肝癌肝移植的米兰外标准.ppt

LiverTransplantationforHCCBeyondtheMilanCriteria CharlesM Miller MDTheRecanati MillerTransplantationInstituteMountSinaiMedicalCenterNewYork NY LONGTERMRESULTSOFLIVERTRANSPLANTATIONANDMULTIMODALADJUVANTTHERAPYFORTHETREATMENTOFHEPATOCELLULARCARCINOMALARGERTHAN5CM SasanRoayaie SukruEmre ThomasFishbein PatriciaSheiner CharlesMiller andMyronSchwartz TheRecanati MillerTransplantationInstituteMountSinaiMedicalCenterNewYork NYAnnalsofSurgeryVol 235 No 4533 539April 2002 Background HCC mostcommonsolidorgantumorworldwideonemilliondeathsannuallyincidencerisinginUS2 4per100 000goodsurvivalwithtransplantfortumors 5cm75 at4yearspoorsurvivalwithtransplantfortumors 5cm18 30 at5years PreviousStudies CandidateEntryCriteria unresectableHCC 5cmfreeofextrahepaticdiseaseCTchest abdomen pelvisbonescanpatentmajorhepatic mainportalveinsmulticentrictumorsnotexcludedlargesttumorinlessinvolvedlobe 5cmtumorinvolving 75 parenchyma EntryCriteria nosignificantascitesorencephalopathyINR 1 5creatinine 2mg dlbilirubin 2mg dlunlesssufferingfromcholestaticliverdiseasenormalMUGAnopriorchemotherapyorradiation PretransplantManagement subselectivearterialchemoembolizationmitomycin C doxorubicin cisplatincollagenorpolyvinylalcoholCTscan AFPlevelevery3monthsresponse AFPdecrease 50 TACErepeatedasneededexcludedwhenentrycriterianolongermet Intra OperativeProtocol backuprecipientinhospitalexploratorylaparotomyforextrahepaticdiseasestandardhepatectomyandtransplantdoxorubicin10mg m2whileanhepatic Post transplantProtocol chemotherapybeginning6thpostopweekdoxorubicin50mg m2G CSF5 g kgfor14daysrepeatedastoleratedevery3weeksx6cyclesimmunosuppressioncorticosteroidswithcyclosporineortacrolimuspulsesteroids OKT3forrejectionnoazathioprine Follow up CTscanchestandabdomen pelvisevery3months 1styearevery6monthsthereafterAFPevery6weeks 1styearevery3monthsthereafter Results October1991 January199980patientsenrolled43transplanted37eventuallyexcludedtumorprogression 2mainportalveintumor 9liverfailure 5lymphnodemetastasis 6mediantimeonwaitinglisttransplanted 142 168daysexcluded 207 306days distantmetastasis 6GIbleeding 4othermalignancies 2patientpreference 3 Demographics TumorCharacteristics UnderlyingLiverDisease Complications TACE2 80 2 5 mortalityfromliverfailureperioperativemortality2 43 4 7 chemotherapymean4 8 1 79cycles4 43 9 3 didnotreceiveanypostopchemo2perioperativemortalities1patientrefusal1poorpostopcardiacfunction Complications Chemotherapydiscontinuedearly3 7 thrombocytopenia2 5 hepatotoxicity4 9 progressiverecurrenttumor2 5 refusaltocontinue Follow up medianfollow up55 1 24 9mo 19 43 44 alive17 43 40 freeofdiseaserecurrencein17 43 40 mediantimetorecurrence12 5 12 6mo intrahepaticonly2extrahepaticonly9both5riseinAFP1 OverallSurvival 44 p 0 0001 Recurrence freeSurvival 48 Recurrence tumorsize p 0 024 Recurrence freesurvival 55 34 p 0 0237 Recurrence vascularinvasion p 0 036 Recurrence freeSurvival p 0 101 Recurrence freesurvival P 0 147 Recurrence freesurvival p 0 136 Conclusions livertransplantationforHCC 5cm5yearoverallsurvival44 5yearrecurrence freesurvival48 predictorsofrecurrencetumorsize 7cmpresenceofvascularinvasionpossiblepredictorsofrecurrencepoorlydifferentiatedtumorsunderlyingliverdiseaseotherthanhepatitisB Roleofadjuvanttherapies resultsbetterthanhistoricseries but notarandomizedstudycarefulscrutinyofcases naturalselectionduetowaitingtimechemoembolizationmaybeusefulindelayingtumorprogressionwhilewaitingsystemicchemotherapyofquestionablevalue Conclusions decreasedsurvivalcomparedtoHCC 5cmoverallsurvival4