Duffy JP, Vardanian A, Benjamin E, Watson M, Farmer DG, Ghobrial RM, Lipshutz G, Yersiz H, Lu DS, Lassman C, Tong MJ, Hiatt JR, Busuttil RW.
洛杉矶Dumont-UCLA移植中心,外科, 加州大学洛杉矶分校David Geffen医学院, 洛杉矶, 加利福尼亚州。
目标：评估原位肝移植（OLT）对肝细胞癌（HCC）的疗效，以及目前分级标准对长期存活的影响。
背景资料概要：目前肝癌正逐渐成为原位肝移植的适应症。医疗保险制度规定，只有符合米兰标准的肝癌患者才能进行原位肝移植，因此限制了潜在的肝移植受体。我们分析了应用原位肝移植治疗肝癌的经验，以此来判断是否需要扩大米兰标准。
方法：1984年至2006年间因肝癌进行原位肝移植的所有患者都被纳入评估范围。对符合以下两种标准的结果进行了对比：米兰标准（单发肿瘤≤5厘米，或多发肿瘤≤3个，且每个直径不超过3 厘米），加州旧金山大学(UCSF)标准（单发肿瘤≤6.5厘米，或多发肿瘤≤3个，且每个直径不超过4.5 厘米，累积肿瘤大小<8厘米），或超出UCSF标准。
结果：因肝癌原因进行的移植手术共467例。在平均6.6年（+/- 0.9）的随访中，复发率为21.2%，1年、3年和5年的存活率分别为82%、65%和52%。根据术前影像学（79%和64%；P=0.061）和外置体病理学（86%和71%；P=0.057）显示，符合米兰标准的患者，其5年术后存活率与符合UCSF标准的患者相似。超出UCSF标准的带瘤患者存活率明显更低，5年存活率低于50%。多元分析法表明，肿瘤数目（P < 0.001）、淋巴浸润性（ p < 0.001 ）、低分化（P = 0.002）等是生存质量差的独立预测指标。
结论：这个最大的独立机构运用原位肝移植治疗肝癌的经验证明，通过术前影像学和外置体病理学分类的超出米兰标准但符合UCSF标准的肿瘤患者，在肝移植后也能长期存活。因此，将原位肝移植的衡量标准扩大到不超出UCSF标准是正确的。
PMID: 17717454 [PubMed - in process]
Liver transplantation criteria for hepatocellular carcinoma should be expanded: a 22-year experience with 467 patients at UCLA.
Duffy JP, Vardanian A, Benjamin E, Watson M, Farmer DG, Ghobrial RM, Lipshutz G, Yersiz H, Lu DS, Lassman C, Tong MJ, Hiatt JR, Busuttil RW.
From the Dumont-UCLA Transplant Center, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
OBJECTIVE: To assess the efficacy of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) and the impact of current staging criteria on long term survival.
SUMMARY BACKGROUND DATA: HCC is becoming an increasingly common indication for OLT. Medicare approves OLT only for HCCs meeting the Milan criteria, thus limiting OLT for an expanding pool of potential liver recipients. We analyzed our experience with OLT for HCC to determine if expansion of criteria for OLT for HCC is warranted.
METHODS: All patients undergoing OLT for HCC from 1984 to 2006 were evaluated. Outcomes were compared for patients who met Milan criteria (single tumor </=5 cm, maximum of 3 total tumors with none >3 cm), University of California, San Francisco (UCSF) criteria (single tumor <6.5 cm, maximum of 3 total tumors with none >4.5 cm, and cumulative tumor size <8 cm), or exceeded UCSF criteria.
RESULTS: A total of 467 transplants were performed for HCC. At mean follow up of 6.6 +/- 0.9 years, recurrence rate was 21.2%, and overall 1, 3, and 5-year survival was 82%, 65%, and 52%, respectively. Patients meeting Milan criteria had similar 5-year post-transplant survival to patients meeting UCSF criteria by preoperative imaging (79% vs. 64%; P = 0.061) and explant pathology (86% vs. 71%; P = 0.057). Survival for patients with tumors beyond UCSF criteria was significantly lower and was below 50% at 5 years. Multivariate analysis showed that tumor number (P < 0.001), lymphovascular invasion (P < 0.001), and poor differentiation (P = 0.002) independently predicted poor survival.
CONCLUSIONS: This largest single institution experience with OLT for HCC demonstrates prolonged survival after liver transplantation for tumors beyond Milan criteria but within UCSF criteria, both when classified by preoperative imaging and by explant pathology. Measured expansion of OLT criteria is justified for tumors not exceeding the UCSF criteria.
PMID: 17717454 [PubMed - in process]
[责任编辑:刘 聪]
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