North Shore-LIJ Health Systems, Lenox Hill Hospital, New York, NY.
Brookdale's Medical Center, Department of Urology, Brooklyn, NY.
Hepatology. 2015 Aug;62(2):440-51. doi: 10.1002/hep.27745. Epub 2015 Mar 20.
Current guidelines recommend surgical resection as the primary treatment for a single hepatocellular cancer (HCC) with Child's A cirrhosis, normal serum bilirubin, and no clinically significant portal hypertension. We determined how frequently guidelines were followed and whether straying from them impacted survival. BRIDGE is a multiregional cohort study including HCC patients diagnosed between January 1, 2005 and June 30, 2011. A total of 8,656 patients from 20 sites were classified into four groups: (A) 718 ideal resection candidates who were resected; (B) 144 ideal resection candidates who were not resected; (C) 1,624 nonideal resection candidates who were resected; and (D) 6,170 nonideal resection candidates who were not resected. Median follow-up was 27 months. Log-rank and Cox's regression analyses were conducted to determine differences between groups and variables associated with survival. Multivariate analysis of all ideal candidates for resection (A+B) revealed a higher risk of mortality with treatments other than resection. For all resected patients (A+C), portal hypertension and bilirubin >1 mg/dL were not associated with mortality. For all patients who were not ideal candidates for resection (C+D), resection was associated with better survival, compared to embolization and "other" treatments, but was inferior to ablation and transplantation.
The majority of patients undergoing resection would not be considered ideal candidates based on current guidelines. Not resecting ideal candidates was associated with higher mortality. The study suggests that selection criteria for resection may be modestly expanded without compromising outcomes, and that some nonideal candidates may still potentially benefit from resection over other treatment modalities.
目前的指南建议对单个肝细胞癌（HCC）进行手术切除作为主要治疗方法，这些 HCC 患者具有 Child's A 级肝硬化、正常血清胆红素和无临床显著门静脉高压。我们确定了指南遵循的频率，以及偏离这些指南是否会影响生存。BRIDGE 是一项多区域队列研究，包括 2005 年 1 月 1 日至 2011 年 6 月 30 日期间诊断为 HCC 的患者。来自 20 个地点的 8656 名患者分为四组：（A）718 名理想的手术切除候选者接受了切除手术；（B）144 名理想的手术切除候选者未接受手术；（C）1624 名非理想手术切除候选者接受了切除手术；（D）6170 名非理想手术切除候选者未接受手术。中位随访时间为 27 个月。进行对数秩和 Cox 回归分析以确定各组之间的差异和与生存相关的变量。对所有适合手术切除的理想候选者（A+B）进行多变量分析显示，除手术以外的其他治疗方法与死亡率升高相关。对于所有接受切除手术的患者（A+C），门静脉高压和胆红素>1mg/dL 与死亡率无关。对于所有不适合手术切除的患者（C+D），与栓塞和“其他”治疗相比，手术切除与更好的生存相关，但逊于消融和移植。
根据目前的指南，接受切除术的大多数患者可能不被视为理想的候选者。未对理想的候选者进行切除与更高的死亡率相关。该研究表明，在不影响结果的情况下，切除术的选择标准可能会适度放宽，并且一些非理想的候选者仍可能从切除中受益于其他治疗方式。
