2019年结直肠癌治疗进展盘点

Treatment progress of colorectal cancer in 2019

2019年,结直肠癌领域可能改变临床实践的治疗进展不多。在Ⅰ~Ⅲ期的早期疾病领域,手术相关的进展有2项,经肛直肠癌全系膜切除手术由于较高的局部复发风险而在挪威被全面叫停,引发全球业界广泛关注;同样关于局部进展期直肠癌手术的问题,侧方淋巴结清扫的适应证及时机也是近年国内同行热议的话题;术前新辅助治疗的进展也有2项,局部进展期直肠癌的术前同步放化疗中加入第二个药物如伊立替康、奥沙利铂的价值值得重新审视,而局部进展期结肠癌的术前新辅助化疗则整体未见获益,标准治疗仍然是直接手术;高危Ⅱ期术后奥沙利铂辅助化疗疗程仍存在争议;早期疾病领域,未来最值得期待的是ctDNA在早期复发转移的监测以及个体化术后辅助化疗决策中的价值。在转移性结直肠癌(metastatic colorectal cancer,mCRC)领域进展相对较少,主要包括如下三点:mCRC的一线强烈治疗新策略相较标准治疗策略能带来更多生存获益;mCRC末线治疗中针对特殊靶点的精准治疗取得突破:BRAF突变型mCRC的EGFR通路三靶向治疗(EGFR单抗+BRAF抑制剂+MEK抑制剂)和HER2扩增型mCRC的HER2双抗治疗;最后就是MSS型mCRC的末线免疫治疗取得了一些进展:TMB可能有助于甄别能从免疫治疗中获益的群体,放疗和小分子TKI抑制剂如瑞戈非尼可能逆转部分MSS型mCRC的免疫耐受,尤其是瑞戈非尼联合nivolumab的REGONIVO治疗模式,值得进一步探索。

Those practice-changing treatment progress of colorectal cancer in 2019 include the following:in the field of earlystage disease,there are controversies for surgical procedures of trans-anal total mesorectum excision and LLND for rectal cancer,reconsidering the value of addition of second drug such as oxaliplatin or irinotecan to the standard neoadjuvant fluoropyrimidine-based chemoradiation for locally advanced rectal cancer,no survival benefit of neoadjuvant chemotherapy for locally advanced colon cancer,controversy of oxaliplatin-base adjuvant duration for high risk stageⅡcolon cancer,and promising value of ctDNA for postoperative surveillance,early detection for recurrence,and decision-making of customized adjuvant chemotherapy.In the field of metastastic disease,there are less progress,including new strategy of extensive first line treatment in the palliative setting,precision medicine targeting particular genetic change such as BRAF mutation and HER2 over-expression in late line treatment,and promising progress of immunotherapy for MSS mCRC,such as TMB as a useful biomarker to identify the population with potential benefit,radiation and regorafenib as a potentially effective combination with immunotherapy.