Azoulay Daniel, Audureau Etienne, Bhangui Prashant, Belghiti Jacques, Boillot Olivier, Andreani Paola, Castaing Denis, Cherqui Daniel, Irtan Sabine, Calmus Yvon, Chazouillères Olivier, Soubrane Olivier, Luciani Alain, Feray Cyrille
*Service de Chirurgie Hépato-Bilio-Pancréatique, AP-HP Hôpital Henri Mondor, Créteil, France †Service de Santé Publique, AP-HP Hôpital Henri Mondor, Université Paris- Est Créteil, Créteil, France ‡Service de Chirurgie Hépato-Bilio-Pancréatique, AP-HP Hôpital Paul Brousse, Villejuif, France §Service de Chirurgie Hépato-Bilio-Pancréatique, AP-HP Hôpital Beaujon, Clichy, France ¶Service de Chirurgie Hépato-Bilio-Pancréatique, Hôpital Edouard Herriot, Lyon, France ||Service de Chirurgie Hépato-Bilio-Pancréatique, AP-HP Hôpital Saint Antoine, Paris, France **Service de Radiologie, AP-HP Hôpital Henri Mondor, Créteil, France ††Service d'Hépatologie, Hôpital Henri Mondor, Créteil, France.
Ann Surg. 2017 Dec;266(6):1035-1044. doi: 10.1097/SLA.0000000000001986.
An intent-to-treat analysis of overall survival (ITT-OS) of cirrhotic patients with hepatocellular carcinoma (HCC) listed for living donor liver transplantation (LDLT) or brain-dead donor liver transplantation (BDLT) across 5 French liver transplant (LT) centers.
Comparisons of HCC outcomes after LDLT and BDLT measured from time of transplantation have yielded conflicting results.
Records from 861 cirrhotic patients with HCC consecutively listed for either LDLT (n = 79) or BDLT (n = 782) from 2000 to 2009 were analyzed for ITT-OS using a Cox model; and tumor recurrence using 2 competitive risk models.
Tumor staging was similar between groups. In total, 162 patients dropped out (20.7%), all from Group BDLT (P < 0.0001). The postoperative mortality rate and the retransplantation rate were similar between LDLT and BDLT. At 5 years, no statistically significant difference was found in ITT-OS between LDLT and BDLT groups (73.2% vs 66.7%; P = 0.062). LDLT waitlist inclusion (hazard ratio: 0.61 (0.39-0.96); P = 0.034) and a time-of-listing MELD score ≥ 25 (hazard ratio: 1.93 (1.15-3.26); P = 0.014) were independent predictors of ITT-OS. Similar 5-year post-LT OS rates (73.2% and 73.0% for Group LDLT and Group BDLT, respectively; P = 0.407) and HCC recurrence rates (10.9% and 11.2% for Group LDLT and Group BDLT, respectively; P = 0.753) were found. Upon explant analysis, tumors exceeding the Milan criteria, macroscopic vascular invasion, and AFP score>2 were independent predictors of recurrence, whereas LT type was not.
LDLT improves ITT-OS, and it is not a risk factor for tumor recurrence. Therefore, LDLT and BDLT should be equally encouraged in countries where both are available.
对法国5家肝移植（LT）中心登记等待活体供肝肝移植（LDLT）或脑死亡供体肝移植（BDLT）的肝细胞癌（HCC）肝硬化患者进行总生存意向性分析（ITT-OS）。
从移植时间开始比较LDLT和BDLT后HCC的预后，结果相互矛盾。
分析2000年至2009年连续登记等待LDLT（n = 79）或BDLT（n = 782）的861例HCC肝硬化患者的记录，使用Cox模型进行ITT-OS分析；使用2种竞争风险模型分析肿瘤复发情况。
两组间肿瘤分期相似。共有162例患者退出（20.7%），均来自BDLT组（P < 0.0001）。LDLT和BDLT术后死亡率和再次移植率相似。5年时，LDLT组和BDLT组的ITT-OS无统计学显著差异（73.2%对66.7%；P = 0.062）。列入LDLT等待名单（风险比：0.61（0.39 - 0.96）；P = 0.034）和列入名单时MELD评分≥25（风险比：1.93（1.15 - 3.26）；P = 0.014）是ITT-OS的独立预测因素。LT术后5年总生存率相似（LDLT组和BDLT组分别为73.2%和73.0%；P = 0.407），HCC复发率也相似（LDLT组和BDLT组分别为10.9%和11.2%；P = 0.753）。在切除分析中，超过米兰标准的肿瘤、宏观血管侵犯和AFP评分>2是复发的独立预测因素，而LT类型不是。
LDLT可改善ITT-OS，且不是肿瘤复发的危险因素。因此，在LDLT和BDLT均可开展的国家，应同样鼓励采用这两种方式。
