of liver metastases is 80% to 90%. In addition, PET-CT examination has obvious advantages in sensitivity and specificity, and helps to detect extrahepatic metastases, which is the most accurate method for staging progressive colorectal cancer.
After radical colorectal cancer surgery, patients should be closely followed up. Serum CEA, CA199 and AFP should be tested every 3-6 months, as well as liver ultrasound and CT and MRI if necessary.
5.For patients with liver metastases, whether the liver metastases can be surgically removed or not has a great impact on the prognosis and survival of the patients, so what kind of patients can have the primary foci and liver metastases surgically removed at the same time?
For the management of liver metastases from colorectal cancer, there are many international debates and different views. In recent years, the general principle and trend is positive, as long as.
(1) the patient can tolerate ;
(2) Adequate liver reserve (30-50% of residual liver volume) is ensured;
(3) the surgical incision can be accommodated;
(4) there are no unresectable extrahepatic metastases and R0 resection (radical resection) is achieved, then stage 1 resection should be pursued.
On 2010-6-19 at the 6th International Colorectal Cancer Summit Forum, the 2010 edition of China’s Guidelines for the Treatment of Colorectal Cancer Liver Metastases was officially announced. This Guideline will make the diagnosis and treatment of colorectal cancer liver metastasis more reasonable and standardized. It is clearly stated in the guideline that if the primary colorectal foci can be radically resected; if the liver metastases are small and mostly located in the periphery of the liver or confined to the half liver, and the amount of liver resection is less than 50%; if there are no other inoperable hilar lymph nodes, abdominal or distant metastases; if the patient’s physical condition can tolerate surgery; and if stage I resection is advocated. The emphasis is on R0 resection, which means that the margins are negative, i.e., no cancer remains, which is very important for the prognosis of the operated patient. Most experts believe that the margin of liver metastases should be at least l
cm.
6.If the patient’s physical condition does not allow the resection of colon tumor and liver at the same time, does the patient still have a chance to have a second surgery to remove liver metastases?
You are talking about the second stage resection of liver metastases. For those who cannot be resected simultaneously in one stage in preoperative evaluation, performing second stage resection 4-6 weeks after radical colorectal cancer surgery reduces the risk of surgery and can also provide better treatment effect. Some studies have now confirmed that 3-6 cycles of chemotherapy before metastasectomy does not affect the resection rate of liver metastases and can prolong disease-free survival, which is not a better option. The prerequisites for second-stage resection are also that the liver metastases can be radically resected and sufficient amount of residual liver is ensured; there are no other inoperable hilar lymph nodes, abdominal or distant metastases; the primary colorectal foci have been radically resected and are not accompanied by recurrence of the primary foci; and the patient can tolerate surgical treatment.
7, then for those patients who can not be removed how to do?
This requires specific treatment for specific conditions. For patients with colorectal cancer without obstruction, bleeding or perforation, neoadjuvant chemotherapy + local radiotherapy is currently advocated, and active measures can be taken as far as possible to turn 10% of unresectable lesions into resectable ones, and their survival is comparable to that of patients with resectable liver metastases at the time of initial diagnosis.
8.So what is neoadjuvant chemotherapy? What is the significance of neoadjuvant chemotherapy for patients with rectal cancer liver metastases?
Neoadjuvant chemotherapy refers to systemic chemotherapy applied before local surgery or radiotherapy for malignant tumors. Its clinical significance includes.
(1) to make the previously unresectable liver metastases resectable, and to shrink the previously resectable lesions to ensure sufficient margins;
②Reducing the resection of liver parenchyma and maximizing the preservation of liver function;
③It can also remove the proliferating cancer cells that are prone to metastasis and eliminate the micro-metastases in the liver;
④ Preoperative chemotherapy is a reliable drug sensitivity screening test, and through radiological and pathological evaluation of the lesions after chemotherapy, an effective regimen is selected as the first choice for postoperative chemotherapy.
9.Since neoadjuvant chemotherapy has so many advantages, should all patients be treated with current neoadjuvant chemotherapy?
There are disadvantages and shortcomings of neoadjuvant chemotherapy, which may damage the liver and affect liver regeneration, especially in large part of the liver (>70%) after resection.
) after resection is an important issue regarding the safety of the procedure. Some patients may have rapid disease progression during neoadjuvant therapy, and that patient may not benefit from resection. How to get the maximum benefit after neoadjuvant chemotherapy, minimize liver damage and get the best surgical timing for R0 surgery, in addition to choosing the suitable number of chemotherapy cycles and chemotherapy regimen, it is necessary to form a group of experts from multiple disciplines, including surgery, internal medicine, oncology and pathology, to discuss together and develop a reasonable treatment plan.
10.Patients with liver metastasis of colorectal cancer should all need postoperative chemotherapy, right?
Yes, because all patients with metastasis belong to stage IV or above, they should have at least 6 cycles of chemotherapy after surgery. At present, the combination of FOLFOX and FOLFIRI based on oxaliplatin and irinotecan is the standard regimen for first-line treatment.
11.Apart from the above two chemotherapy regimens, are there any new drugs for patients with liver metastases from colorectal cancer?
In recent years, with the emergence of molecularly targeted drugs, such as anti-VEGF monoclonal antibody (bevacizumab) and anti-EGFR monoclonal antibody (cetuximab) in combination with traditional chemotherapy drugs, the efficiency and median survival of metastatic colorectal cancer have been further improved.
The NCCN clinical practice guidelines (2009) clearly indicate the use of cetuximab for first-line treatment of metastatic colorectal cancer. Bevacizumab has also shown more promising results in the treatment of metastatic colorectal cancer. In combination with 5-FU, LV and irinotecan, the overall efficacy of first-line therapy ranged from 45% to 70%. cetuximab added to FOLFOX in patients with K-RAS wild type achieved good results, while no benefit was seen in patients with mutant type. Currently, chemotherapy combined with the application of molecularly targeted drugs is considered the most promising treatment to improve the resection rate of liver metastases.
12.Is there any non-surgical treatment for liver metastases that cannot be surgically resected?
There are many methods. For example, radiofrequency ablation (RFA) for liver metastases is a classical and practical method. Its advantages are: simple operation, small trauma, few complications, easily tolerated by patients and repeatable operation, especially for those who cannot tolerate surgery; it is effective for tumors below 3cm. Because of the effective radius of ablation, local ablation therapy is mostly used as palliative or adjuvant treatment when the liver metastases are too large. There are also: microwave knife: B-ultrasound or CT-guided percutaneous puncture microwave knife generates local high temperature of up to 65~100℃ in a very short period of time, which causes coagulation and denaturation of tumor tissues and irreversible necrosis to achieve in situ inactivation to form ellipsoidal necrotic area or local radical treatment. Local hepatic artery infusion chemotherapy, embolization, stereotactic radiation therapy, anhydrous alcohol injection, cryoablation, high-intensity ultrasound therapy, radioactive 125 iodine ion implantation, etc. However, each method has certain advantages and shortcomings, and only as part of the comprehensive treatment, it may lose its therapeutic significance when used alone.
13.Does colorectal cancer have metastasis of other organs besides liver metastasis?
Yes, extrahepatic metastasis of colorectal cancer is more common in lung, brain, ovary, bone and adrenal gland. In the past, extrahepatic lesions were considered as absolute contraindications for resection of liver metastases from colorectal cancer, but with the application of new chemotherapeutic agents and advances in perioperative treatment, many surgeons have revised this view.
14.What are the factors of poor prognosis of liver metastasis from colorectal cancer?
The prognosis of patients with liver metastases from colorectal cancer is influenced by 10 factors: site of liver metastases, number of liver metastases, size of maximum liver metastases, pathological type of primary tumor, degree of differentiation of primary tumor, depth of infiltration of primary tumor, regional lymph node metastases, presence or absence of abdominal implantation, presence or absence of extrahepatic metastases and treatment for liver metastases.