Manzini Giulia, Henne-Bruns Doris, Porzsolt Franz, Kremer Michael
Department of General and Visceral Surgery , University of Ulm , Ulm , Germany.
Health Care Research Group at the Hospital of General and Visceral Surgery, University Hospital of Ulm , Ulm , Germany.
BMJ Open Gastroenterol. 2017 Mar 24;4(1):e000129. doi: 10.1136/bmjgast-2016-000129. eCollection 2017.
Liver resection (LR) and transplantation are the most reliable treatments for hepatocellular carcinoma (HCC). Aim was to compare different guidelines regarding indication for resection and transplantation because of HCC with and without underlying cirrhosis.
We compared the following guidelines published after 1 January 2010: American (American Association for the Study of Liver Diseases (AASLD)), Spanish (Sociedad Espanola de Oncologia Medica (SEOM)), European (European Association for the study of liver-European Organization for Research and Treatment of Cancer (EASL-EORTC) and European Society for Medical Oncology-European Society of Digestive Oncology (ESMO-ESDO)), Asian (Asian Pacific Association for the Study of Liver (APASL)), Japanese (Japan Society of Hepatology (JSH)), Italian (Associazione Italiana Oncologia Medica (AIOM)) and German (S3) guidelines.
All guidelines recommend resection as therapy of choice in healthy liver. Guidelines based on the Barcelona Clinic Liver Cancer staging system recommend resection for single HCC<2 cm and Child-Pugh A cirrhosis and for HCC≤5 cm with normal bilirubin and portal pressure, whereas transplantation is recommended for multiple tumours between Milan criteria and for single tumours ≤5 cm and advanced liver dysfunction. Patients with HCC and Child-Pugh C cirrhosis are not candidates for transplantation. JSH guidelines recommend LR for patients with Child-Pugh A/B with HCC without tumour size restriction; APASL guidelines in general exclude patients with Child-Pugh A from transplantation. In patients with Child-Pugh B, transplantation is the second-line therapy, if resection is not possible for patients within Milan criteria. German and Italian guidelines recommend transplantation for all patients within Milan criteria.
Whereas resection is the standard therapy of HCC in healthy liver, a standard regarding the indication for LR and transplantation for HCC in cirrhotic liver does not exist, although nearly all guidelines claim to be evidence based. Surprisingly, despite European guidelines, Germany and Italy use their own national guidelines which partially differ from the European. Possible solutions of the problems are discussed.
肝切除术（LR）和肝移植是肝细胞癌（HCC）最可靠的治疗方法。目的是比较因伴有或不伴有潜在肝硬化的HCC而制定的关于肝切除和肝移植指征的不同指南。
我们比较了2010年1月1日之后发布的以下指南：美国（美国肝病研究协会（AASLD））、西班牙（西班牙医学肿瘤学会（SEOM））、欧洲（欧洲肝脏研究协会 - 欧洲癌症研究与治疗组织（EASL - EORTC）以及欧洲医学肿瘤学会 - 欧洲消化肿瘤学会（ESMO - ESDO））、亚洲（亚太肝脏研究协会（APASL））、日本（日本肝病学会（JSH））、意大利（意大利医学肿瘤协会（AIOM））和德国（S3）指南。
所有指南均推荐在肝脏健康时将肝切除术作为首选治疗方法。基于巴塞罗那临床肝癌分期系统的指南推荐，对于单个直径<2 cm且Child - Pugh A级肝硬化的HCC，以及胆红素和门静脉压力正常的直径≤5 cm的HCC进行肝切除，而对于介于米兰标准之间的多个肿瘤以及单个直径≤5 cm且肝功能严重受损的肿瘤则推荐进行肝移植。HCC合并Child - Pugh C级肝硬化的患者不适合进行肝移植。JSH指南推荐对Child - Pugh A/B级且患有HCC的患者进行肝切除，不受肿瘤大小限制；APASL指南一般将Child - Pugh A级患者排除在肝移植之外。对于Child - Pugh B级患者，如果符合米兰标准的患者无法进行肝切除，则肝移植是二线治疗方法。德国和意大利指南推荐所有符合米兰标准的患者进行肝移植。
虽然肝切除术是肝脏健康时HCC的标准治疗方法，但对于肝硬化肝脏中HCC的肝切除和肝移植指征，目前尚无标准，尽管几乎所有指南都声称以证据为基础。令人惊讶的是，尽管有欧洲指南，但德国和意大利使用各自的国家指南，这些指南与欧洲指南部分不同。文中讨论了这些问题可能的解决方案。
