Durand François, Belghiti Jacques
Department of Hepatology, Hôpital Beaujon, Clichy, France.
Hepatogastroenterology. 2002 Jan-Feb;49(43):47-52.
Liver transplantation has become the best option in patients with decompensated cirrhosis and a small hepatocellular carcinoma. Indeed, because of the severity of cirrhosis, resection is usually impossible and in addition, transplantation provides survival rates close to those obtained in cirrhotic patients without malignancy (70 to 80% 3-year survival rate). In patients with a small hepatocellular carcinoma and compensated cirrhosis, both resection and transplantation can be performed. Because of the scarcity of donors, there have been reservations concerning transplantation in patients who otherwise could have undergone resection. However, there is increasing evidence that long-term results of transplantation are significantly superior to those of resection. Therefore, patients with a small hepatocellular carcinoma and compensated cirrhosis are increasingly considered as suitable candidates for transplantation. In contrast to cirrhotic patients with a small hepatocellular carcinoma, patients with large and/or multifocal tumors should no longer be transplanted because of a high rate of early recurrence and the accelerated course of tumor progression due to immunosuppression, both factors being the source of poor results. On rare occasions, hepatocellular carcinoma develops in patients without underlying liver disease. In such cases the tumor is usually recognized when it is large and symptomatic. The absence of underlying liver lesions offers the possibility of extended resection. However, in case of nonresectable (bilobar) tumors or limited recurrence after resection, transplantation may be considered due to the slow progression this subtype of hepatocellular carcinoma. Whatever the underlying liver parenchymal status, efforts should be made to reduce the risk of recurrence.
肝移植已成为失代偿期肝硬化合并小肝细胞癌患者的最佳选择。的确，由于肝硬化的严重性，通常无法进行切除，此外，肝移植提供的生存率接近无恶性肿瘤的肝硬化患者（3年生存率为70%至80%）。对于小肝细胞癌合并代偿期肝硬化的患者，切除和肝移植均可进行。由于供体稀缺，对于原本可以接受切除的患者进行肝移植存在疑虑。然而，越来越多的证据表明，肝移植的长期效果明显优于切除。因此，小肝细胞癌合并代偿期肝硬化的患者越来越被视为肝移植的合适候选者。与小肝细胞癌的肝硬化患者相反，肿瘤大或多灶性的患者不应再进行肝移植，因为早期复发率高，且免疫抑制会加速肿瘤进展，这两个因素都会导致不良后果。在极少数情况下，肝细胞癌会在无潜在肝脏疾病的患者中发生。在这种情况下，肿瘤通常在体积较大且出现症状时才被发现。无潜在肝脏病变使得扩大切除成为可能。然而，对于不可切除（双侧）肿瘤或切除后有限复发的情况，由于这种亚型的肝细胞癌进展缓慢，可考虑进行肝移植。无论潜在的肝实质状态如何，都应努力降低复发风险。
