Is radioembolization or sorafenib the best option for patients with hepatocellular carcinoma and portal vein invasion?
Is radioembolization or sorafenib the best option for patients with hepatocellular carcinoma and portal vein invasion?
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放射栓塞或索拉非尼是肝细胞癌合并门静脉侵犯患者的最佳选择吗？
DOI：
10.1111/liv.13208
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发表时间：
2016-11
影响因子：
6.7
通讯作者：
Li, Le-Qun
中科院分区：
文献类型：
--
作者：
Zhong, Jian-Hong;Tong, Tie-Jun;Peng, Ning-Fu;Li, Le-Qun
我们饶有兴趣地阅读了de la Torre等人的研究，该研究比较了使用钇-90微球（n=26）或索拉非尼治疗（n=47）进行放射性栓塞后患有肝细胞癌（HCC）和门静脉浸润（PVI）的白人患者的生存时间。中位随访6个月后，中位生存时间分别为8.8和5.4个月（p= 0.047）。大约在同一时间，Cho等人报告了接受放射性栓塞（n=32）或索拉非尼（n=31）的HCC和PVI亚洲患者的中位生存时间相似（13.8 vs 10.0个月，p= 0.22）。这些结果通过倾向评分分析得到证实。我们赞赏这些作者对HCC和PVI患者进行放射性栓塞的适用性研究，这些患者目前的治疗选择很少，预后极差。同时，我们认为需要进行更详细的分析，以确定可能从放射性栓塞或索拉非尼中获益的最合适的患者亚组，特别是鉴于强有力的证据表明肝切除术对某些HCC和PVI患者是安全有效的。de la Torre等人和Cho等人的研究未按肺静脉隔离等级进行亚组分析，尽管这些等级与实质上不同的肺静脉疾病相关。一项涉及4389例HCC和大血管浸润患者的系统性综述研究发现，肝切除与1年中位总生存率50%和5年中位总生存率18%相关。一项对6474例HCC和PVI患者的日本全国性调查发现，肝切除术与其他治疗相比，中位生存期显著延长（2.87 vs 1.10年，p<0.001），术后90天死亡率仅为3.7%。这一发现也得到了倾向评分分析的支持。无论患者年龄、HCC病因、肿瘤标志物或肿瘤数量如何，均观察到肝切除术的生存获益。这一广泛的证据表明，肝切除术在门静脉节段或扇形分支（Vp 0 -2）的选定PVI患者中安全有效。然而，尚不清楚主动脉或门静脉分叉处肺静脉隔离患者是否需要行肝切除术（Vp 3 -4）。我们同意de la Torre等人和Cho等人的观点，即放射性栓塞可以为HCC和PVI患者提供良好的生存率，但其安全性和有效性应在不同的PVI分级中进行验证。临床医生还应考虑将肝切除术作为选定的肺静脉隔离仅限于一级分支的患者的一种选择。财政支持
We read with interest the study by de la Torre et al. comparing survival time of Caucasian patients with hepatocellular carcinoma (HCC) and portal vein invasion (PVI) after radioembolization using yttrium-90 microspheres (n=26) or sorafenib therapy (n=47). Respective median survival time was 8.8 and 5.4 months (p=.047) after median follow-up of 6 months. Around the same time, Cho et al. reported similar median survival time for Asian patients with HCC and PVI who received radioembolization (n=32) or sorafenib (n=31) (13.8 vs 10.0 months, p=.22). These results were confirmed by propensity score analysis. We applaud those authors for examining the suitability of radioembolization for patients with HCC and PVI, who currently have few treatment options and face extremely poor prognosis. At the same time, we think that more detailed analysis is needed in order to identify the most appropriate patient subgroups who may benefit from radioembolization or sorafenib, especially in the light of strong evidence that hepatic resection can be safe and effective for certain patients with HCC and PVI. The studies by de la Torre et al. and Cho et al. did not perform subgroup analyses by PVI grade, even though the grades are associated with substantially different prognoses. A systematic review of studies involving 4389 patients with HCC and macrovascular invasion found that hepatic resection was associated with median overall survival of 50% at 1 year and 18% at 5 years. A Japanese nationwide survey of 6474 patients with HCC and PVI found hepatic resection to be associated with significantly longer median survival than other treatments (2.87 vs 1.10 years, p<.001), and the rate of postoperative 90-day mortality rate was only 3.7%. This finding was also supported by propensity score analysis. Hepatic resection survival benefit was observed regardless of patient age, HCC etiology, tumour markers or tumour number. This extensive evidence suggests that hepatic resection can be safe and effective in selected patients with PVI in the segmental or sectoral branches of the portal vein (Vp0-2). It is less clear, however, whether hepatic resection is justified in patients with PVI in the main trunk or portal bifurcation (Vp3-4). We agree with de la Torre et al. and Cho et al. that radioembolization can provide good survival in patients with HCC and PVI, but its safety and efficacy should be verified in different PVI grades. Clinicians should also consider hepatic resection as an option for selected patients with PVI limited to the first-order branch. Financial Support
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