Halazun Karim J, Najjar Marc, Abdelmessih Rita M, Samstein Benjamin, Griesemer Adam D, Guarrera James V, Kato Tomoaki, Verna Elizabeth C, Emond Jean C, Brown Robert S
*Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY †Center for Liver Disease and Transplantation, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY ‡Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY.
Ann Surg. 2017 Mar;265(3):557-564. doi: 10.1097/SLA.0000000000001966.
We sought to develop a "Model Of Recurrence After Liver transplant" (MORAL) for hepatocellular carcinoma (HCC).
The Milan criteria are used to allocate livers to patients with HCC requiring liver transplantation (LT) but do not include objective measures of tumor biology. Biological markers including the neutrophil-lymphocyte ratio (NLR) and alpha-fetoprotein (AFP) have been associated with recurrence risk.
Prospective cohort study of adults undergoing LT for HCC between January 2001 and December 2012.
A total of 339 patients were included. On multivariable Cox regression analysis, 3 preoperatively available factors were independent predictors of worse recurrence-free survival (RFS), namely, an NLR ≥ 5 (P < 0.0001, hazard ratio, HR: 6.2), AFP > 200 (P < 0.0001, HR: 3.8), and Size >3 cm (P < 0.001, HR: 3.2). The Pre-MORAL score was constructed from the hazard ratios and assigning patients points in an additive fashion, with a minimum of 0 points (no factors) and a maximum of 13 points (all 3 factors). The highest risk patients in the Pre-MORAL had a 5-year RFS of 17.9% compared with 98.6% for the low risk group (P < 0.0001). The post-MORAL was constructed similarly using the 4 postoperatively available independent predictors of worse RFS, grade 4 HCC's (P < 0.0001, HR: 5.6), vascular invasion (P = 0.019, HR: 2.0), size >3 cm (P < 0.0001, HR: 3.2) and number >3 (P = 0.048, HR: 1.8). The pre- and post-MORAL were superior to Milan at predicting recurrence with c-statistics of 0.82 and 0.87, compared with 0.63, respectively. We then combined the scores to produce a combo-MORAL, with a c-statistic of 0.91 for predicting recurrence.
The MORAL score provides a simple, highly accurate tool for predicting recurrence and risk-stratification pre- and postoperatively.
我们试图为肝细胞癌（HCC）开发一种“肝移植后复发模型”（MORAL）。
米兰标准用于将肝脏分配给需要肝移植（LT）的HCC患者，但不包括肿瘤生物学的客观指标。包括中性粒细胞与淋巴细胞比值（NLR）和甲胎蛋白（AFP）在内的生物学标志物与复发风险相关。
对2001年1月至2012年12月期间接受LT治疗HCC的成年人进行前瞻性队列研究。
共纳入339例患者。多变量Cox回归分析显示，术前可获得的3个因素是无复发生存期（RFS）较差的独立预测因素，即NLR≥5（P<0.0001，风险比，HR：6.2）、AFP>200（P<0.0001，HR：3.8）和肿瘤大小>3cm（P<0.001，HR：3.2）。术前MORAL评分根据风险比构建，以累加方式为患者计分，最低0分（无风险因素），最高13分（所有3个风险因素）。术前MORAL评分中风险最高的患者5年RFS为17.9%，而低风险组为98.6%（P<0.0001）。术后MORAL评分同样根据术后可获得的RFS较差的4个独立预测因素构建，即4级HCC（P<0.0001，HR：5.6）、血管侵犯（P=0.019，HR：2.0）、肿瘤大小>3cm（P<0.0001，HR：3.2）和肿瘤数量>3（P=0.048，HR：1.8）。术前和术后MORAL评分在预测复发方面优于米兰标准，c统计量分别为0.82和0.87，而米兰标准为0.63。然后我们将这些评分合并生成综合MORAL评分，其预测复发的c统计量为0.91。
MORAL评分提供了一种简单、高度准确的工具，用于术前和术后预测复发及风险分层。
