不同移植标准下挽救性肝移植的疗效对比分析

Prognostic outcomes of salvage liver transplantation under different transplantation criteria

目的:分析比较符合米兰标准、UCSF标准、杭州标准的肝细胞肝癌(hepatocellular carcinoma,HCC)切除术后肿瘤复发患者肝移植术后的预后情况。方法:回顾性分析2015年1月至2019年10月在复旦大学附属华山医院行公民逝世后器官捐献(donation after citizen death,DCD)肝移植的256例HCC患者的临床资料。其中,行初期肝移植175例(PLT组),挽救性肝移植81例(SLT组)。采用t检验、秩和检验或χ^(2)检验比较两组受者的一般资料、肿瘤病理特征、术后并发症等,用Kaplan-Meier法和Log-rank检验比较两组受者的术后总生存率(overall survival rate,OS)和无复发生存率(recurrence-free survival rate,RFS)。SLT组符合米兰标准者31例(米兰标准组)、符合加州大学旧金山分校(UCSF)标准者45例(UCSF标准组)、符合杭州标准者69例(杭州标准组),比较三组受者的OS和RFS。按肝移植术前是否接受降期/桥接治疗,将SLT组受者再分为降期治疗组(32例)和未降期治疗组(49例),比较两组受者的OS和RFS。按RESCIT 1.1标准,将接受降期治疗的32例SLT组受者分为缓解组(14例)和未缓解组(18例),比较两组术后的OS和RFS。结果:PLT组与SLT组的手术时间分别为(439.5±74.9)min和(475.1±83.4)min,组间比较,差异有统计学意义(P<0.05);但两组术中出血量、输血量、术后住院时间及术后并发症发生率比较,差异均无统计学意义(P均>0.05)。PLT组和SLT组OS和RFS比较,差异无统计学意义(P均>0.05)。米兰标准、UCSF标准、杭州标准三组SLT受者术后1、3、5年OS比较,差异亦无统计学意义P均>0.05)。米兰标准组受者术后1、3、5年RFS分别为93.5%、81.7%、81.7%,显著优于UCSF标准组的68.9%、59.7%、59.7%及杭州标准组的78.3%、58.8%、55.5%,且差异均有统计学意义(P均<0.05)。接受术前降期治疗的SLT组受者中,缓解组术后1、3、5年OS(100%、73%、73%)和RFS(100%、62.5%、46.9%)均优于未缓解组1、3、5年OS(83.3%、49.4%、0)和RFS(52.9%、0、0),组间差异有统计学意义(P均<0.05)。结论:肝癌肝切除术后复发患者行挽救性肝移植可获得与初期肝移植受者相近的生存预后。符合米兰、UCSF、杭州标准的挽救性肝移植受者总生存时间相近。符合米兰标准的肝移植受者无复发生存时间最长。SLT受者术前降期治疗后缓解者的预后优于未缓解者。

Objective To compare the prognoses of salvage liver transplantation fulfilling the Criteria of Milan,University of California San Francisco(UCSF)and Hangzhou.Methods Clinical data were retrospectively reviewed for 256 patients with recurrent hepatocellular carcinoma(HCC)undergoing donation after citizen death(DCD)liver transplantation(LT)from January 2015 to October 2019.They were divided into two groups of primary(PLT,n=175)and salvage(SLT,n=81).General profiles,tumor pathological characteristics and postoperative complications of two groups were compared by T-test,rank-sum orχ^(2) test.Kaplan-Meier method and Log rank test were employed for comparing overall survival rate(OS)and recurrence-free survival rate(RFS)between two groups.In SLT group,31 cases fulfilled Milan criteria,45 cases UCSF criteria and 69 cases Hangzhou criteria.OS/RFS of three groups were compared.According to there was downstaging or bridging treatment pre-LT,SLT group was divided into downstaging group(n=32)and non-downstaging group(n=49).OS/RFS of two groups were compared.According to the Rescit1.1 criteria,downstaging group were divided into remission group(n=14)and non-remission group(n=18)and OS/RFS of two groups were compared.Results The operative durations of PLT and SLT groups were(439.5±74.9)and(475.1±83.4)min respectively.There was significant inter-group difference(P<0.05);However,no significant inter-group difference existed in amount of intraoperative bleeding,blood transfusion,postoperative hospital stay or incidence of postoperative complications(all P>0.05).No significant difference existed in OS/RFS between PLT and SLT groups(P>0.05).No significant difference existed in OS at 1/3/5 years post-SLT among Milan,UCSF and Hangzhou criteria groups(all P>0.05);However,RFS in Milan criteria group at 1/3/5 years post-SLT were 93.5%,81.7%and 81.7%respectively.They were significantly higher than 68.9%,59.7%and 59.7%in UCSF criteria group and 78.3%,58.8%and 55.5%in Hangzhou criteria group(all P<0.05).For patients on downstaging therapy,OS in the Remission group at 1,3 and 5 years post-SLT were 100%,73%and 73%respectively,which was significantly higher than 83.3%,49.4%and 0 in non-Remission group(P=0.042).RFS in the Remission group at 1,3 and 5 years post-SLT were 100%,62.5%and 46.9%respectively,which was significantly higher than 52.9%,0 and 0 in no-Remission group(P=0.001).Conclusions The survival outcome of SLT recipients is similar to that of PLT recipients.The overall survival of SLT recipients shows no significant difference between Milan,UCSF and Hangzhou criteria.However,SLT recipients fulfilling Milan criteria have the longest recurrence-free time.The prognosis of patients with remission after preoperative descending treatment is superior to that of patients without remission.