Capussotti L, Ferrero A, Viganò L, Polastri R, Tabone M
Department of Surgery, Ospedale Mauriziano Umberto I, Largo Turati 62, Torino, Italy.
Eur J Surg Oncol. 2009 Jan;35(1):11-5. doi: 10.1016/j.ejso.2007.06.005. Epub 2007 Aug 3.
EASL/AASLD guidelines clearly define indications for liver surgery for HCC: patients with single HCC and completely preserved liver function without portal hypertension. These guidelines exclude from operation many patients that could benefit from radical resection and that are daily scheduled for hepatectomy in surgical centers. Patients with large tumors or with portal vein thrombosis cannot be transplanted or treated by interstitial treatments. In selected cases liver resection may obtain good long-term outcomes, significantly better than non-curative therapies. In cases of multinodular HCC, liver transplantation is the treatment of choice within Milan criteria; patients beyond these limits can benefit from liver resection, especially if only two nodules are diagnosed: even if they have a worse prognosis, survival results after liver surgery are better than those reported after TACE or conservative treatments. EASL/AASLD guidelines excluded from operating patients with portal hypertension but data about this topic are not conclusive and further studies are necessary. Selected patients with mild portal hypertension could probably be scheduled for liver resection and, considering the shortage of donors, listing for transplantation could be avoided. In conclusion, guidelines for HCC treatment should consider good results of liver resection for advanced HCC, and indications for hepatectomy should be expanded in order not to exclude from radical therapy patients that could benefit from it.
欧洲肝脏研究学会（EASL）/美国肝病研究学会（AASLD）指南明确界定了肝癌肝手术的适应症：单个肝癌且肝功能完全保留、无门静脉高压的患者。这些指南将许多本可从根治性切除中获益且在外科中心每日安排行肝切除术的患者排除在手术之外。肿瘤较大或有门静脉血栓形成的患者无法进行移植或接受间质治疗。在某些特定情况下，肝切除可能会取得良好的长期疗效，明显优于非根治性治疗。对于多结节性肝癌，在米兰标准范围内肝移植是首选治疗方法；超出这些标准的患者可从肝切除中获益，尤其是仅诊断出两个结节的患者：即使他们预后较差，但肝手术后的生存结果仍优于经动脉化疗栓塞术（TACE）或保守治疗后的结果。EASL/AASLD指南将有门静脉高压的患者排除在手术之外，但关于该主题的数据尚无定论，还需要进一步研究。部分轻度门静脉高压的患者可能可以安排肝切除术，并且考虑到供体短缺，可以避免将其列入移植名单。总之，肝癌治疗指南应考虑晚期肝癌肝切除的良好效果，应扩大肝切除术的适应症，以免将可能从中获益的患者排除在根治性治疗之外。
