肝切除术治疗大/多结节或大血管侵犯肝细胞癌效果的荟萃分析

Hepatic resection for hepatocellular carcinoma involving a single large tumor, multiple tumors or macrovascular invasion

目的 系统分析巴塞罗那临床肝癌分期系统（BCLC）不推荐肝切除术治疗大肿瘤（＞5 cm）/多结节（＞2个）或大血管侵犯的肝细胞癌（HCC）肝切除术治疗患者的疗效及安全性.方法 系统检索PubMed数据库,分析肝切除术治疗大/多结节或大血管侵犯的HCC的疗效及安全性的研究.结果 52个研究评价了肝切除术治疗大/多结节HCC的疗效和安全性,包含14 922例患者.评价肝切除治疗大血管侵犯HCC的研究25个,共4 412例患者.总样本分析显示,亚洲患者围手术期中位死亡率显著低于非亚洲患者（2.7％与7.3％,P ＜0.001）.对于大/多结节HCC,亚洲患者的1、5年中位总生存率均显著高于非亚洲患者（81％与65％,P＜0.001;42％与32％,P＜0.001）.然而,对于大血管侵犯的HCC,亚洲患者的1、5年中位总生存率与非亚洲患者相似（50％与52％,P=0.46;18％与15％,P=0.95）.随着时间的推移,近30年患者5年总生存率呈显著上升趋势（P＜0.001）.结论 肝切除术治疗大/多结节或大血管侵犯的HCC是安全有效的.目前证据显示,有必要扩大欧美HCC治疗指南中肝切除术的适应证.

Objective To investigate the safety and efficacy of hepatic resection for those patients with large/multinodular hepatocellular carcinoma （HCC） or those involving macrovascular invasion （MVI）.Methods PubMed was systematically searched for studies examining the safety and efficacy of hepatic resection for treatment of HCC involving a single large tumor （〉 5 cm） or multiple tumors （〉 2）,or those involving MVI.Results The identified 52 studies involving 14 922 patients that investigated the use of hepatic resection for large/multinodular HCC,and 25 studies with 4 412 patients that investigated hepatic resection for HCC with MVI.Median in-hospital mortality of patients with either type of HCC was significantly lower in Asian studies （2.7%） than in non-Asian studies （7.3%,P 〈 0.001）.Median overall survival rate was significantly higher for all Asian patients with large/multinodular HCC than for all non-Asian patients both at the time of 1 year （81% vs 65%,P 〈0.001） and 5 years （42% vs 32%,P 〈 0.001）.However,median overall survival rate was similar for Asian and non-Asian patients with HCC involving MVI at the time of 1 year （50% vs 52%,P=0.46） and 5 years （18% vs 15%,P=0.95）.There was an increasing trend in 5-year overall survival in patients with either type of HCC.Conclusions Hepatic resection is reasonably safe and effective for the treatment of large/multinodular HCC and HCC with MVI.The available evidence argues for expanding the indications for hepatic resection in official treatment guidelines.