肝细胞癌合并门静脉癌栓肝移植治疗进展

Progress of therapeutic proceeding of liver transplantation in hepatocellular carcinoma with portal vein tumor thrombosis

肝细胞癌(简称肝癌)易侵犯门静脉系统,10%~40%肝癌患者在初诊时已合并肉眼可见门静脉癌栓。在欧美国家,众多肝癌诊治指南将肝癌合并肉眼可见门静脉癌栓定义为进展期肝癌,故推荐该部分患者进行系统治疗。而在亚洲国家,外科医师对于肝癌合并门静脉癌栓的处理方式更加积极,认为其并不是手术绝对禁忌证。目前,关于肝癌合并门静脉癌栓的治疗,尚无全球性共识或标准指南。肝移植是不可切除肝癌的根治性治疗措施,但肝癌合并门静脉癌栓患者行肝移植后肿瘤复发率高,故肝癌合并门静脉癌栓患者一度被视为肝移植的禁忌证。此外,肝癌合并门静脉癌栓常被认为存在肿瘤肝外转移。但临床实践中,在无有效治疗措施的情况下,越来越多的肝癌合并门静脉癌栓患者转向寻求肝移植并最终成功进行了手术。与此同时,诸多研究表明在合理选择受体的前提下,肝移植可以使肝癌合并门静脉癌栓患者生存受益。尤其是同其他治疗方案比较,在采用降期治疗(包括三维适形放疗、经肝动脉化疗栓塞、立体定向体部放疗、经肝动脉放疗栓塞、经肝动脉灌注化疗等)成功的肝癌合并门静脉癌栓患者中继续行肝移植可使患者获得更佳预后。鉴于肝移植在肝癌合并门静脉癌栓患者中的治疗争议显著,笔者深入阐述肝癌合并门静脉癌栓肝移植治疗进展,主要包括肝癌合并门静脉癌栓诊断和分型、支持肝移植证据以及反对肝移植理由。

Hepatocellular carcinoma(hereinafter referred to as liver cancer)often invades portal vein system.Usually,10%−40%of liver cancer patients present with portal vein tumor thrombosis(PVTT)at the time of diagnosis.In Europe and the United States,liver cancer combined with PVTT is defined as advanced stage,thus,systemic therapy is recommended for these patients according to most published guidelines.But,in Asian countries,liver cancer combined with PVTT is treated in a more positive way,since not all cases of liver cancer combined with PVTT are deemed as a contraindication of surgery.Up to now,no global consensus or standard guideline for liver cancer combined with PVTT has been reached yet.Liver transplantation(LT)serves as a curative therapeutic option for unresectable liver cancer,but liver cancer combined with PVTT has always been regarded as a contraindication for LT due to high tumor recurrence after LT.Meanwhile,liver cancer combined with PVTT is also deemed as a status of extra-hepatic metastasis.In practice,however,many patients with liver cancer combined with PVTT seek LT because other alternatives are not available or suit‐able.Finally,this part of patients successfully received LT.Moreover,emerging studies reveal that well-selected patients with liver cancer combined with PVTT could benefit from LT.Especially,compared to other alternatives,LT following successful downstaging treatment(such as.selective internal radiation therapy,external beam radiation therapy,estereotactic body radiation therapy,and/or transarterial chemoembolization),could bring survival benefit for patients with liver cancer combined with PVTT.The author concentrates on the issue whether patients with liver cancer combined with PVTT are candidates for LT,and reviews the PVTT diagnosis and classification,supporting evidence,and opposing evidence.