肝癌肝移植的现状和展望

亚洲的肝细胞癌(Hepatocellular carcinoma，HCC)绝大多数具有病毒性肝炎和肝硬化的背景，尽管肝脏外科技术日益发展、HCC综合治疗模式渐趋成熟，但能耐受肝叶切除并获得根治不到20％，病人5年存活率低于5％。HCC是否适宜采用肝移植治疗是全球移植界近年来最富争议的问题之一。事实上，自从20世纪60年代起，肝移植技术即应用于治疗HCC。     

肝移植的现状与展望

肝移植的现状与展望刘保池范上达河南医科大学一附院外科郑州４５００５２随着肝移植技术和免疫抑制的研究和发展，肝移植的长期存活率明显提高。对治疗无效的末期肝脏衰竭病人，通过肝移植不但可以延长生命，而且肝移植后可以从事正常的工作和生活。因此，肝移植已成为...     

肝癌患者肝移植的选择标准

由于与那些没有HCC患的移植存活率相似，所以肝移植是肝硬化和肝细胞癌(HCC)患最佳的治疗方法。供体器官的缺乏和移植名单长久的等待，是导致肿瘤和肝病进展的两个主要的限制因素。包括最佳的选择标准和手术前辅助治疗的作用在内的有些问题尚待解决。     

肝移植的内科指征及其临床进展

肝移植是挽救终末期肝病和急性肝功能衰竭的治疗手段。尽管移植外科技术日臻完善,肝移植已成为常规治疗手段,但肝移植过程仍然会有许多使外科和内科医师感到棘手的情况发生。肝移植依然存在许多并发症,患者移植前状态、供体状况、免疫因素均可能影响并发症的发生。本文回顾性分析肝移植过程中及其后所引起的内科学问题,包括在移植指征、患者选择、术后早期和中晚期并发症处理方面的最新进展。随着肝移植患者以及长期生存者数量的不断增加,移植医师越来越关注患者的中长期生存,其内科并发症包括慢性肾功能不全、高血压、新发糖尿病、肥胖以及新发肿瘤等,直接或间接均与免疫抑制剂的使用密切相关,这也对移植内科医师提出了更多的挑战。     

肝癌肝移植

随着外科技术的提高和新的免疫抑制剂的使用，使得肝移植的适应证逐渐放宽。对肝癌患者是否适宜作肝移植一直存在争论，一方面，确有部分肝癌患者在接受肝移植术后获得了治愈并长期存活，但另一方面，仍有很多肝癌患者移植术后２年内死于肿瘤复发，中、长期疗效不理想。近年来随着临床资料的积累，人们对肝癌肝移植的认识不断加深，从最初的适应证，后来一度改为禁忌证，然后又变为相对适应证，虽然仍有争议但目前还是认为肝癌是肝移植的适应证之一，只要病例选择适当，加以必要的围手术期辅助治疗以减少术后的复发，肝移植治疗肝癌仍可取得…     

肝癌肝移植

肝移植和肝切除是目前肝癌的2种主要治疗方法。早期肝癌合并晚期肝病患者肝移植后疗效评估最佳;但是对于肝功能代偿尚可、不伴门静脉高压的早期肝癌患者来说,最佳的治疗方案仍存在争议。大量的研究证明肝移植后无病生存率更高,但是尚不清楚长期生存率如何。通过改进手术技术和实行补救性肝移植的方法可明显改善肝切除后患者生存率,且避免了可因切除治愈的患者因等待移植时间过长而失去机会。     

肝移植新进展（下）

丙型肝炎患的肝移植——结局、抗病毒策略和免疫抑制 丙型肝炎是美国最常见的单一肝移植指征。在免疫抑制的个体中会加速复发性丙型肝炎相关肝硬化的进程，在8-44％的患中仅需要5-7年的时间。丙型肝炎复发的患与没有丙肝的受相比预后明显要差得多，在超过700天的随访期中，死亡风险升高23％并且移植物衰竭的风险增加30％。因为与别的原因造成的肝病相比，丙型肝炎的预后较差（1年死亡率接近50％），因此对丙肝患进行再移植存在争议。[第一段]     

确定肝移植指征时应考虑的若干问题

肝移植的指征只是相对的，而且仍在不断修正。例如在欧美近年恶性肿瘤在移植病人中所占的比例已在明显地不断下降，但随着抗肿瘤治疗效果的改善，有可能再度上升。以下讨论在肝移植中存在的某些问题。     

肝癌肝移植转化治疗策略进展

肝移植能够在彻底去除肿瘤的同时完整移除病肝,对于合并肝硬化的肝癌患者是最佳选择。近年来,随着肝癌综合治疗研究的进展,转化治疗理念被引入肝癌外科治疗领域以及肝移植领域,成功的转化治疗有望将超出标准肝癌患者转变为符合标准而接受肝移植手术,从而极大改善其预后。就肝癌肝移植转化治疗的进展进行简要介绍。     

Hepatocellular cancer in liver transplantation

Hepatocellular carcinoma (HCC) is a malignant epithelial tumor that accounts for over 80% of primary liver tumors. It affects males more than females, and is responsible for over 1 million yearly deaths worldwide. HCC tends to be relentless in nature and of rapid evolution. Most cases of HCC are associated with cirrhosis, usually caused by chronic viral hepatitis or alcohol ingestion. In cases of established cirrhosis, HCC develops with an annual incidence of 3–10%. Hepatocellular carcinoma may present in a generalized way with overall clinical deterioration and malaise, as a palpable liver mass, or as an asymptomatic lesion that is discovered incidentally. Alpha‐fetoprotein (AFP) measurements allow for the differentiation of HCC in cirrhotics, and can act as predictive markers. Patients with cirrhosis and small tumors (up to 3 cm, or 5 cm if solitary), no more than three nodules, and no portal vein involvement were found to benefit more from orthotopic liver transplantation (OLTx) than from resection. Tumors under 3 cm in size were unlikely to recur, while those over 5 cm posed the greatest risk. An incidental HCC in a transplant patient should be treated as seriously and aggressively as if the transplant had been undertaken for HCC.     

免疫治疗时代下的肝癌肝移植

我国大部分肝癌患者在就诊时不能获得根治性手术治疗,近年来肝癌免疫治疗的突破性进展为这些中晚期肝癌患者带来了曙光。在肝癌肝移植领域,免疫治疗更是因为在肿瘤免疫和移植免疫中扮演的双重角色而备受关注。在术前降期治疗和移植术后肿瘤复发的治疗中均有创新性的应用。在免疫治疗的时代下如何应用移植肿瘤学思维使肝癌肝移植患者获益是一个崭新的课题,这需要在临床实践中进行多学科团队协作,探讨最佳的肝癌肝移植患者治疗策略,最终改善中晚期肝癌患者的预后。     

粪菌移植与肝癌

<正>人体胃肠道栖息着大量的、种类繁多的微生物,其中最主要的是细菌,我们称之为肠道菌群。作为人体最复杂的微生态系统之一,肠道菌群对人类健康有着重要的影响。通过与肠粘膜相互作用,肠道菌群参与机体营养物质的新陈代谢和免疫调节等过程~([1])。不仅如此,肠道菌群和人体疾病的发生发展亦有重要的联系~([2])。肠道菌群失调不仅打破了所处肠道微环境的动态平衡,直接导致肠道疾病,而     

Incidence and risk factors for cancer after liver transplantation

De novo tumors (DNT) are a serious complication after orthotopic liver transplantation (OLT), showing a higher overall incidence ranging from 4.7% to 15.7% in non-selected series. Skin cancer (SC) is the most frequent malignancy observed, ranging from 6% to 70% of the tumors observed, followed by post-transplant lymphoproliferative disorders (PTLD) (4.3-30%). Different immunosuppressive protocols do not seem to influence DNT appearance. Colon and upper aerodigestive cancer after OLT seems to be more prone to develop when there are associated risk factors, such as primary sclerosing cholangitis (PSC) and alcoholic liver cirrhosis (ALC). Some risk factors, such as age, smoking, alcohol and others seem to play a role in higher risk for malignancy, but the presence of a long-term immunosuppressive state, more than the specific regimen used, is the basis for this higher incidence. Ethnic and demographic factors are also important variables influencing the heterogeneity of the results, especially influencing Kaposi's sarcoma and skin tumors.     

Colorectal cancer after orthotopic liver transplantation

There is an increased incidence of de novo malignancies in post-liver transplant patients, commonly associated with chronic viral infection comprising lymphoproliferative disease and skin cancers, including squamous cell carcinoma and Kaposi's sarcoma. The overall incidence of colorectal cancer however in this population seems to be no different to the age and sex matched general population. In identified high risk patients like those with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD), the incidence of colorectal cancer appears to be higher. In IBD, like other pre-malignant conditions, the risk of developing malignancy increases exponentially with time, raising the question of whether the apparent increase in the incidence of colorectal cancer is the result of liver transplantation and immunosuppression or due to the natural history of IBD. For these PSC recipients, pre-transplant screening with colonoscopy and post-transplant surveillance for malignant change in the large bowel is crucial. The behaviour of inflammatory bowel disease post-liver transplant is largely unpredictable despite immunosuppression. Colorectal cancer when it occurs in the post-liver transplant patient should be managed according to current guidelines, stage for stage as for the population in general coupled with reduction in immunosuppression treatment.     

Liver transplantation in the treatment of primary liver cancer

One hundred and fifteen patients underwent orthotopic liver transplantation (OLT) for primary liver malignancy. Overall survivals of these patients were significantly lower than those of patients with non-malignant diseases (5-year survival rates 37% and 65%, respectively). Hepatocellular carcinoma (HCC) was the most common malignancy among our patients (n = 80). Fibrolamellar HCC (n = 9) was associated with better survival than non-fibrolamellar HCC (N = 71) among the lesions greater than or equal to 5 cm in diameter. More frequent recurrence was noted in patients with large tumors (greater than or equal to 5 cm), multiple tumors, and gross vascular involvement. A significant lower survival rate was observed in patients with bile duct cancer (n = 19) than in those with HCC or epithelioid hemangioendothelioma (n = 8). Careful patient selection and effective adjuvant anti-cancer therapy are needed to improve the results of OLT for primary liver malignancy.     

Indications for liver transplantation in chronic liver diseases

Surgical resection of the diseased liver together with the implantation of a new donor organ allows patients with chronic liver failure to survive longer as well as to achieve a better quality of life. In life-threatening acute and chronic hepatic failure liver transplantation represents the only causal and long-term therapeutic option. This is also true for several genetically defined liver diseases. Five-year survival approaches 70 % in most cases. Three of four patients regain a nearly normal life with complete reintegration into their professional work. Drawbacks of this therapeutic option relate to a life-long dependence on drugs and medical services as well as to the risks associated with the surgical procedure and the side-effects of a continuous drug-induced immunosuppression. Mortality and morbidity are considerably increased during the first three months after operation. These limitations and the dramatically low availability of donor organs necessitate the application of all conservative measures before a transplantation procedure should be performed. However, the surgical option should be evaluated early enough to allow for a good chance of success. Profound knowledge of prognosis and medical treatment of each individual liver disease is a prerequisite for correct indication and timing of liver transplantation.