Thomas Gruenberger教授专访
推动结直肠癌肝转移的多学科综合诊疗
2023年6月17日，由复旦大学附属中山医院、复旦大学附属中山医院结直肠癌中心和上海结直肠肿瘤微创工程技术研究中心共同举办的第19届上海国际大肠癌高峰论坛（2023 SICS）正式拉开帷幕。来自全球10多个国家的结直肠癌学术领军专家、学者久别重逢，再次共赴上海参加这一声名远播的结直肠癌学术盛会。本次大会秉承规范和创新的理念，围绕结直肠癌诊疗最新研究进展和方向展开学术汇报，共同探讨结直肠癌领域前沿诊疗技术、精准医学转化和临床指南规范等关键问题。
论坛现场,【肿瘤资讯】对来自奥地利维也纳Clinicum Favoriten和Sigmund Freud私立大学的Thomas Gruenberger教授进行现场专访并探讨同时转移性结直肠癌的治疗顺序，以及欧洲结直肠癌肝转移的治疗实践。现将访谈内容精要整理如下，以飨读者。
手术切除是转移性结直肠癌潜在的根治手段
Thomas Gruenberger教授：2016年我们团队发表的综述重点讨论了针对初诊同时性转移性结直肠癌(mCRC)患者应如何安排治疗顺序。当时，化疗几乎为所有mCRC患者的首选治疗。时至今日，这一领域发生了改变，即原发灶及转移灶容易切除的病人可以接受简单的切除手术，而不需要围手术期的系统治疗。
因此对于肿瘤学指标较好（如≤3个转移灶等）和技术可切除性良好的患者，可能不需要围手术期的全身治疗，应直接进行切除。但大多数具有广泛mCRC患者初始不适合进行根治性手术。因此，通过病理或分子肿瘤检测区分转移灶初始可切除或不可切除的患者是治疗的关键所在。包括RAS、BRAF等突变状态在内的生物学决定因素可能影响治疗策略，故对于伴有不利预后因素的患者建议首先进行全身治疗。在全身治疗出现明显的肿瘤退缩后或可进行手术切除，其治疗的目的是将最初不可切除的转移灶转化为可切除。术前进行靶向药物联合细胞毒性药物双药或三药联合方案（如FOLFOXIRI等）新辅助治疗被证明可提高手术切除率。当患者因对诱导治疗有实质性反应而变得可切除时，应行切除，并应在2个月内通过重新分期CT进行检测。
此外，由于吻合口漏是直肠癌术后常见的严重的并发症，因此术前应进行机械性肠道准备联合口服非肠道吸收抗生素降低吻合口漏发生风险，帮助患者改善预后。
多学科诊疗团队的组建及诊疗模式
Thomas Gruenberger教授：多学科肿瘤治疗团队模式（MDT）的开展是至关重要的。结直肠癌MDT团队的建立意味着通过多学科专家的紧密合作与密切沟通，充分考虑患者个体之间的差异、肿瘤的异质性，确保患者治疗过程实现个性化的诊疗。
目前认为，结直肠癌的治疗需要多学科专家的协同工作，以确保最佳的患者管理。除了外科医生外，MDT离不开以下5种类型专家的积极参与：
肿瘤内科专家：具有化疗、辅助、新辅助治疗等方面丰富的诊疗经验；
介入放射科专家：在医学影像技术（如超声、CT、MRI、内窥镜等微创技术）的引导下对肿瘤患者进行干预性诊断和治疗；
病理学专家：通过患者的肿瘤组织等进行病理诊断，对肿瘤患者的治疗选择和预后判断具有重要的指导意义；
放射学家：使用多模态影响评估实现精准诊断，以帮助制定患者个体化治疗方案；个人病例管理/个案管理者。在奥地利，根据法律规定，每个新诊断的癌症患者都必须获得MDT团队的接诊。随着多种治疗新模式的不断涌现，具有一定专业知识的个案管理者可以在MDT中发挥关键作用，作为医生和患者及患者家庭之间沟通的桥梁，侧重于患者个人（身体、精神状态及经济状况）评估以及健康需求评估，以确保患者及时且充分地参与调查与治疗。
Promoting multidisciplinary establishments of liver metastases in Colorectal Cancer
On June 17, 2023, the 19th Shanghai International Colorectal Cancer Summit (2023 SICS) co-organized by Zhongshan Hospital of Fudan University, Colorectal Cancer Center of Zhongshan Hospital of Fudan University and Shanghai Minimally Invasive Colorectal Tumor Engineering Technology Research Center took placed in Shanghai, China. Leading colorectal cancer experts and academics from more than 10 countries around the world gathered together in Shanghai to participate in this prestigious colorectal cancer academic event. The conference adheres to the concept of standardization and innovation, focuses on the latest research progress and direction of colorectal cancer diagnosis and treatment, and discusses key issues such as cutting-edge diagnosis and treatment technology, precision medicine translation and clinical guideline standardization in the field of colorectal cancer.
【Oncology News】interviewed Prof. Thomas Gruenberger from Clinicum Favoriten and Sigmund Freud Private University, Vienna, Austria to talk about the treatment sequence of simultaneous metastatic colorectal cancer as well as European treatment practice of colorectal cancer with liver metastasis.
Resection is a potentially curative treatment for metastatic colorectal cancer
Prof. Thomas Gruenberger: Yes, our team published the review in 2016 focused on the treatment sequence for patients newly diagnosed with metastases and a primary in the colon (mCC), Back then, starting with chemotherapy was the recommendation in the majority of patients. However, nowadays, the surgical paradigm has changed in that way, that patients with easily resectable primary and metastasis can undergo a simple resection without perioperative systemic therapy. Therefore, for patients presenting with oncologic criteria (e.g., ≤3 metastases, etc.) , perioperative systemic therapy may not be required, while resection should be performed directly.
However, immediate bowel surgery to resect the primary tumor is rarely necessary for all patients with extensive metastatic disease who would otherwise be unresectable. New treatment strategies that use pathologic and molecular tumor testing including mutations tests of RAS and BRAF to select therapy have the potential to improve prognosis. Systemic chemotherapy is the primary treatment for mCRC. The combination of advances in medical therapy, such as systemic chemotherapy, and the improvement in surgical techniques for metastatic disease, have enhanced prognosis with prolongation of the survival rate and cure. The use of FOLFOXIRI--several conventional chemotherapy regimens and molecular-targeted agents combination as double or triplet regimen may also increase the number of patients suitable for surgical treatment. Resection should be kept in mind when patients become resectable due to a substantial response to induction therapy and that should be tested via restaging CT all 2 months.
In addition, since anastomotic leakage (AL) is a common and serious postoperative complication of rectal cancer, preoperative mechanical bowel preparation with additive oral non-intestinal absorption antibiotics should be performed prior to elective colorectal surgery to reduce the risk of AL and help patients to improve their prognosis.
Perceptions and implementation of a multidisciplinary team
Prof. Thomas Gruenberger: A multidisciplinary cancer team is extremely important. The center where you have your treatment should have access to multiple medical specialists who communicate regularly. A multidisciplinary approach to colorectal cancer with liver metastases means that the patients will get an optimized plan based on his/her individual medical history, tumor type and genes.
Several types of cancer specialists work together on your team so you can benefit from their combined expertise, because one type of specialist alone is not able to manage your care. This truly requires collaboration. Besides surgeon, there are generally other 5 types of specialists on a multidisciplinary cancer team: medical oncologist, a medical oncologist specializes in treating cancer with chemotherapy and other targeted therapies. Interventional radiologists perform image-guided diagnostic and therapeutic procedures for patients with cancer and other conditions. Pathologists, who specialize in interpreting tests from tissues, in order to make a conclusive diagnosis; Radiologist, radiologists specialize in diagnosing medical conditions through the use of imaging techniques, radiologists also work with the team to determine the exact location of tumors in the liver in order to help treatment planning in individual cases.
The last but not the least is the case manager. In my country, subject to law every newly diagnosed cancer patient must be involved in a MDT discussion. In this evolving scenario, case manager is an emerging professional role as clinician expert in coordinating care pathways, who takes into account the specific needs of an individual, in a cost-effective way. The participants defined the role of the case manager fundamental for the information regarding the person and his/her family attendance, thus guaranteeing an adequate clinical and therapeutic process.
排版编辑：肿瘤资讯-Lynn
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1.Gruenberger T, Beets G, Van Laethem JL,et al.Treatment sequence of synchronously (liver) metastasized colon cancer. Dig Liver Dis. 2016 Oct;48(10):1119-23. doi: 10.1016/j.dld.2016.06.009. Epub 2016 Jun 17. PMID: 27375207.
2.J Clin Oncol 41, 2023 (suppl 17; abstr LBA3504)
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