Benefit of initial resection of hepatocellular carcinoma followed by transplantation in case of recurrence: An intention-to-treat analysis
Benefit of initial resection of hepatocellular carcinoma followed by transplantation in case of recurrence: An intention-to-treat analysis
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DOI：
10.1002/hep.24680
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发表时间：
2012-01-01
期刊：
影响因子：
13.5
通讯作者：
Belghiti, Jacques
中科院分区：
文献类型：
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作者：
Fuks, David;Dokmak, Safi;Belghiti, Jacques
肝切除术（LR）作为肝细胞癌（HCC）的一线治疗，在可移植患者中，如果复发，则进行挽救性移植（ST）是一个有吸引力的概念。目的是在意向治疗研究中确定从这种方法中获益的患者。从1998年到2008年，在米兰标准（MC）内的329例肝移植（LT）潜在候选人中，138例肝功能良好的患者从ST的角度切除（LR组），191例患者首先进行LT（LT组）。在意向治疗的基础上比较两组患者，特别是LR后复发和移植的管理。进行单变量和多变量分析，以确定切除的患者谁发展超过MC复发。两组的5年总生存率和无病生存率相似：LT组和LR组分别为60%和77%，56%和40%。在LR组的138例患者中，20例在复发前接受了LT，39例（28%）患有ST，51例（37%）复发患者未接受移植，包括21例因高龄、获得性合并症或拒绝而被排除的MC内患者和30例（22%）MC后复发患者。MC后复发导致不可移植性的预测因素包括显微镜下血管浸润（危险比[HR] 2.38 [范围，1.10-7.29]），卫星结核（HR 2.46 [范围，1.01-6.68]），肿瘤大小> 3 cm（HR 1.34 [范围，1.03-3.12]）、低分化肿瘤（HR 3.18 [范围，1.31-7.70]）和肝硬化（HR 1.90 [范围，1.04-3.12]）。结论：MC内HCC初次LR后ST失败的高风险提示使用组织分析作为选择标准。挽救性LT策略应限于具有有利肿瘤因素的患者。（肝脏学2012;;55：132140）
Liver resection (LR) for hepatocellular carcinoma (HCC) as the first-line treatment in transplantable patients followed by salvage transplantation (ST) in case of recurrence is an attractive concept. The aim was to identify patients who gain benefit from this approach in an intention-to-treat study. From 1998 to 2008, among 329 potential candidates for liver transplantation (LT) with HCC within the Milan criteria (MC), 138 with good liver function were resected (LR group) from a perspective of ST in case of recurrence, and 191 were listed for LT first (LT group). The two groups were compared on an intention-to-treat basis with special reference to management of recurrences and transplantability after LR. Univariate and multivariate analyses were performed to identify resected patients who developed recurrence beyond MC. Five-year overall and disease-free survival was similar in both groups: LT versus LR group, 60% versus 77% and 56% versus 40%, respectively. Among the 138 patients in the LR group, 20 underwent LT before recurrence, 39 (28%) had ST, and 51 (37%) with recurrence were not transplanted including 21 within MC who were excluded for advanced age, acquired comorbidities, or refusal and 30 (22%) with recurrence beyond MC. Predictive factors for nontransplantability due to recurrence beyond MC included microscopic vascular invasion (hazard ratio [HR] 2.38 [range, 1.10-7.29]), satellite nodules (HR 2.46 [range, 1.01-6.68]), tumor size > 3 cm (HR 1.34 [range, 1.03-3.12]), poorly differentiated tumor (HR 3.18 [range, 1.31-7.70]), and liver cirrhosis (HR 1.90 [range, 1.04-3.12]). Conclusion: The high risk of failure of ST after initial LR for HCC within MC suggests the use of tissue analysis as a selection criterion. The salvage LT strategy should be restricted to patients with favorable oncological factors. (HEPATOLOGY 2012;;55:132140)