Yin Chao, Armstrong Samantha, Shin Richard, Geng Xue, Wang Hongkun, Satoskar Rohit S, Fishbein Thomas, Smith Coleman, Banovac Filip, Kim Alexander Y, He Aiwu Ruth
Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center Georgetown University Washington District of Columbia USA.
Department of Biostatistics Georgetown University Washington District of Columbia USA.
Ann Gastroenterol Surg. 2022 Nov 24;7(2):295-305. doi: 10.1002/ags3.12622. eCollection 2023 Mar.
In patients with surgically unresectable early and intermediate stage hepatocellular carcinoma (HCC), only liver transplant (LT) offers a cure. Locoregional therapies, such as transarterial chemoembolization (TACE), are widely used to bridge patients waiting for an LT or downstage tumors beyond Milan Criteria (MC). However, there are no formal guidelines on the number of TACE procedures patients should receive. Our study explores the extent to which repeated TACE might offer diminishing gains toward LT.
We retrospectively analyzed 324 patients with BCLC stage A and B HCC who had received TACE with the intention of disease downstaging or bridging to LT. In addition to baseline demographics, we collected data on LT status, survival, and the number of TACE procedures. Overall survival (OS) rates were estimated using the Kaplan-Meier method, and correlative studies were calculated using chi-square or Fisher's exact test.
Out of 324 patients, 126 (39%) received an LT, 32 (25%) of whom had responded favorably to TACE. LT significantly improved OS: HR 0.174 (0.094-0.322, < .001). However, the LT rate significantly decreased if patients received ≥3 vs < 3 TACE procedures (21.6% vs 48.6%, < .001). If their cancer was beyond MC after the third TACE, the LT rate was 3.7%.
An increased number of TACE procedures may have diminishing returns in preparing patients for LT. Our study suggests that alternatives to LT, such as novel systemic therapies, should be considered for patients whose cancers are beyond MC after three TACE procedures.
对于手术无法切除的早期和中期肝细胞癌（HCC）患者，只有肝移植（LT）能实现治愈。局部区域治疗，如经动脉化疗栓塞术（TACE），被广泛用于帮助等待肝移植的患者过渡或使超出米兰标准（MC）的肿瘤降期。然而，对于患者应接受的TACE治疗次数，尚无正式指南。我们的研究探讨了重复进行TACE对肝移植带来的益处逐渐减少的程度。
我们回顾性分析了324例BCLC A期和B期HCC患者，这些患者接受TACE治疗的目的是使疾病降期或过渡到肝移植。除了基线人口统计学数据外，我们还收集了肝移植状态、生存率和TACE治疗次数的数据。总生存率（OS）采用Kaplan-Meier方法估算，相关性研究采用卡方检验或Fisher精确检验进行计算。
在324例患者中，126例（39%）接受了肝移植，其中32例（25%）对TACE反应良好。肝移植显著改善了总生存率：风险比为0.174（0.094 - 0.322，P < 0.001）。然而，如果患者接受≥3次TACE治疗与<3次TACE治疗相比，肝移植率显著降低（21.6%对48.6%，P < 0.001）。如果第三次TACE治疗后其癌症超出米兰标准，肝移植率为3.7%。
增加TACE治疗次数在为患者准备肝移植方面的收益可能会逐渐减少。我们的研究表明，对于经过三次TACE治疗后癌症超出米兰标准的患者，应考虑肝移植的替代方案，如新型全身治疗。
