肝癌肝移植适应证的选择:上海复旦标准

Indication of liver transplantation for hepatocellular carcinoma: Shanghai Fudan Criteria

目的评估不同适应证标准对肝癌肝移植预后的影响,探讨建立适合中国国情的肝癌肝移植适应证新标准。方法回顾性分析我院2001年4月至2006年1月间251例肝细胞癌肝移植病例,Kaplan Meier法统计分析不同病例入选标准对肝癌肝移植术后生存率及无瘤生存率的影响,Log Rank检验组间差异。结果93例米兰标准术后1、2、3年的生存率为:86%、77%、77%,无瘤生存率为:91%、86%、86%;131例加利福尼亚标准术后1、2、3年的生存率为:90%、83%、83%,无瘤生存率为:92%、89%、89%;207例匹兹堡标准术后1、2、3年的生存率为:84%、74%、67%。无瘤生存率为:85%,83%,73%。而超出匹兹堡标准的44例患者,1、2、3年生存率及无瘤生存率则显著降低(65%,43%,43%及47%,43%,43%)。当将适应证扩大为:单发肿瘤直径≤9cm;或多发肿瘤≤3个,且最大肿瘤直径≤5cm,全部肿瘤直径总和≤9cm,无大血管侵犯、淋巴结转移及肝外转移(即“上海复旦标准”),其1、2、3年生存率及无瘤生存率(88%,80%,80%及90%,88%,88%)与最为严格的米兰标准相比差异无统计学意义,但入选病例显著增至为151例。结论“上海复旦标准”扩大了肝癌肝移植适应证的范围,且并未降低术后总体生存率及无瘤生存率,可能较米兰标准等更符合中国国情。

Objective To evaluate the effects of different selection criteria on the prognosis of hepatocellular carcinoma （HCC） patients undergoing liver transplantation （LT） and to explore the new criteria adapted for Chinese National Situation. Methods A retrospective analysis was performed on 251 consecutive patients with HCC who underwent LT between April 2001 and January 2006 at our institution. We compared the outcome of the patients meeting different criteria such as milan, UCSF and the Pittsburgh modified TNM criteria Survival rates were calculated using the Kaplan-Meier method, and differences between the curves were assessed by log-rank test. Results There was no significant difference in 1, 2, 3- year survival rates and recurrence-free survival rates between milan criteria （n = 93; 86% ,77% ,77% and 91%, 86%, 86% ） and UCSF criteria （n = 131 ; 90% ,83% ,83% and 92% ,89% ,89% ）. According to Pittsburgh criteria （n = 207）, the 1, 2, 3-year survival rates and recurrence-free survival rates were 84%, 74% ,67% and 85% ,83% ,73%, repectively. For advanced tumors （over all the criteria）, the survival rates and recurrence-free survival rates decreased significantly （n = 44 ; 65% ,43 % ,43% and 47% ,43%, 43% respectively）. When criteria （named as Shanghai Fudan Criteria） were expanded to HCC patients with solitary lesions ≤9 cm in diameter, or no more than 3 lesions, the largest ≤5 cm, with a total tumor diameter ≤ 9 cm, there was no significant difference in 1, 2, 3-year survival rates and recurrence-free survival rates （n = 151; 88% ,80% ,80% and 90% ,88% ,88%, respectively） as compared with milan criteria, but more patients using Shanghai Fudan Criteria could undergo liver transplantation. Conclusion Shanghai Fudan Criteria, which expanded the tumor size limits, does not adversely impact survival of HCC patients after LT.