Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA.
Department of Pediatric Surgery and Transplantation, Kumamoto University Hospital, Kumamoto, Japan.
Ann Surg Oncol. 2020 Dec;27(13):5209-5221. doi: 10.1245/s10434-020-08682-5. Epub 2020 Jun 3.
Based on favorable outcomes reported by experienced centers, perihilar cholangiocarcinoma (Ph-CCA) has become an accepted indication for liver transplantation (LT). What is less clear is if the reported outcomes have been reproduced nationwide in the US.
The aim of this study was to evaluate post-transplant outcomes in patients with Ph-CCA and to determine prognostic factors.
Patients who underwent LT with Model for End-stage Liver Disease exception scores for Ph-CCA between 2010 and 2017 were evaluated. Transplant centers were classified into well- and less-experienced groups: Group 1 [well-experienced (≥ 6 LTs), 7 centers]; Group 2 [less-experienced (< 6 LTs), 23 centers]. Post-transplant mortality due to all-cause and recurrence of Ph-CCA were set as endpoints.
Post-transplant outcomes were significantly better in Group 1 than in Group 2, with 1-, 3-, and 5-year patient survival rates of 91.8%, 56.9%, and 45.8%, versus 65.6%, 48.8%, and 26.0%, respectively. Group 2 showed a significantly higher risk of 1-, 3-, and 5-year all-cause mortality and 1-year mortality associated with Ph-CCA recurrence. Center experience was an independent risk factor for post-transplant mortality. In intention-to-treat analysis, a positive prognostic effect of LT was significant and LT decreased the mortality risk by 86% in the well-experienced group [hazard ratio (HR) 0.14, p < 0.001], whereas this effect was not observed in the less-experienced group (HR 1.35, p = 0.47).
Risk of recurrence of malignancy and mortality was significantly higher in the less-experienced center group. Center effects on post-transplant outcomes in patients with Ph-CCA should be recognized, and the introduction of center approval for LT for Ph-CCA may be justified to achieve comparable outcomes between centers.
基于经验丰富的中心报告的良好结果，肝门部胆管癌（Ph-CCA）已成为肝移植（LT）的公认适应证。目前尚不清楚这些报告的结果在美国全国范围内是否得到了重现。
本研究旨在评估 Ph-CCA 患者 LT 后的转归，并确定预后因素。
评估了 2010 年至 2017 年间因 Ph-CCA 行模型末期肝病评分例外的 LT 患者。将移植中心分为经验丰富和经验较少两组：第 1 组（经验丰富[≥6 例 LT]，7 个中心）；第 2 组（经验较少[<6 例 LT]，23 个中心）。移植后因所有原因和 Ph-CCA 复发导致的死亡均作为终点。
第 1 组的移植后结果明显优于第 2 组，1、3 和 5 年患者生存率分别为 91.8%、56.9%和 45.8%，而第 2 组分别为 65.6%、48.8%和 26.0%。第 2 组的 1、3 和 5 年全因死亡率以及与 Ph-CCA 复发相关的 1 年死亡率明显更高。中心经验是移植后死亡的独立危险因素。意向治疗分析显示，LT 具有显著的预后效果，在经验丰富的组中 LT 将死亡率降低了 86%（风险比[HR]0.14，p<0.001），而在经验较少的组中未见此效果（HR 1.35，p=0.47）。
在经验较少的中心组中，恶性肿瘤复发和死亡的风险明显更高。应认识到中心对 Ph-CCA 患者移植后结局的影响，并且 LT 中心的批准可能是合理的，以实现中心之间的可比结局。
