Ruzzenente Andrea, Capra Franco, Pachera Silvia, Iacono Calogero, Piccirillo Gianluca, Lunardi Marta, Pistoso Stefano, Valdegamberi Alessandro, D'Onofrio Mirko, Guglielmi Alfredo
Department of Surgery and Gastroenterology, Division of General Surgery A, GB Rossi University Hospital, University of Verona Medical School, Piazzale LA Scuro 10, 37134, Verona, Italy.
J Gastrointest Surg. 2009 Jul;13(7):1313-20. doi: 10.1007/s11605-009-0903-x. Epub 2009 May 6.
The role of liver resection in advanced hepatocellular carcinoma (multinodular or with macroscopic vascular involvement) is still controversial. The aim of this study is to evaluate the role of surgical resection compared to other therapeutic modalities in patients with advanced hepatocellular carcinoma (HCC).
Four hundred sixty four patients with HCC observed from 1991 to 2007 were included in the study. All the patients were evaluated for the treatment of HCC in relation to the severity of liver impairment and tumor stage. All the patients included in the study had no evidence of distant metastases.
Median follow up time for surviving patients was 25 months (range 1-155). Two-hundred and eighty-three patients were in Child-Pugh class A, 161 in class B, and 20 in class C. Two-hundred and seventy-one patients had single HCC, 121 patients had two or three HCCs, and 72 more than three HCCs. One-hundred and thirty-six patients (29.3%) were submitted to liver resection (LR), 232 (50.0%) to local ablative therapies (LAT) (ethanol injection, radiofrequency ablation, chemoembolization), eight (1.7%) to liver transplantation (LT), and 88 (19%) to supportive therapy (ST). Median survival time for all patients was 36 months (95% CI 24-36). Median survival time was 57 months for LR, 30 months for LAT, and 8 months for ST, with a 5-year survival of 47%, 20%, and 2.5%, respectively (p = 0.001). Actuarial 5-year survival for patients submitted to LT was 75%. Overall survival was significantly shorter in patients with multiple HCCs compared to single HCC, with median survival times of 39, 16, and 11 months for patients with a single HCC, with two to three HCCs, and with more than three HCCs, respectively (p = 0.01). Survival for patients with single HCC was significantly longer in patients submitted to LR compared to LAT and ST with median survival times of 57, 37, and 14 months, respectively (p = 0.02). Also, in patients with multinodular HCCs (2-3 HCCs) LR showed the best results with a median survival time of 58 months compared to 22 and 8 months for LAT and ST (p = 0.01). In patients with more than three HCCs, LR did not show different results compared to LAT and ST. Seventy-three patients had evidence of macroscopic vascular involvement; median survival in this subgroup of patients was significantly shorter compared to patients without vascular involvement, 10 and 36 months, respectively. Survival for patients with macroscopic vascular involvement submitted to LR or LAT was significant longer compared to ST, with mean survivals of 27, 30, and 12 months, respectively (p = 0.01).
The present study shows that the surgery can achieve good results in patients with single HCC and good liver function. Also, patients with multinodular HCCs (two to three nodules) could benefit from LR where survival is longer than after LAT or ST. In patients with more than three HCCs, LR have similar results of LAT. Macroscopic vascular invasion is a major prognostic factor, and the LR is justified in selected patients, where it can allow good long-term results compared to ST.
肝切除术在晚期肝细胞癌（多结节或伴有肉眼可见血管侵犯）中的作用仍存在争议。本研究的目的是评估手术切除与其他治疗方式相比在晚期肝细胞癌（HCC）患者中的作用。
本研究纳入了1991年至2007年间观察的464例HCC患者。根据肝功能损害程度和肿瘤分期对所有患者进行HCC治疗评估。纳入研究的所有患者均无远处转移证据。
存活患者的中位随访时间为25个月（范围1 - 155个月）。283例患者为Child-Pugh A级，161例为B级，20例为C级。271例患者为单发性HCC，121例患者有2个或3个HCC，72例患者有3个以上HCC。136例患者（29.3%）接受了肝切除术（LR），232例（50.0%）接受了局部消融治疗（LAT）（乙醇注射、射频消融、化疗栓塞），8例（1.7%）接受了肝移植（LT），88例（19%）接受了支持治疗（ST）。所有患者的中位生存时间为36个月（95%可信区间24 - 36个月）。LR组的中位生存时间为57个月，LAT组为30个月，ST组为8个月，5年生存率分别为47%、20%和2.5%（p = 0.001）。接受LT患者的精算5年生存率为75%。与单发性HCC患者相比，多发性HCC患者的总生存期明显缩短，单发性HCC、2 - 3个HCC和3个以上HCC患者的中位生存时间分别为39个月、16个月和11个月（p = 0.01）。与LAT和ST相比，接受LR治疗的单发性HCC患者的生存期明显更长，中位生存时间分别为57个月、37个月和14个月（p = 0.02）。同样，在多结节HCC（2 - 3个HCC）患者中，LR显示出最佳结果，中位生存时间为58个月，而LAT和ST分别为22个月和8个月（p = 0.01）。在有3个以上HCC的患者中，LR与LAT相比未显示出不同结果。73例患者有肉眼可见血管侵犯证据；该亚组患者的中位生存期与无血管侵犯患者相比明显缩短，分别为10个月和36个月。与ST相比，接受LR或LAT治疗的有肉眼可见血管侵犯患者的生存期明显更长，平均生存期分别为27个月、30个月和12个月（p = 0.01）。
本研究表明，手术可在肝功能良好的单发性HCC患者中取得良好效果。此外，多结节HCC（2 - 3个结节）患者可从LR中获益，其生存期长于LAT或ST后。在有3个以上HCC的患者中，LR与LAT结果相似。肉眼可见血管侵犯是一个主要的预后因素，在选定患者中LR是合理的，与ST相比它可获得良好的长期结果。
