Kornberg A, Witt U, Küpper B, Wildgruber M, Friess H
Department of Surgery, Klinikum rechts der Isar, Technical University, Munich, Germany.
Transplant Proc. 2013 Jun;45(5):1913-5. doi: 10.1016/j.transproceed.2013.01.004.
Locoregional interventional bridging treatment (IBT) before liver transplantation (LT) is an accepted neoadjuvant approach in liver transplant patients with hepatocellular carcinoma (HCC). However, the effect of postinterventional tumor necrosis on posttransplantation outcome is known.
A total of 93 consecutive liver transplant patients with HCC were included in this prospective trial. Fifty-nine patients underwent pretransplantation IBT, by either transarterial chemoembolization (n = 51) or radiofrequency ablation (n = 8). The extent of tumor necrosis assessed at explant pathology (≥50% tumor necrosis rate = extended post-IBT tumor necrosis; <50% tumor necrosis rate = less extended tumor necrosis) and its impact on recurrence-free survival in the context of other prognostic relevant histopathologic variables were analyzed in uni- and multivariate analyses.
Extended tumor necrosis was assessed in 44 patients among the IBT population, and tumor necrosis rate was <50% in 15 patients of the IBT and 34 patients of the non-IBT population, respectively. Five-year recurrence-free survival rates were 96% in patients with and 55% in patients without extended tumor necrosis rates (P < .001). Recurrence-free survival rates were similar between patients with HCC meeting the Milan criteria (85%) and those exceeding the Milan criteria but demonstrating extended post-IBT tumor necrosis on explant pathology (80%). On multivariate analysis, only microvascular invasion (odds ratio 6.4) and extended postinterventional tumor necrosis (odds ratio 9.2) were identified as independent histopathologic predictors of recurrence-free outcome (P < .05).
Extended tumor necrosis should be the major objective of neoadjuvant IBT in liver transplant patients with HCC, because it significantly improves posttransplantation outcome. Thereby, even patients with HCC beyond the Milan criteria may achieve excellent survival rates.
肝移植（LT）前的局部区域介入桥接治疗（IBT）是肝细胞癌（HCC）肝移植患者中一种被认可的新辅助治疗方法。然而，介入后肿瘤坏死对移植后结局的影响尚不清楚。
本前瞻性试验共纳入93例连续的HCC肝移植患者。59例患者在移植前行IBT，其中经动脉化疗栓塞术（n = 51）或射频消融术（n = 8）。通过移植肝病理检查评估肿瘤坏死程度（肿瘤坏死率≥50% = 介入后肿瘤坏死范围扩大；肿瘤坏死率<50% = 肿瘤坏死范围扩大程度较小），并在单因素和多因素分析中分析其在其他预后相关组织病理学变量背景下对无复发生存的影响。
IBT组44例患者评估为肿瘤坏死范围扩大，IBT组15例患者和非IBT组34例患者的肿瘤坏死率<50%。肿瘤坏死范围扩大的患者5年无复发生存率为96%，未扩大的患者为55%（P <.001）。符合米兰标准的HCC患者（85%）与超过米兰标准但移植肝病理显示介入后肿瘤坏死范围扩大的患者（80%）的无复发生存率相似。多因素分析显示，仅微血管侵犯（比值比6.4）和介入后肿瘤坏死范围扩大（比值比9.2）被确定为无复发生存结局独立的组织病理学预测因素（P <.05）。
肿瘤坏死范围扩大应是HCC肝移植患者新辅助IBT的主要目标，因为它能显著改善移植后结局。因此，即使是超过米兰标准的HCC患者也可能获得优异的生存率。
