乙状结肠癌伴肝巨大转移灶患者的MDT诊疗

MDT diagnosis and treatment of sigmoid colon cancer with huge liver metastases

本文介绍1例乙状结肠癌伴肝巨大转移灶的多学科专家组(multi-disciplinary team,MDT)诊疗过程。该病例初诊时乙状结肠癌即伴肝右叶巨大多发转移灶,病理证实为腺癌,鼠类肉瘤病毒癌基因(Kirsten rat sarcoma viral oncogene,KRAS)基因突变型,肝转移瘤因切除后剩余肝脏体积不足,考虑为潜在可切除,经MDT讨论后行4个周期m FOLFOXIRI三药化疗方案(氟尿嘧啶+奥沙利铂+伊立替康)联合贝伐珠单抗靶向治疗先行缩瘤转化治疗,化疗后评估肝转移灶较前缩小,乙状结肠病灶退缩良好,第2次MDT讨论考虑具备手术条件,进行门静脉栓塞(portal vein embolization,PVE)代偿性增大左肝体积后,行腹腔镜辅助乙状结肠切除术+开腹肝转移瘤切除术。术后m FOLFOXIRI联合贝伐珠单抗治疗6个周期,后因化疗耐受不佳改卡培他滨联合贝伐珠单抗维持治疗,术后近1年发现肝脏转移复发,再次引入m FOLFOXIRI联合贝伐珠单抗治疗无效,行肝脏转移瘤切除术,后因新发肝脏转移和盆腔淋巴结转移予以口服呋喹替尼治疗维持,近期肝脏新发转移灶,行根治性切除术,术后恢复佳。该病例考虑了患者意愿、个人身体状况并结合MDT团队的意见,通过转化治疗+PVE术后腹腔镜结合开腹同期切除乙状结肠癌伴肝巨大转移灶,有效控制疾病进展,患者获得较好的生活质量。

This study introduced the diagnosis and treatment of a case of sigmoid colon cancer with huge liver metastases by multidisciplinary team(MDT).At the initial diagnosis,this case had sigmoid colon cancer accompanied by huge multiple metastases in the right lobe of the liver,which was pathologically confirmed as adenocarcinoma with Kirsten rat sarcoma viral oncogene(KRAS)gene mutation.Liver metastases were considered as potentially resectable due to the insufficient volume of the remaining liver after resection.After MDT discussion,four cycles of mFOLFOXIRI chemotherapy(5-fluorouracil+oxaliplatin+irinotecan)combined with bevacizumab targeted therapy were performed,followed by tumor shrinkage and transformation treatment.After chemotherapy,the liver metastases were evaluated to be smaller than before,and the sigmoid colon lesions had good regression.The second MDT discussion considered that the surgery was suitable to be performed.After portal vein embolization(PVE)compensated to increase the left liver volume,laparoscopic-assisted sigmoid colectomy+open resection of liver metastases were performed.After the operation,mFOLFOXIRI+bevacizumab was performed for 6 cycles,and then capecitabine combined with bevacizumab was used for maintenance treatment due to poor tolerance of chemotherapy.Liver metastasis and recurrence were found nearly one year after the operation.The reintroduction of mFOLFOXIRI combined with bevacizumab was ineffective,and liver metastasis resection was performed.After that,due to new liver metastasis and pelvic lymph nodes metastasis,oral fruquintinib was maintained.Recently,radical resection was performed for new liver metastases,and the postoperative recovery was good.By considering the patient’s wishes,personal physical conditions and the opinions of the MDT team,the progression of the disease was effectively controlled and a better quality of life was obtained through conversion treatment,PVE,and laparoscopy combined with open surgery to remove sigmoid colon cancer together with huge liver metastases.