Hepatocellular carcinoma(HCC) is rapidly becoming one of the most prevalent cancers worldwide. With a rising rate, it is a prominent source of mortality. Patients with advanced fibrosis, predominantly cirrhosis and he...Hepatocellular carcinoma(HCC) is rapidly becoming one of the most prevalent cancers worldwide. With a rising rate, it is a prominent source of mortality. Patients with advanced fibrosis, predominantly cirrhosis and hepatitis B are predisposed to developing HCC. Individuals withchronic hepatitis B and C infections are most commonly afflicted. Different therapeutic options, including liver resection, transplantation, systemic and local therapy, must be tailored to each patient. Liver transplantation offers leading results to achieve a cure. The Milan criteria is acknowledged as the model to classify the individuals that meet requirements to undergo transplantation. Mean survival remains suboptimal because of long waiting times and limited donor organ resources. Recent debates involve expansion of these criteria to create options for patients with HCC to increase overall survival.展开更多
Hepatocellular carcinoma represents an important cause of morbidity and mortality worldwide. It is the sixth most common cancer and the fourth leading cause of cancer death. Liver transplantation is a key tool for the...Hepatocellular carcinoma represents an important cause of morbidity and mortality worldwide. It is the sixth most common cancer and the fourth leading cause of cancer death. Liver transplantation is a key tool for the treatment of this disease in human therefore hepatocellular carcinoma is increasing as primary indication for grafting. Although liver transplantation represents an outstanding therapy for hepatocellular carcinoma, due to organ shortage, the careful selection and management of patients who may have a major survival benefit after grafting remains a fundamental question. In fact, only some stages of the disease seem amenable of this therapeutic option, stimulating the debate on the appropriate criteria to select candidates. In this review we focused on current criteria to select patients with hepatocellular carcinoma for liver transplantation as well as on the strategies (bridging) to avoid disease progression and exclusion from grafting during the stay on wait list. The treatments used to bring patients within acceptable criteria (down-staging), when their tumor burden exceeds the standard criteria for transplant, are also reported. Finally, we examined tumor reappearance following liver transplantation. This occurrence is estimated to be approximately 8%-20% in different studies. The possible approaches to prevent this outcome after transplant are reported with the corresponding results.展开更多
Milan criteria are currently the benchmark related to liver transplantation(LT) for hepatocellular carcinoma. However, several groups have proposed different expanded criteria with acceptable results. In this article,...Milan criteria are currently the benchmark related to liver transplantation(LT) for hepatocellular carcinoma. However, several groups have proposed different expanded criteria with acceptable results. In this article, we review the current status of LT beyond the Milan criteria in three different scenarios-expanded criteria with cadaveric LT, downstaging to Milan criteria before LT, and expansion in the context of adult living donor LT. The review focuses on three main questions: what would the impact of the expansion beyond Milan criteria be on the patients on the waiting list; whether the dichotomous criteria(yes/no) currently used are appropriate for LT or continuous survival estimations, such as the one of "Metroticket" and whether it should enter into the clinical practice; and, whether the use of living donor LT in the context of expansion beyond Milan criteria is justified.展开更多
AIM To perform a systematic review to determine the survival outcomes after curative resection of intermediate and advanced hepatocellular carcinomas(HCC).METHODS A systematic review of the published literature was pe...AIM To perform a systematic review to determine the survival outcomes after curative resection of intermediate and advanced hepatocellular carcinomas(HCC).METHODS A systematic review of the published literature was performed using the PubM ed database from 1 st January 1999 to 31 st Dec 2014 to identify studies that reported outcomes of liver resection as the primary curative treatment for Barcelona Clinic Liver Cancer(BCLC) stage B or C HCC. The primary end point was to determine the overall survival(OS) and disease free survival(DFS) of liver resection of HCC in BCLC stage B or C in patients with adequate liver reserve(i.e., Child's A or B status). The secondary end points were to assess the morbidity and mortality of liver resection in large HCC(defined as lesions larger than 10 cm in diameter) and to compare the OS and DFS after surgical resection of solitary vs multifocal HCC.RESULTS We identified 74 articles which met the inclusion criteria and were analyzed in this systematic review. Analysis of the resection outcomes of the included studies were grouped according to(1) BCLC stage B or C HCC,(2) Size of HCC and(3) multifocal tumors. The median 5-year OS of BCLC stage B was 38.7%(range 10.0-57.0); while the median 5-year OS of BCLC stage C was 20.0%(range 0.0-42.0). The collective median 5-year OS of both stages was 27.9%(0.0-57.0). In examining the morbidity and mortality following liver resection in large HCC, the pooled RR for morbidity [RR(95%CI) = 1.00(0.76-1.31)] and mortality [RR(95%CI) = 1.15(0.73-1.80)] were not significant. Within the spectrum of BCLC B and C lesions, tumors greater than 10 cm were reported to have median 5-year OS of 33.0% and multifocal lesions 54.0%.CONCLUSION Indication for surgical resection should be extended to BCLC stage B lesions in selected patients. Further studies are needed to stratify stage C lesions for resection.展开更多
目的：探讨补救性肝移植和再次肝切除治疗肝癌切除术后复发的疗效。方法回顾性分析2004年9月至2010年8月72例符合米兰标准且肝功能为 Child A 肝癌复发患者的资料，依据手术方式不同分为再次肝切除组（53例）和补救性肝移植组（19例）。...目的：探讨补救性肝移植和再次肝切除治疗肝癌切除术后复发的疗效。方法回顾性分析2004年9月至2010年8月72例符合米兰标准且肝功能为 Child A 肝癌复发患者的资料，依据手术方式不同分为再次肝切除组（53例）和补救性肝移植组（19例）。Kaplan-Meier 曲线检验2组患者肝癌切除术后复发的术后生存率和术后无瘤生存率的差异。COX 比例风险回归模型分析影响复发患者再次手术后生存的因素。结果再次肝切除组1年、3年、5年生存率为86．79％、62．26％、45．28％，补救性肝移植组治疗1年、3年、5年生存率为89．47％、68．42％、57．89％，2组比较差异无统计学意义（χ2＝2．530，P ＝0．112）；再次肝切除术组1年、3年、5年无瘤生存率分别为67．92％、47．17％、35．85％，补救性肝移植组1年、3年、5年无瘤生存率分别为94．74％、68．42％、52．63％，2组比较差异有统计学意义（χ2＝4．395，P ＝0．036）。单因素和多因素分析结果显示，微血管侵犯、卫星灶和肿瘤多发影响肝癌术后复发再次术后生存的独立危险因素。结论当肝癌术后复发符合米兰标准且肝功能为 Child A 时，补救性肝移植可取得稍优于再次肝切除治疗的效果，行补救性肝移植是一种可行有效的治疗方法。展开更多
Alpha-fetoprotein(AFP) behavior in patients with hepatocellular carcinoma(HCC) waiting for liver transplant(LT) represents a perfect biological example of a fractal model in which its progressive modification and poss...Alpha-fetoprotein(AFP) behavior in patients with hepatocellular carcinoma(HCC) waiting for liver transplant(LT) represents a perfect biological example of a fractal model in which its progressive modification and possible future prediction of its values are very hard to capture. As a consequence, AFP represents a useful but poorly manageable tool to increase the ability to better select HCC patients waiting for LT. Trying to find a "filrouge" in the recent literature, no definitive answers can be done to several open questions:(1) the best AFP value to adopt;(2) the best cut-off measurement; and(3) the best way to comfortably capture the effective, time-related, fluctuations of this biological marker. More, structured and prospective, studies using serial determination of AFP values within and without the context of locoregional therapies are needed in order to find the "ideal"(static and dynamic) cut-off values allowing to respond to all the still open questions in this field of transplant oncology.展开更多
Hepatocellular carcinoma(HCC) is one of the most common cancers worldwide and has a poor prognosis if untreated. It is ranked the third among the causes of cancer-related death. There are multiple etiologic factors th...Hepatocellular carcinoma(HCC) is one of the most common cancers worldwide and has a poor prognosis if untreated. It is ranked the third among the causes of cancer-related death. There are multiple etiologic factors that can lead to HCC. Screening for early HCC is challenging due to the lack of well specific biomarkers. However,early diagnosis through successful screening is very important to provide cure rate. Liver transplantation(LT) did not gain wide acceptance until the mid-1980 s,after the effective immunosuppression withcyclosporine became available. Orthotopic LT is the best therapeutic option for early,unresectable HCC. It is limited by both,graft shortage and the need for appropriate patient selection. It provides both,the removal of tumor and the remaining cirrhotic liver. In Milan,a prospective cohort study defined restrictive selection criteria known as Milan criteria(MC) that led to superior survival for transplant patients in comparison with any other previous experience with transplantation or other options for HCC. When transplantation occurs within the established MC,the outcomes are similar to those for nonmalignant liver disease after transplantation. The shortage of organs from deceased donors has led to the problems of long waiting times and dropouts. This has led to the adoption of extended criteria by many centers. Several measures have been taken to solve these problems including prioritization of patients with HCC,use of pretransplant adjuvant treatment,and living donor LT.展开更多
文摘Hepatocellular carcinoma(HCC) is rapidly becoming one of the most prevalent cancers worldwide. With a rising rate, it is a prominent source of mortality. Patients with advanced fibrosis, predominantly cirrhosis and hepatitis B are predisposed to developing HCC. Individuals withchronic hepatitis B and C infections are most commonly afflicted. Different therapeutic options, including liver resection, transplantation, systemic and local therapy, must be tailored to each patient. Liver transplantation offers leading results to achieve a cure. The Milan criteria is acknowledged as the model to classify the individuals that meet requirements to undergo transplantation. Mean survival remains suboptimal because of long waiting times and limited donor organ resources. Recent debates involve expansion of these criteria to create options for patients with HCC to increase overall survival.
文摘Hepatocellular carcinoma represents an important cause of morbidity and mortality worldwide. It is the sixth most common cancer and the fourth leading cause of cancer death. Liver transplantation is a key tool for the treatment of this disease in human therefore hepatocellular carcinoma is increasing as primary indication for grafting. Although liver transplantation represents an outstanding therapy for hepatocellular carcinoma, due to organ shortage, the careful selection and management of patients who may have a major survival benefit after grafting remains a fundamental question. In fact, only some stages of the disease seem amenable of this therapeutic option, stimulating the debate on the appropriate criteria to select candidates. In this review we focused on current criteria to select patients with hepatocellular carcinoma for liver transplantation as well as on the strategies (bridging) to avoid disease progression and exclusion from grafting during the stay on wait list. The treatments used to bring patients within acceptable criteria (down-staging), when their tumor burden exceeds the standard criteria for transplant, are also reported. Finally, we examined tumor reappearance following liver transplantation. This occurrence is estimated to be approximately 8%-20% in different studies. The possible approaches to prevent this outcome after transplant are reported with the corresponding results.
基金Supported by the Association Llavaneres contra el Cáncer,No.IP004500
文摘Milan criteria are currently the benchmark related to liver transplantation(LT) for hepatocellular carcinoma. However, several groups have proposed different expanded criteria with acceptable results. In this article, we review the current status of LT beyond the Milan criteria in three different scenarios-expanded criteria with cadaveric LT, downstaging to Milan criteria before LT, and expansion in the context of adult living donor LT. The review focuses on three main questions: what would the impact of the expansion beyond Milan criteria be on the patients on the waiting list; whether the dichotomous criteria(yes/no) currently used are appropriate for LT or continuous survival estimations, such as the one of "Metroticket" and whether it should enter into the clinical practice; and, whether the use of living donor LT in the context of expansion beyond Milan criteria is justified.
文摘目的比较射频消融术(Radiofrequency ablation,RFA)与手术切除术治疗(Surgical resection,SR)米兰标准下小肝癌的临床有效性和安全性。方法利用计算机和人工检索的方式检索Pub Med、The Cochrane Library、Embase、CNKI、维普期刊、万方数据、中国生物医学文献数据库(CBM),全面搜集射频消融术与手术切除治疗米兰标准下小肝癌的临床对照研究。按照Cochrane协作网提供的方法用Rev Man5.3软件进行Meta分析。结果一共检索出11篇文献,2274名患者纳入此次研究,其中RFA组1160名,SR组1114。RFA组与SR组1、3年总体生存率(OR,0.79(95%CI,0.46 to 1.36),Z检验:P=0.39,OR,0.72(95%CI,0.50 to 1.02),Z检验:P=0.06)无统计学差异(P>0.05),5年总体生存率RFA组低于SR组(OR,0.55(95%CI,0.41 to 0.73),Z检验:P<0.0001),差异有统计学意义(P<0.05)。SR组在1、3、5年无瘤生存率中比RFA组更高,差异有统计学意义。RFA组比SR组的并发症发生率低(OR,0.23(95%CI,0.11 to 0.52),Z检验:P=0.0003),安全性更高。结论 RFA相较于SR有更少的并发症,安全性更高。就短期来说RFA与SR的治疗效果相当,长期效果而言SR疗效是优于RFA的。
文摘AIM To perform a systematic review to determine the survival outcomes after curative resection of intermediate and advanced hepatocellular carcinomas(HCC).METHODS A systematic review of the published literature was performed using the PubM ed database from 1 st January 1999 to 31 st Dec 2014 to identify studies that reported outcomes of liver resection as the primary curative treatment for Barcelona Clinic Liver Cancer(BCLC) stage B or C HCC. The primary end point was to determine the overall survival(OS) and disease free survival(DFS) of liver resection of HCC in BCLC stage B or C in patients with adequate liver reserve(i.e., Child's A or B status). The secondary end points were to assess the morbidity and mortality of liver resection in large HCC(defined as lesions larger than 10 cm in diameter) and to compare the OS and DFS after surgical resection of solitary vs multifocal HCC.RESULTS We identified 74 articles which met the inclusion criteria and were analyzed in this systematic review. Analysis of the resection outcomes of the included studies were grouped according to(1) BCLC stage B or C HCC,(2) Size of HCC and(3) multifocal tumors. The median 5-year OS of BCLC stage B was 38.7%(range 10.0-57.0); while the median 5-year OS of BCLC stage C was 20.0%(range 0.0-42.0). The collective median 5-year OS of both stages was 27.9%(0.0-57.0). In examining the morbidity and mortality following liver resection in large HCC, the pooled RR for morbidity [RR(95%CI) = 1.00(0.76-1.31)] and mortality [RR(95%CI) = 1.15(0.73-1.80)] were not significant. Within the spectrum of BCLC B and C lesions, tumors greater than 10 cm were reported to have median 5-year OS of 33.0% and multifocal lesions 54.0%.CONCLUSION Indication for surgical resection should be extended to BCLC stage B lesions in selected patients. Further studies are needed to stratify stage C lesions for resection.
文摘Alpha-fetoprotein(AFP) behavior in patients with hepatocellular carcinoma(HCC) waiting for liver transplant(LT) represents a perfect biological example of a fractal model in which its progressive modification and possible future prediction of its values are very hard to capture. As a consequence, AFP represents a useful but poorly manageable tool to increase the ability to better select HCC patients waiting for LT. Trying to find a "filrouge" in the recent literature, no definitive answers can be done to several open questions:(1) the best AFP value to adopt;(2) the best cut-off measurement; and(3) the best way to comfortably capture the effective, time-related, fluctuations of this biological marker. More, structured and prospective, studies using serial determination of AFP values within and without the context of locoregional therapies are needed in order to find the "ideal"(static and dynamic) cut-off values allowing to respond to all the still open questions in this field of transplant oncology.
文摘Hepatocellular carcinoma(HCC) is one of the most common cancers worldwide and has a poor prognosis if untreated. It is ranked the third among the causes of cancer-related death. There are multiple etiologic factors that can lead to HCC. Screening for early HCC is challenging due to the lack of well specific biomarkers. However,early diagnosis through successful screening is very important to provide cure rate. Liver transplantation(LT) did not gain wide acceptance until the mid-1980 s,after the effective immunosuppression withcyclosporine became available. Orthotopic LT is the best therapeutic option for early,unresectable HCC. It is limited by both,graft shortage and the need for appropriate patient selection. It provides both,the removal of tumor and the remaining cirrhotic liver. In Milan,a prospective cohort study defined restrictive selection criteria known as Milan criteria(MC) that led to superior survival for transplant patients in comparison with any other previous experience with transplantation or other options for HCC. When transplantation occurs within the established MC,the outcomes are similar to those for nonmalignant liver disease after transplantation. The shortage of organs from deceased donors has led to the problems of long waiting times and dropouts. This has led to the adoption of extended criteria by many centers. Several measures have been taken to solve these problems including prioritization of patients with HCC,use of pretransplant adjuvant treatment,and living donor LT.
