大腸癌肝転移に対する集学的治療―新たなエビデンスの創出をめざして  [in Japanese] Multidisciplinary Treatment of Liver Metastasis from Colorectal Cancer to Create Novel Evidences  [in Japanese]

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Author(s)

    • 別府 透 Beppu Toru
    • 山鹿市民医療センター外科|熊本大学大学院消化器外科学|大腸癌肝転移データベース合同委員会 Department of Surgery, Yamaga Municipal Medical Center|Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University|Joint Committee of Liver Metastases Survey from Colorectal Cancer
    • 馬場 秀夫 Baba Hideo
    • 熊本大学大学院消化器外科学 Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University
    • 遠藤 格 Endo Itaru
    • 大腸癌肝転移データベース合同委員会|横浜市立大学医学部消化器・腫瘍外科学 Joint Committee of Liver Metastases Survey from Colorectal Cancer|Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine
    • Popescu Irinel
    • Dan Setlacec Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute
    • 吉野 孝之 Yoshino Takayuki
    • 国立がん研究センター東病院消化管内科 Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East
    • 小林 信 Kobayashi Shin
    • 大腸癌肝転移データベース合同委員会|仙台厚生病院消化器外科 Joint Committee of Liver Metastases Survey from Colorectal Cancer|Department of Gastrointestinal Surgery, Sendai Kousei Hospital
    • 進藤 潤一 Shindoh Junichi
    • 虎の門病院消化器外科|Department of Surgical Oncology, MD Anderson Cancer Center Hepatobiliary Surgery Division, Toranomon Hospital|Department of Surgical Oncology, MD Anderson Cancer Center
    • 波多野 悦朗 Hatano Etsuro
    • 京都大学大学院肝胆膵・移植外科学|兵庫医科大学外科学講座・肝胆膵外科 Department of Surgery, Graduate School of Medicine, Kyoto University|Department of Surgery, Hyogo College of Medicine
    • 今井 克憲 Imai Katsunori
    • 熊本大学大学院消化器外科学|Centre Hépato-Biliaire, AP-HP, Hôpital Universitaire Paul Brousse Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University|Centre Hépato-Biliaire, AP-HP, Hôpital Universitaire Paul Brousse

Abstract

<p><b>目的:</b>第71回本学会総会 パネルディスカッション4『大腸癌肝転移に対する集学的治療―新たなエビデンスの創出をめざして』の討論結果の共有を目的とした.<b>方法:</b>五つのポイントについてアンサーパッドを交えて討論を行った.<b>結果:</b>1.5個以上同時性肝転移に対して,手術先行が77%を占めたが肝切除先行は10%弱であった.広範囲肝切除+直腸切除症例においてはほとんどが分割手術を選択し,interval chemotherapyを行う施設が2/3以上であった.2.切除可能肝単独転移の治療方針を検討した.再発低頻度予測例では肝切除単独69%,肝切除+術後化学療法31%が選択され,再発高頻度予測例では90%以上の症例で肝切除+周術期化学療法が行われた.3.RASは77%で,BRAFは9%で測定された.Conversion therapyでは,oxaliplatinベースの化学療法+分子標的薬が頻用されたが,FOLFOXIRI±bevacizumabが期待されていた.その治療効果判定には,RECIST基準に加えてearly tumor shrinkageやdeepness of responseが活用されていた.4.腫瘍学的進行例で単回肝切除が困難な症例には化学療法が79%で先行され,門脈塞栓術後の肝切除と二段階肝切除がほぼ同数に選択され,associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)の選択は1%であった.5.新しい臨床試験として,切除可能例に対するFOLFOX+LV/UFTによる補助療法,RASのstatusを考慮した補助療法,再発高危険群を対象とした組織学的効果を考慮した試験が,切除不能同時性肝転移に対する肝切除先行と大腸切除先行アプローチの比較試験が,提案された.<b>結語:</b>大腸癌肝転移の集学的治療の現状をまとめた.本領域のさらなる発展には臨床試験により,確固たるエビデンスを創ることが重要である.</p>

<p>We discussed five points about colorectal liver metastases (CRLM) using answer pads. 1. Synchronous CRLM ≥5 cm was treated with upfront hepatectomy for 90% of patients; however liver-first approach was selected for approximately 10%. Staged operation was mainly performed for major hepatectomy and 67% of patients were received interval chemotherapy. 2. In patients with high-risk resectable CRLM, surgery alone for 69% of patients and surgery+postoperative chemotherapy for 31%; in low-risk CRLM, perioperative chemotherapy and surgery over 90% of patients were selected. 3. RAS and BRAF was measured in 77% and 9% of CRLM patients. In conversion therapy, oxaliplatin-based chemotherapy+targeted drugs was frequently used, especially FOLFOXIRI+(bevacizumab) has been desirable. For assessment of tumor response, RECIST and/or early tumor shrinkage and deepness of response was commonly used. 4. For oncologically advanced CRLM patents being difficult to resect at one time, induction chemotherapy was performed for 79% of patients. One-step hepatectomy after portal embolization and two-step hepatectomy was selected for almost the same number, and ALPPS was for only 1% of patients. 5. New clinical trials were proposed; adjuvant chemotherapy using "FOLFOX+LV/UFT following hepatectomy for resectable CRLM", "perioperative chemotherapy depending on histological therapeutic effects for high-risk CRLM", and "surgery-first or primary-first for unresectable synchronous CRLM". With active discussion using answer pads, it was possible to consolidate the opinion of the gastroenterological surgeon at the present time and make recommendations for the future.</p>

Journal

  • The Japanese Journal of Gastroenterological Surgery

    The Japanese Journal of Gastroenterological Surgery 52(7), 390-403, 2019

    The Japanese Society of Gastroenterological Surgery

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