Department of Transplantation, Mayo Clinic, Jacksonville, FL.
General Surgery Residency, Department of Surgery, Duke University School of Medicine, Durham, NC.
Liver Transpl. 2019 Feb;25(2):228-241. doi: 10.1002/lt.25333.
With recent changes in United Network for Organ Sharing policy, patients in the United States with hepatocellular carcinoma (HCC) are likely to spend more time on the liver transplantation (LT) waiting list. The increasing wait time will allow for an opportunity to assess tumor biology prior to LT. Modified Response Evaluation Criteria in Solid Tumors (mRECIST) paradigm provides such a framework for this assessment, and yet little is understood of its utility as it would apply for patients listed for LT in the United States. Through a collaboration between the University of California, San Francisco, and the Mayo Clinic, Jacksonville, Florida, the experience of 772 patients listed for LT were retrospectively reviewed to study the impact of immediate mRECIST classification following locoregional therapy (LRT) on pre- and post-LT outcomes. Patients who had progression of disease (PD; n = 72), failed to respond to LRT (n = 89) at any time point, or did not achieve radiologic complete response (CR; n = 224) were all at significant risk for wait-list dropout (odds ratio [OR] = 12.11, 4.81, and 2.48; respectively). CR identified a cohort of patients who were at a reduced risk for wait-list dropout. However, 24.9% eventually required further intervention while waiting for transplant, and as many as 82.4% were found to have residual HCC on explant pathology. Failure to respond to LRT was associated with increased risk for recurrence (OR = 3.00) more so than PD (OR = 1.36), suggesting that despite PD, patients who eventually can respond to LRT may represent favorable candidates for LT. In conclusion, for patients awaiting LT, the mRECIST assessment provides critical guidance for patient management. Although PD portends a poor prognosis, our findings suggest that further aggressive LRT should be pursued because a response to LRT may yield acceptable results for patients awaiting LT as well as after LT.
随着美国器官共享联合网络政策的最新变化，美国的肝细胞癌 (HCC) 患者在肝移植 (LT) 候补名单上的等待时间可能会更长。等待时间的增加将为 LT 前评估肿瘤生物学提供机会。改良实体瘤反应评估标准 (mRECIST) 范式为此类评估提供了一个框架，但对于即将在美国接受 LT 的患者，人们对其适用性知之甚少。通过加利福尼亚大学旧金山分校和佛罗里达州杰克逊维尔的梅奥诊所之间的合作，回顾性地审查了 772 名 LT 候补患者的经验，以研究局部区域治疗 (LRT) 后即刻 mRECIST 分类对 LT 前后结果的影响。任何时间点疾病进展 (PD; n = 72)、对 LRT 无反应 (n = 89) 或未达到影像学完全缓解 (CR; n = 224) 的患者，都有很高的候补名单退出风险（比值比 [OR] = 12.11、4.81 和 2.48；分别）。CR 确定了一组候补名单退出风险降低的患者。然而，24.9%的患者在等待移植期间仍需要进一步干预，多达 82.4%的患者在移植肝组织病理学上发现有残留 HCC。对 LRT 无反应与复发风险增加相关（OR = 3.00）甚于 PD（OR = 1.36），这表明尽管 PD，但最终可以对 LRT 有反应的患者可能更适合 LT。总之，对于等待 LT 的患者，mRECIST 评估为患者管理提供了关键指导。尽管 PD 预示着预后不良，但我们的研究结果表明，应进一步积极进行 LRT，因为对 LRT 的反应可能为等待 LT 的患者以及 LT 后患者带来可接受的结果。
