肝癌患者接受肝移植的价值评估

目的　探讨肝癌患者接受肝移植治疗的价值。方法　对 5 0例肝癌患者施行肝移植 ,根据肿瘤的大小、数量和侵犯范围将肝癌分为三期 ,统计分析不同期患者肝移植后的存活率及医疗费用。结果　Ⅰ期患者共 4例 ,术后存活时间均超过 1年 ,最长者已达 3年 ,其半年医疗费用为 (2 1.6 8± 1.0 8)万元 ;Ⅱ期患者共 32例 ,有 7例存活时间超过 1年 ,6个月存活率为 6 8.8% ,半年医疗费用为(2 5 .2 2± 2 .6 0 )万元 ;Ⅲ期患者共 14例 ,仅 1例存活达 12个月 ,平均存活时间 4 .1个月 ,医疗费用为(2 8.4 5± 1.34)万元。结论　综合考虑治疗效果及医疗费用 ,Ⅰ期和Ⅱ期肝癌患者可接受肝移植治疗 ,而Ⅲ期肝癌患者由于肝移植的效果差 ,费用昂贵 ,不宜提倡。     

肝脏移植治疗原发性肝癌20例报告

目的　探讨原位肝移植技术在治疗原发性肝癌中的地位和疗效。　方法　对1993年4月至2000年6月中山医科大学器官移植中心进行的20例原位肝移植术治疗原发性肝癌临床资料进行回顾性研究。其中大肝癌14例（直径＞5cm）,小肝癌6例（直径≤5cm）。　结果　大肝癌组肝移植术后平均存活6.5个月,肝癌复发率为71%(10/14);小肝癌组移植术后1、2年存活率分别为83％(5/6)和67%（4/6）,肝癌复发率为17%(1/6),两组肝癌复发率的差异有显著意义(P＜0.05)。　结论肝移植对肝癌单发,直径小于或等于5cm,无血管侵犯的小肝癌有良好的疗效;对部分病例选择适当的大肝癌患者可获得较好的姑息疗效;肝移植围手术期辅助化学药物治疗可能会减少肝癌复发。     

小肝癌微创治疗的临床研究--附164例报告

目的　探讨经皮肝动脉栓塞化疗 (TACE)、瘤内无水酒精注射 (PEI)和经皮射频消融 (RFA)等介入性微创治疗方法综合治疗小肝癌 (≤ 5cm)的疗效。　方法　 1989年 9月至 2 0 0 1年 9月 16 4例分为五个治疗组 :1.TACE组 39例 ;2 .PEI组 2 8例 ;3 .TACE联合PEI或RFA组 2 1例 ;4.RFA组 37例 ;5 .RFA联合PEI组 39例。　结果　TACE组 39例中有 13例接受二期手术切除 ,7例标本中均见残留的癌细胞 ;余 2 6例治疗后 1、2、3年复发率分别为 2 3 0 %、38 4%、6 1 5 % ,1、2、3、4、5年生存率分别为 76 9%、5 3 8%、30 7%、7 6 7%、7 6 7%。PEI组 2 8例治疗后 1、2、3年复发率分别为 17 8%、32 1%、5 0 % ,1、2、3、4、5年生存率分别为 85 7%、71 4%、5 3 6 %、35 7%、14 3 %。TACE联合PEI或RFA组 2 1例治疗后 1、2、3年复发率分别为 14 3 %、33 3%、5 2 3 % ,1、2、3、4、5年生存率分别为 90 5 %、76 2 %、5 7 2 %、38 1%、19 0 %。RFA组 37例 ,1年复发率为 10 8% (4/ 37) ,死亡 3例 ,1年生存率为 91 9% (34/ 37)。RFA联合PEI组 39例 ,1年复发率为 7 6 9% (3/ 39) ,1年生存率为 97 4% (38/ 39)。　结论　RFA、PEI和TACE是小肝癌微创治疗的有效方法 ,其中RFA对小肝癌治疗有较好的近期疗效。     

肝癌肝移植术后个体化化疗疗效初步分析

目的　探讨肝癌肝移植术后辅助个体化化疗对预防肝癌复发、提高肝癌肝移植疗效的临床意义。方法　回顾分析 2 0 0 1年 4月～ 2 0 0 3年 1月 2 1例肝癌肝移植术后依据ATP TCA结果制定并实施个体化化疗患者的临床资料。 5 2例单纯采用肝移植治疗的肝癌患者作为对照组 ,比较两组肝癌患者的累计生存率和累计无瘤生存率。结果　个体化化疗组和未作化疗组肝移植术后 1年、2年生存率分别为 92 31%、73 85 %和 92 0 6 %、6 3 93% ,两组术后累计生存率比较差异无显著意义 ;个体化化疗组和未作化疗组患者肝移植术后 6、12、18、2 4个月的无瘤生存率分别为 90 0 0 %、80 0 0 %、80 0 0 %、6 0 0 0 %和 6 7 31%、5 1 92 %、4 0 0 3%、37 81% ,二组术后累计无瘤生存率差异有显著意义 (P <0 0 5 )。结论　肝移植术后辅助个体化化疗能显著降低肝癌肝移植术后的肿瘤复发率 ,明显延长肝移植术后的无瘤生存时间。根据ATP TCA技术指导制定的肝癌肝移植术后个体化化疗方案具有临床应用价值。     

肝脏移植对23例肝细胞性肝癌的治疗价值研究

目的进一步探讨肝细胞性肝癌肝移植治疗的疗效 ,评价其应用价值。方法对 1999年 2月～ 2 0 0 2年 3月连续实施的 95例肝移植中的 2 3例肝细胞肝癌患者进行随访和回顾性分析 ,探讨肝细胞性肝癌临床病理学因素对肝移植术后生存率和肝癌复发的影响。结果本组肝细胞性肝癌总的复发率为 6 5 % (15 /2 3) ,6个月、12个月的无癌生存率分别为 75 %、5 8%。多元分析表明 ,肝细胞性肝癌的直径与它的复发率有相关性 (P =0 0 2 4 ) ,而其他的临床病理学因素未显示有统计学意义(Wald =5 113,P =0 0 2 4 )。而年龄、性别、癌灶数目、门静脉癌栓形成、TNM分期、术前AFP水平、术前治疗、合并肝硬化等病理学因素则在统计学上未显示有显著意义 (P >0 0 5 )。结论大肝癌是肝移植的相对禁忌证 ,而小肝癌是肝移植的良好适应证     

肝移植治疗原发性肝癌切除术后肝内复发七例

目的 探讨对原发性肝癌切除术后肝内复发患者进行肝移植手术的适应证和围手术期的治疗经验.方法 回顾性分析2000年9月至2005年9月间7例原发性肝癌切除术后肝内复发的患者接受原位肝移植治疗的临床资料,其中男性6例,女性1例,平均年龄43.7岁,肝移植术前均经病理学检查确诊为原发性肝癌,肿瘤组织学分级为高、中分化,肝癌切除术后无瘤期为6～31个月,均未发生肿瘤细胞侵犯大血管和肝外转移.所有患者均采用改良背驮式肝移植术.术后采用他克莫司(或西罗莫司)+霉酚酸酯+激素的三联免疫抑制方案.观察肝移植术后受者并发症及存活率情况.总结肝移植治疗原发性肝癌切除术后肝内复发的经验.结果 所有受者肝移植手术过程顺利,围手术期无死亡.1例术后22 h发生腹腔出血,1例术后13 d发生腹腔感染,1例术后4个月发生门静脉血栓,其余未发生严重并发症,7例受者均顺利出院.有3例受者分别于移植术后9、13及19个月时,因肿瘤复发而死亡,其余4例均长期无瘤存活,最长已达52个月.受者的1、2年存活率分别为85.7%和57.1%.结论 肝移植能有效治疗原发性肝癌切除术后肝内复发,受者适应证的选择和围手术期的辅助治疗非常关键.     

1038例原发性肝癌的外科治疗

目的　探讨提高我国肝癌手术治疗的安全性及疗效的措施。方法　分析 1990年 1月至 1998年 12月经手术治疗的原发性肝癌 10 38例 ,其中前期组 (1990年 1月至 1996年 12月 ) 731例 ,肿瘤切除手术 312例 (42 7% ) ,非切除手术 419例 ;后期组 (1997年 1个月至 1998年 12月 ) 30 7例 ,肿瘤切除手术 2 17例 (70 7% ) ,非切除手术 90例。　结果　小肝癌 (直径≤ 5cm)前期组占 7 1% ,后期组 19 9% ;前期组肝癌切除术后 1个月内病死率 2 2 % ,并发症发生率 2 3 7% ,术后 1、3、5年生存率分别为 73 1%、5 4 2 %及 34 0 % ,后期组肝癌切除术后 1个月病死率 0 7% ,并发症发生率 2 2 1% ,术后1、3、5年生存率为 91 1%、6 3 8%及 40 2 %。　结论　 (1)对高危患者定期随访有助于早期发现小肝癌 ;(2 )小肝癌比例的上升 ,围手术期处理的进步及手术技术的改进有助于提高肝癌切除率及长期生存率 ;(3)治疗模式的规范化及新技术 ,如半肝血流阻断、体外静脉转流、门静脉癌栓摘取、原位肝移植等有助于提高手术安全性及疗效。     

原发性肝癌肝切除术后复发患者的肝移植治疗

目的观察肝移植治疗原发性肝癌肝切除术后复发患者的疗效。方法回顾性分析11例原发性肝癌肝切除术后复发接受经典原位肝移植治疗的受者的临床资料,观察移植效果。结果在围手术期,1例术后发生移植肝功能不全和凝血功能障碍并发肾功能衰竭死亡;1例术后出现急性胰腺炎,给予生长抑素治疗10d缓解;2例发生急性排斥反应,行大剂量甲泼尼龙冲击治疗3d逆转。10例受者顺利出院。出院后,3例分别于术后第5个月、第7个月、第19个月死于肝癌复发,1、2年受者存活率分别为72．7％（8／11）和63．6％（7／11）,至今最长存活的1例已达4年余。获长期存活的受者肝癌肝切除术前原发病均为小肝癌,肝切除术后复发行肝移植时肝癌均符合Milan标准。结论小肝癌行肝癌肝切除术后应密切随访,如发现肝癌复发且符合Milan标准可考虑行肝移植治疗,患者仍有可能获较长时间生存。     

12例胆管细胞癌患者肝移植的预后分析

目的分析影响胆管细胞癌患者肝移植预后的肿瘤相关因素，为肝移植受者的选择提供依据。方法12例胆管细胞癌患者接受肝移植治疗，肿瘤Edmondson分级为Ⅲ-Ⅳ级者5例；肿瘤TNM分期超过Ⅱ期者9例；肿瘤累及两叶者5例，无包膜者9例，肝门淋巴结肿大者5例，肝外膈肌浸润1例，门静脉分支有癌栓者1例；个体最大肿瘤直径平均为6．1cm。均行经典原位肝移植。采用Kaplan-Meier生存率分析肝移植术后患者存活率及无瘤存活率，Log-Rank检验各影响因素的组间差异。结果12例术后均得到随访，随访时间7-31．2个月，中位数为18．5个月，受者的存活时间为178-905d，中位数为370d，其0．5、1和2年存活率分别为90．9％、61．4％及24．6％，0．5、1和2年无瘤存活率分别为46．9％、37．5％和0。8例（66．7％，8／12）于肝移植后100．6d肿瘤复发。死亡6例，其中5例死于肿瘤复发。以肝细胞癌施行肝移植的标准（Milan标准、加州大学旧金山分校标准、上海复旦标准者、Pittsburgh标准和超过Pittsburgh标准）来评价，结果符合各标准患者肝移植后的存活率及无瘤存活率的差异均无统计学意义。淋巴结转移或门静脉癌栓、TNM分期为Ⅲ期、Edmondson分级为Ⅲ级、肿瘤累及两叶、肿瘤无包膜及术前糖链抗原19-9≥37kU／L等，可能对预后有一定影响。结论胆管细胞癌患者施行肝移植的预后不佳，应慎重选择，尽量以小肝癌为主，对肿瘤过大、TNM分期为Ⅲ期、肿瘤分布于两叶、无法排除淋巴结转移或门静脉癌栓者，应列为肝移植禁忌证。     

不同比例缩小体积肝移植的大动物研究

目的研究不同比例缩小体积肝移植的结果,确定猪能耐受的最小体积的肝移植。方法远系繁殖猪70头分为原位全肝移植作为对照组和3组不同比例缩小体积原位肝移植(按照缩小体积的移植肝占受体切除肝脏重量的百分比;1组:60%;2组:30%;3组:20%);实验采用原位经典肝移植方式(静脉转流)。术后第3天和第5天取肝标本。结果对照组和3组不同比例缩小体积肝移植的移植物与受体肝脏重量百分比(GIWRW)分别为87·4%±8·3%、59·9%±5·2%、33·6%±4·9%和22·1%±3·4%;移植物与受体体重百分比(GIWBW)分别2·4%±0·4%、1·43%±0·17%、0·81%±0·09%和0·53%±0·06%。对照组、1组和2组存活率达100%;3组存活率仅为53%。4个组的动物处死后肝脏移植物重量均有显著的增加。结论安全的缩小体积肝移植,应以移植物与受体肝脏重量百分比不小于33%,同时移植肝与受体重量百分比不小于0·8%为限。     

Liver transplantation outcomes in patients with cirrhosis and hepatocellular carcinoma: experience of a single center in a viral hepatitis endemic area

Our center has performed 205 orthotopic liver transplantations (OLT) in 201 patients. Hepatocellular carcinoma (HCC) was discovered in 32 (15%) patients, 5 of whom were diagnosed incidentally in recipient explants. The main underlying diagnosis was viral hepatitis (n = 28; 87.5%). Most patients (17; 53.1%) were diagnosed as having Child class B cirrhosis. Single tumors measuring <3 cm were diagnosed in 29 (90.6%) patients. Downstaging chemoembolization was performed in 7 (21.8%) patients. Preoperative aFP levels were normal in 20 (62.5%) patients. In the rest (n = 12; 37.5%), aFP levels normalized immediately after the OLT. In the latter group, 2 patients had a delayed (2 years) postoperative increase in aFP levels; both patients had tumor recurrence in the graft. All patients with hepatitis B received antiviral treatment with HBIG and lamivudine. There were 9 deaths (28.1%) in the immediate postoperative period (<30 days). One-year survival rate was 62.5% (n = 20). Actuarial 5-year survival rate was 55%, and actuarial 10-year survival rate was 40%. In conclusion, OLT has become the standard treatment for patients diagnosed with HCC in a population that shows cirrhosis most of the time to be secondary to viral hepatitis, provided that recipients are selected according to the size of the neoplasm and that they receive adequate antiviral prophylaxis.     

Liver transplantation criteria for hepatocellular carcinoma should be expanded: a 22-year experience with 467 patients at UCLA

OBJECTIVE: To assess the efficacy of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) and the impact of current staging criteria on long term survival. SUMMARY BACKGROUND DATA: HCC is becoming an increasingly common indication for OLT. Medicare approves OLT only for HCCs meeting the Milan criteria, thus limiting OLT for an expanding pool of potential liver recipients. We analyzed our experience with OLT for HCC to determine if expansion of criteria for OLT for HCC is warranted. METHODS:: All patients undergoing OLT for HCC from 1984 to 2006 were evaluated. Outcomes were compared for patients who met Milan criteria (single tumor < opr =5 cm, maximum of 3 total tumors with none >3 cm), University of California, San Francisco (UCSF) criteria (single tumor <6.5 cm, maximum of 3 total tumors with none >4.5 cm, and cumulative tumor size <8 cm), or exceeded UCSF criteria. RESULTS: A total of 467 transplants were performed for HCC. At mean follow up of 6.6 +/- 0.9 years, recurrence rate was 21.2%, and overall 1, 3, and 5-year survival was 82%, 65%, and 52%, respectively. Patients meeting Milan criteria had similar 5-year post-transplant survival to patients meeting UCSF criteria by preoperative imaging (79% vs. 64%; P = 0.061) and explant pathology (86% vs. 71%; P = 0.057). Survival for patients with tumors beyond UCSF criteria was significantly lower and was below 50% at 5 years. Multivariate analysis showed that tumor number (P < 0.001), lymphovascular invasion (P < 0.001), and poor differentiation (P = 0.002) independently predicted poor survival. CONCLUSIONS: This largest single institution experience with OLT for HCC demonstrates prolonged survival after liver transplantation for tumors beyond Milan criteria but within UCSF criteria, both when classified by preoperative imaging and by explant pathology. Measured expansion of OLT criteria is justified for tumors not exceeding the UCSF criteria.     

肝移植治疗肝细胞型肝癌的67例临床分析

目的探讨肝移植治疗肝细胞型肝癌的临床价值及影响预后的因素。方法对67例接受肝移植治疗、且随访时间≥6个月的肝细胞型肝癌患者的临床资料进行回顾性分析。结果67例患者肝移植术后1年、2年存活率分别为89.96%、65.59%,1年、2年无瘤存活率分别为77.51%、62.49%;单因素分析显示,甲胎蛋白水平、肿瘤最大直径、门静脉癌栓、肿瘤累及肝脏左右两叶、肿瘤分化程度和肿瘤TNM分期是影响无瘤存活率的重要因素,Cox风险模型多因素分析显示,肿瘤最大直径和门静脉癌栓是影响无瘤存活率的独立危险因素。结论肝移植是目前治疗肝细胞型肝癌的有效方法,肿瘤直径>5cm和门静脉癌栓严重影响患者的无瘤存活率。     

Outcomes of Hepatic Resection for a Single Large Hepatocellular Carcinoma

BACKGROUND: The proper role of surgical resection, given the various treatment modalities available, needs to be further clarified in patients with a single large hepatocellular carcinoma (HCC). To evaluate the role of surgical resection in this group of patients, we studied the long-term outcomes of patients that received hepatic resection for a single large (> 5-10 cm in diameter) HCC. METHODS: The clinicopathologic data and long-term outcomes of 61 patients with a single large HCC (> 5-10 cm in diameter; L group) were compared with those of 169 patients with a single small HCC (< or = 5 cm; S group). Prognostic factors were evaluated by univariate and multivariate analysis. RESULTS: Operative mortality rates were low in both groups (0.6% in group S and 1.6% in group L), and the incidence of postoperative hepatic failure was rare even in group L (1.6%). The cumulative 5-year overall survival rate in group S was 59.0%, whereas in group L it was 52.9% (p = 0.385), and the corresponding cumulative 5-year disease-free survival rates were 44.1% and 31.7%, respectively (p = 0.063). Child class B was found to predict poor overall and disease-free survival by multivariate analysis versus Child class A in both groups. The presence of microvascular invasion was also identified as a significant prognostic factor, but it only affected disease-free survival in the two groups. CONCLUSIONS: Single large HCCs do not require a large extent of hepatic resection and the associated increased risk of postoperative liver failure. The long-term survival of patients with a single large HCC is as good as that of patients with a single small HCC. We conclude that hepatic resection is a safe and effective therapy for single large HCCs.     

Resection or transplantation for hepatocellular carcinoma in cirrhotic patients: outcomes based on indicated treatment strategy

BACKGROUND: Surgical resection has been the treatment of choice for hepatocellular carcinoma (HCC), but the resection rate remains low in cirrhotic patients and recurrence is common. Unfavorable results compared with benign disease and the shortage of organ donors have led to a restricted indication for orthotopic liver transplantation (OLT) for HCC. STUDY DESIGN: The aim of this study was to analyze the results of our surgical approach to HCC in patients with cirrhosis. The first treatment strategy indicated in these patients was OLT. From January 1990 to May 1999, 85 patients underwent OLT and the remaining 35 had surgical resection. RESULTS: One-, 3-, and 5-year survival rates were 84%, 74%, and 60% versus 83%, 57%, and 51%, respectively, in the OLT and resection groups (p = 0.34). Hepatic tumor recurrence was much less frequent in the OLT group than in the resection group. The 1-, 3-, and 5-year disease-free survival rates were 83%, 72%, and 60% versus 70%, 44%, and 31%, respectively (p = 0.027). In the multivariate Cox regression analysis, macroscopic vascular invasion was the only factor independently associated with death or recurrence after OLT (p = 0.006). After partial liver resection, the tumors significantly associated with mortality and recurrence in the multivariate analysis were solitary or multiple tumors greater than 2cm with microscopic vascular invasion (pathologic pT3) (p = 0.01). CONCLUSIONS: Our results confirm that in cirrhotic patients, OLT may provide better outcomes than liver resection in carefully selected HCC and that longterm survival is similar to the results of OLT in cirrhotic patients without tumors.     

Superiority of transplantation versus resection for the treatment of small hepatocellular carcinoma

The best therapy for hepatocellular carcinoma (HCC) is still debated. Hepatic resection (HR) is the treatment of choice for single HCC in Child A patients, whereas liver transplantation (OLT) is usually reserved for Child B and C patients with multiple nodules. The aim of this study was to compare HR and OLT for HCC within the Milan criteria on an intention-to-treat basis. Forty-eight patients were treated by OLT and 38 by HR. Three- and 5-year patient survival rates were significantly higher (P = .0057) in the OLT group (79% and 74%) than after HR (61% and 26%). The 3- and 5-year disease-free survival rate was better (P = .0005) for OLT (74% and 74%) versus HR (41% and 11%). The probability of HCC recurrences after resection was greater (P = .0002) than after transplantation, achieving 31% and 76% for HR and 2% and 2% for OLT at 3 and 5 years after surgery. The median waiting list time was 118 days; two patients dropped out for HCC progression. We concluded that OLT is superior to HR for small HCC in cirrhotic patients assuming that OLT can be performed within 6 to 10 months after listing to reduce dropouts due to tumor progression.     

Predictive factors of outcome after liver transplantation in patients with cirrhosis and hepatocellular carcinoma

Studies to define the optimal upper limits of tumor size and number as predictors of outcome after orthotopic liver transplantation (OLT) have yielded conflicting results. We analyzed 72 patients with cirrhosis and hepatocellular carcinoma (HCC) who underwent OLT over a 12-year period in a single center. Predictive factors for survival and tumor recurrence, according to the Milan criteria, were also examined. Our cohort included 60 men and 12 women of mean age 54 +/- 8 years and mean follow-up of 40 +/- 39 months. Origin of cirrhosis was postviral in 70% and Child class B or C in two thirds of patients. HCC was multifocal in 61%; about one fifth of patients had micro- or macrovascular involvement or positive nodes upon histologic examination. The cumulative size of the lesions was <3 cm in 17 patients; >3 to < or =5 cm in 28 patients; >5 to < or =8 cm in 14 patients; and >8 cm in 13 patients. According to the number and size of tumor nodules, 49 patients met the Milan criteria. During follow-up 25 patients died, 13 due to tumor recurrence. The 1- and 2-year survivals were 90% and 85% for patients who met the Milan criteria versus 57% and 51% for patients exceeding those limits (P = .006). A cumulative tumor size >8 cm was predictive of survival and tumor recurrence upon multivariate analysis. The adoption of Milan criteria for selection of cirrhotic patients has improved survival and reduced the rate of tumor recurrence. The evaluation of cumulative tumor size might further improve patient selection.     

Influence of coexisting cirrhosis on outcomes after partial hepatic resection for hepatocellular carcinoma fulfilling the Milan criteria: an analysis of 293 patients

BACKGROUND: For patients with liver cirrhosis and hepatocellular carcinoma (HCC) satisfying the Milan criteria (single tumor < or =5 cm or 2 or 3 tumors < or =3 cm), orthotopic liver transplantation (OLT) is an effective treatment. Nevertheless, it remains controversial whether OLT is the best treatment strategy for patients with resectable HCC. METHODS: This study included 293 HCC patients (both with and without cirrhosis) oncologically satisfying the Milan criteria who underwent primary and curative liver resection between 1990 and 2003. RESULTS: There were 127 noncirrhotic, 129 Child-Pugh A cirrhotic, and 37 Child-Pugh B cirrhotic patients. Five-year survival rates in each population were 81%, 54%, and 28%, respectively. Coexisting cirrhosis, Child-Pugh classification, alpha-fetoprotein value, tumor burden, and vascular invasion by the tumor were identified as significant prognostic factors. Among these factors, coexisting cirrhosis was the most crucial variable by multivariate analysis. During the initial 3 postoperative years, yearly tumor recurrence rate was 22% in cirrhotic patients and 15% in noncirrhotic patients. In cirrhotic patients, the recurrence rate did not decrease even after three years of tumor-free survival post-resection, whereas in noncirrhotic patients the recurrence rate decreased to 9%. Cirrhosis was associated with a higher probability of recurrence exceeding the Milan criteria. CONCLUSIONS: Hepatic resection offers an acceptable survival result for HCC patients fulfilling the Milan criteria. Coexisting cirrhosis is associated with higher mortality and recurrence rate, possibly due to multicentric carcinogenesis which limits the efficacy of hepatic resection.     

Microvascular tumor embolism: independent prognostic factor after liver transplantation in hepatocellular carcinoma

Microscopic tumor cell dissemination may be a more important factor in the recurrence of hepatocellular carcinoma (HCC) after liver transplantation, probably because of posttransplant immunosuppression. The presence of microvascular tumor embolism was undetermined as a factor for HCC recurrence after orthotopic liver transplantation (OLT). This study evaluated whether microvascular tumor embolism affects recurrence-free survival and correlates with other clinicopathologic factors after OLT among patients with HCC. From September 1996 to June 2003, 72 OLTs for HCC were enrolled in this study. Median follow-up was 22.8 months. Among 41 patients without microvascular tumor embolism, 1-year, 2-year, and 5-year recurrence-free survival rates were all 97.6%, while these rates were 77.3%, 68.2%, and 59.7%, respectively, for 31 patients (43.1%) with microvascular tumor embolism (P = .0006). The 5-year recurrence-free survival rate showed significant differences for a pT2 tumor (P = .0073), for maximal tumor size <3 cm (P = .0328), for > or =5 cm solitary tumor (P = .0095), and for the presence of a tumor capsule (P = .0012), within the Milan criteria (P = .0376). At multivariate analysis, significant independent predictors for HCC recurrence were microvascular tumor embolism and histopathologic grade. In conclusion, microvascular tumor embolism is an independent predictor of HCC recurrence after liver transplantation. Although OLT is a safe and effective treatment for HCC within the Milan criteria, the presence of microvascular tumor embolism at pathologic examination can predict its recurrence. In these cases, the feasibility of immunosuppressive therapy or adjuvant chemotherapy must be considered to prevent tumor recurrence.     

The Impact of Pre-Operative Loco-Regional Therapy on Outcome After Liver Transplantation for Hepatocellular Carcinoma

No prior studies have shown that pre-operative loco-regional therapy for hepatocellular carcinoma (HCC) improves survival following orthotopic liver transplantation (OLT). We performed subgroup analyses according to pathologic HCC stage among 168 patients who underwent OLT to test the hypothesis that pre-operative loco-regional therapy confers a survival advantage in a subgroup at intermediate risk for HCC recurrence. Patients with pathologic T3 HCC meeting the proposed UCSF expanded criteria (single lesion not exceeding 6.5 cm or two to three lesions none > 4.5 cm with total tumor diameter within 8 cm) had a similar 5-year recurrence-free survival as patients with pathologic T2 HCC (88.5% vs. 93.8%; p = 0.56). In the subgroup with pathologic T2 or T3 HCC, the 5-year recurrence-free survival was 93.8% for the 85 patients who received pre-operative loco-regional therapy, versus 80.6% for the other 41 patients without treatment (p = 0.049). The treatment benefit, according to 5-year recurrence-free survival, appeared greater for pathologic T3 (85.9% vs. 51.4%; p = 0.05) than T2 HCC (96.4% versus 87.1%; p = 0.12). In conclusion, although the lack of a randomized controlled design precludes drawing firm conclusions, our results suggest that pre-operative loco-regional therapy may confer a survival benefit after OLT in the subgroup with pathologic T2 and T3 HCC.