Biolato Marco, Marrone Giuseppe, Miele Luca, Gasbarrini Antonio, Grieco Antonio
Marco Biolato, Giuseppe Marrone, Luca Miele, Antonio Gasbarrini, Antonio Grieco, Liver Transplant Medicine, Gastroenterological Area, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario Gemelli, Universita' Cattolica del Sacro Cuore, 00168 Roma, Italy.
World J Gastroenterol. 2017 May 14;23(18):3195-3204. doi: 10.3748/wjg.v23.i18.3195.
Hepatocellular carcinoma is becoming an increasing indication for liver transplantation, but selection and allocation of patients are challenging because of organ shortages. Conventional Milan criteria are the reference for the selection of patients worldwide, but many expanded criteria, like University of California San Francisco criteria and up-to-7 criteria, have demonstrated that survival and recurrence results are lower than those for restricted indications. Correct staging is crucial and should include surrogate markers of biological aggressiveness (α-fetoprotein, response to loco-regional treatments). Successful down-staging can select between patients with tumor burden initially beyond transplantation criteria those with a more favorable biology, provided a 3-mo stability in meeting the transplantation criteria. Allocation rules are constantly adjusted to minimize the imbalance between the priorities of candidates with and without hepatocellular carcinoma, and take into account local donor rate and waitlist dynamics. Recently, Mazzaferro et al proposed a benefit-oriented "adaptive approach", in which the selection and allocation of patients are based on their response to non-transplantation treatments: low priority for transplantation in case of complete response, high priority in case of partial response or recurrence, and no listing in case of progression beyond transplantation criteria.
肝细胞癌正日益成为肝移植的适应证，但由于器官短缺，患者的选择和分配具有挑战性。传统的米兰标准是全球患者选择的参考标准，但许多扩展标准，如加利福尼亚大学旧金山标准和7标准，已表明其生存和复发结果低于严格适应证的患者。正确分期至关重要，应包括生物学侵袭性的替代标志物（甲胎蛋白、局部区域治疗反应）。成功的降期可以在肿瘤负荷最初超出移植标准的患者中选择生物学特性更有利的患者，前提是满足移植标准3个月稳定。分配规则不断调整，以尽量减少有和没有肝细胞癌的候选者优先级之间的不平衡，并考虑当地供体率和等待名单动态。最近，马扎法罗等人提出了一种以获益为导向的“适应性方法”，其中患者的选择和分配基于其对非移植治疗的反应：完全缓解时移植优先级低，部分缓解或复发时优先级高，进展超出移植标准时不列入名单。
