Overall Tumor Burden Dictates Outcomes for Patients Undergoing Resection of Multinodular Hepatocellular Carcinoma Beyond the Milan Criteria
Overall Tumor Burden Dictates Outcomes for Patients Undergoing Resection of Multinodular Hepatocellular Carcinoma Beyond the Milan Criteria
复制标题
DOI：
10.1097/sla.0000000000004346
复制
发表时间：
2020-10-01
影响因子：
9
通讯作者：
Pawlik, Timothy M.
中科院分区：
文献类型：
--
作者：
Tsilimigras, Diamantis, I;Mehta, Rittal;Pawlik, Timothy M.
目的：本研究的目的是确定手术切除后的结果多结节肝细胞癌（HCC）超出米兰标准，并制定一个预测工具，以确定哪些患者可能受益最大的切除术。背景：肝切除多结节肝癌，特别是超出米兰标准，仍然存在争议。严格选择最佳切除候选人对于晚期肿瘤肝切除术后实现最佳结局至关重要。方法：从国际多机构数据库中确定2000年至2017年期间接受HCC切除术的患者。根据米兰标准状态对患者进行分类。术前和术后总生存期（OS）预测模型，包括HCC肿瘤负荷评分（TBS）与多结节HCC超出米兰criteria的患者之间的开发和validated.Results：在1037例接受切除HCC，164（15.8%）有多结节HCC超出米兰criteria。在多结节型HCC患者中，25例（15.2%）患者发生严重并发症，90天死亡率为3.7%（n = 6）。超过米兰标准的多结节HCC切除后5年OS为52.8%。基于术前TBS的模型（5年OS：低风险，73.7% vs中风险，45.1% vs高风险，13.1%）和基于术后TBS的模型（5年OS：低风险，80.1% vs中风险，37.2% vs高风险，未达到）将患者分为相对于长期预后的不同预后组（均P < 0.001）。术前和术后模型可以在外部验证队列中准确分层OS（5年OS;低风险vs中风险vs高风险;术前：66.3% vs 25.2% vs未达到，P = 0.012;术后：61.4% vs 42.5% vs未达到，P = 0.045）训练中术前和术后模型的预测准确性良好（c-指数;前：0.68;后：0.71）、内部验证（n = 2000个重新采样）（c-指数，前：0.70;后：0.72）和外部验证（c-指数，前：0.67;后0.68）数据集。单纯TBS可以对超出米兰标准的多结节HCC切除术后5年OS的患者进行分层（c指数：0.65; 5年OS;低TBS：70.2% vs中TBS：54.7% vs高TBS：16.7%; P < 0.001）。根据术前（98.4%）和术后风险评分（95.3%），绝大多数低和中等TBS患者被认为是低或中等风险。结论：多结节性HCC患者的预后在很大程度上取决于总体肿瘤负荷。对于米兰标准以外的多结节性HCC患者，如果TBS为低或中等，则应考虑肝切除。
Objective: The objective of the current study was to define surgical outcomes after resection of multinodular hepatocellular carcinoma (HCC) beyond the Milan criteria, and develop a prediction tool to identify which patients likely benefit the most from resection.Background: Liver resection for multinodular HCC, especially beyond the Milan criteria, remains controversial. Rigorous selection of the best candidates for resection is essential to achieve optimal outcomes after liver resection of advanced tumors.Methods: Patients who underwent resection for HCC between 2000 and 2017 were identified from an international multi-institutional database. Patients were categorized according to Milan criteria status. Pre- and postoperative overall survival (OS) prediction models that included HCC tumor burden score (TBS) among patients with multinodular HCC beyond Milan criteria were developed and validated.Results: Among 1037 patients who underwent resection for HCC, 164 (15.8%) had multinodular HCC beyond the Milan criteria. Among patients with multinodular HCC, 25 (15.2%) patients experienced a serious complication and 90-day mortality was 3.7% (n = 6). Five-year OS after resection of multinodular HCC beyond Milan criteria was 52.8%. A preoperative TBS-based model (5-year OS: low-risk, 73.7% vs intermediate-risk, 45.1% vs high-risk, 13.1%), and postoperative TBS-based model (5-year OS: low-risk, 80.1% vs intermediate-risk, 37.2% vs high-risk, not reached) categorized patients into distinct prognostic groups relative to long-term prognosis (both P < 0.001). Pre- and postoperative models could accurately stratify OS in an external validation cohort (5-year OS; low vs medium vs high risk; pre: 66.3% vs 25.2% vs not reached, P = 0.012; post: 61.4% vs 42.5% vs not reached, P = 0.045) Predictive accuracy of the pre- and postoperative models was good in the training (c-index; pre: 0.68; post: 0.71), internal validation (n = 2000 resamples) (c-index, pre: 0.70; post: 0.72) and external validation (c-index, pre: 0.67; post 0.68) datasets. TBS alone could stratify patients relative to 5-year OS after resection of multinodular HCC beyond Milan criteria (c-index: 0.65; 5-year OS; low TBS: 70.2% vs medium TBS: 54.7% vs high TBS: 16.7%; P < 0.001). The vast majority of patients with low and intermediate TBS were deemed low or medium risk based on both the preoperative (98.4%) and postoperative risk scores (95.3%).Conclusion: Prognosis of patients with multinodular HCC was largely dependent on overall tumor burden. Liver resection should be considered among patients with multinodular HCC beyond the Milan criteria who have a low- or intermediate-TBS.