Department of Hepato-Pancreato-Biliary Surgery, Assistance Publique Hôpitaux de Paris, Clichy, France-Université Denis Didero, Paris 7, France.
Hepatology. 2012 Jan;55(1):132-40. doi: 10.1002/hep.24680.
Liver resection (LR) for hepatocellular carcinoma (HCC) as the first-line treatment in transplantable patients followed by "salvage transplantation" (ST) in case of recurrence is an attractive concept. The aim was to identify patients who gain benefit from this approach in an intention-to-treat study. From 1998 to 2008, among 329 potential candidates for liver transplantation (LT) with HCC within the Milan criteria (MC), 138 with good liver function were resected (LR group) from a perspective of ST in case of recurrence, and 191 were listed for LT first (LT group). The two groups were compared on an intention-to-treat basis with special reference to management of recurrences and transplantability after LR. Univariate and multivariate analyses were performed to identify resected patients who developed recurrence beyond MC. Five-year overall and disease-free survival was similar in both groups: LT versus LR group, 60% versus 77% and 56% versus 40%, respectively. Among the 138 patients in the LR group, 20 underwent LT before recurrence, 39 (28%) had ST, and 51 (37%) with recurrence were not transplanted including 21 within MC who were excluded for advanced age, acquired comorbidities, or refusal and 30 (22%) with recurrence beyond MC. Predictive factors for nontransplantability due to recurrence beyond MC included microscopic vascular invasion (hazard ratio [HR] 2.38 [range, 1.10-7.29]), satellite nodules (HR 2.46 [range, 1.01-6.68]), tumor size > 3 cm (HR 1.34 [range, 1.03-3.12]), poorly differentiated tumor (HR 3.18 [range, 1.31-7.70]), and liver cirrhosis (HR 1.90 [range, 1.04-3.12]).
The high risk of failure of ST after initial LR for HCC within MC suggests the use of tissue analysis as a selection criterion. The salvage LT strategy should be restricted to patients with favorable oncological factors.
肝癌患者行肝切除术（LR）作为米兰标准（MC）内肝移植（LT）的一线治疗，若复发则行挽救性移植（ST），这是一种有吸引力的治疗方法。本研究旨在通过意向性治疗研究，确定从 ST 中获益的患者。
1998 年至 2008 年，MC 内 329 例 HCC 潜在 LT 候选者中，138 例肝功能良好者行 LR（LR 组），以备复发时行 ST，191 例首先列入 LT 组。两组均采用意向性治疗方法进行比较，特别参考复发后的管理和 LR 后的可移植性。采用单因素和多因素分析确定超出 MC 复发的可切除患者。
两组在 LT 组和 LR 组的 5 年总生存率和无病生存率相似：60%比 77%和 56%比 40%。LR 组中，20 例患者在复发前接受 LT，39 例（28%）行 ST，51 例（37%）复发未移植，包括 21 例在 MC 内因高龄、获得性合并症或拒绝而排除，30 例（22%）复发超出 MC。因超出 MC 复发而无法移植的预测因素包括微血管侵犯（HR 2.38 [范围 1.10-7.29]）、卫星结节（HR 2.46 [范围 1.01-6.68]）、肿瘤直径>3cm（HR 1.34 [范围 1.03-3.12]）、低分化肿瘤（HR 3.18 [范围 1.31-7.70]）和肝硬化（HR 1.90 [范围 1.04-3.12]）。
LR 治疗 MC 内 HCC 后 ST 失败风险高，提示采用组织分析作为选择标准。挽救性 LT 策略应仅限于具有良好肿瘤学因素的患者。
