AH-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.
Université Paris-Sud, Villejuif, France.
Hepatology. 2015 Jul;62(1):179-87. doi: 10.1002/hep.27864. Epub 2015 May 20.
Liver transplantation (LT) is the best curative treatment for early hepatocellular carcinoma (HCC) in patients with cirrhosis. However, the current shortage of organs causes prolonged waiting times and poorer intention-to-treat (ITT) survival (i.e., after listing) owing to tumor progression and dropout. Portal hypertension (PH) is a recognized risk factor of HCC development in patients with cirrhosis and its recurrence after resection. The aim of this study was to evaluate the potential impact of PHT on the results of LT on an ITT basis. Patients with cirrhosis listed for LT for HCC were included and their outcomes after listing were compared according to the presence or absence of PH defined as presence of esophageal varices or ascites or low platelet count and splenomegaly. Among 243 consecutively listed patients, 70% were affected by PH, which was associated with a significantly higher risk of tumor progression (38% vs. 22%; P = 0.017) and a higher risk of dropout (22% vs. 8%; P = 0.01). Transarterial chemoembolization (TACE) was similarly applied to the two groups (60% vs. 67%; P = 0.325). An absence of TACE was the only other independent risk factor of dropout owing to tumor progression. Under an ITT analysis, PH reduced overall survival (OS), but there was no difference in OS and time to recurrence post-LT. The only pathological feature that could potentially explain this observation was the lower complete response to TACE in the PHT group (12% vs. 36%; P = 0.001).
PH should be regarded as a major risk factor of dropout owing to tumor progression and should be taken into consideration when managing patients with HCC who are waiting for LT.
肝移植（LT）是治疗肝硬化患者早期肝细胞癌（HCC）的最佳治愈方法。然而，由于器官短缺，导致等待时间延长，并且由于肿瘤进展和脱落，意向治疗（ITT）生存率（即列入名单后）较差。门静脉高压（PH）是肝硬化患者 HCC 发展和切除后复发的公认危险因素。本研究旨在评估 PHT 对 ITT 基础上 LT 结果的潜在影响。
将接受 LT 治疗 HCC 的肝硬化患者纳入研究，并根据是否存在食管静脉曲张、腹水或血小板计数低和脾肿大定义的 PH 来比较其列入名单后的结局。在 243 例连续列入名单的患者中，70%患有 PH，其肿瘤进展（38%比 22%；P=0.017）和脱落（22%比 8%；P=0.01）的风险明显更高。两组均接受经动脉化疗栓塞（TACE）（60%比 67%；P=0.325）。TACE 缺失是肿瘤进展导致脱落的唯一其他独立危险因素。在 ITT 分析中，PH 降低了总生存率（OS），但 LT 后 OS 和复发时间无差异。唯一可能解释这种观察结果的病理特征是 PHT 组 TACE 的完全缓解率较低（12%比 36%；P=0.001）。
PH 应被视为肿瘤进展导致脱落的主要危险因素，在管理等待 LT 的 HCC 患者时应予以考虑。
