未符合Milan標準的肝細胞癌患者仍可獲益於活體肝臟移植


  July 25, 2005 (洛杉磯) - 國際肝臟移植協會的第11屆年度大會上,Yasutugu Takada醫師發表指出,肝細胞癌(HCC)的患者,在接受活體肝臟移植(LDLT)四年後,有60%仍然存活,即使這些患者並未符合Milan標準(MC)中的器官分配要求。
  
  Takada醫師目前在日本京都大學的移植及免疫學系擔任副教授,他向Medscape表示,MC是大體肝臟移植的判定標準,為美國及歐洲所採用;但在日本,因為無法例常的判定腦死,因此只能使用LDLT;在沒有其他選擇的情況下,我們認為應可延伸MC的適用範圍。
  
  在日本京都大學的移植及免疫學系,腫瘤的數量與大小未受限制;患者只有在特定情況下才會被排除於肝臟移植之外,如腫瘤轉移到肝臟以外的器官,或血管嚴重受到侵害;在1999年2月到2004年9月間,114位患者接受了LDLT手術,患者的末期肝病平均模式指數(Median Model End-Stage Liver Disease score)為15(範圍,4-36);根據術前的造影研究,55位患者符合MC標準,48位並未符合(高於MC標準,over-MC);11位患者只有偶發性的腫瘤;追蹤期平均為33個月。
  
  MC組的整體存活率為66%,Over-MC組則分為兩組:A組的腫瘤數少於9個,皆小於5公分直徑,B組的腫瘤數皆高於10個,直徑大於5公分;A組的存活率明顯高於B組(84% vs 36%)。
  
  目前為止,16位HCC患者經歷了術後復發,Over-MC組的四年累積復發率明顯高於MC組(32% vs 15%);多變因分析結果顯示,組織學等級及腫瘤數目為復發最明顯的風險因子。
  
  Takada醫師的發表突顯了日本與美國在醫療作法與政策上的差異,至今,日本只進行過20到30個大體肝臟移植手術,LDLT已經有了3000例;這項數據顯示,如果可以進行活體移植,在沒有選擇的情況下,LDLT可以提供HCC患者的治癒機會;Takada向與會人員表示,如果患者與捐贈者都了解相關的風險,也迫切的想要接受移植,我們也無法說「不」。
  
  本研究由日本厚生省資助。

Living Donor Liver Transplanta

By
Medscape Medical News

July 25, 2005 (Los Angeles) — Sixty percent of patients with hepatocellular carcinoma (HCC) who received a living donor liver transplant (LDLT) survived for four years posttransplantation, although they did not meet the Milan Criteria (MC) for organ allocation, according to a presentation given here by Yasutsugu Takada, MD, at the 11th Annual Congress of the International Liver Transplantation Society.

"MC are the standard criteria for cadaveric liver transplantation in the USA or Europe, but in Japan only LDLT is available, because the problem of brain death is not routinely approved," Dr. Takada, an associate professor in the Department of Transplantation and Immunology, Kyoto University in Japan, and lead investigator of the study, told Medscape. "In such a situation, we think it is possible to extend the MC for participation because they have no other alternative."

At the Kyoto University Department of Transplantation and Immunology, there are no restrictions on the number or size of tumors; patients are only excluded from liver transplantation if they have extrahepatic metastasis or macroscopic vascular invasion. Between February 1999 and September 2004, 114 HCC patients underwent LDLT. Median Model End-Stage Liver Disease score in this population was 15 (range, 4 - 36). Based on preoperative imaging studies, 55 patients met MC and 48 did not (over-MC); 11 had only incidental tumors. Investigators followed up patients for a median of 33 months.

Overall survival was 66% in the MC group and 60% in the over-MC group. Over-MC patients were stratified into two groups: (group A) no more than nine tumors all 5 cm or less in diameter and (group B) 10 or more tumors all more than 5 cm in diameter. The survival rate in group A was significantly larger than in group B (84% vs 36%; P = .0234)

To date, 16 patients with HCC experienced postoperative recurrence. In the over-MC group, cumulative four-year recurrence rates were significantly higher than in the MC group (32% vs 15%; P = .034). In multivariate analysis, the histologic grade and the number of tumors were significant risk factors for recurrence.

This presentation highlighted how policies and medical practice differ between Japan and the U.S. Only 20 to 30 cadaveric liver transplantations have been performed so far in Japan compared with 3,000 LDLT. Dr. Takada's data suggest that if a living donor is available, LDLT may offer a chance of cure for HCC patients who might otherwise die. Dr. Takada told attendees at the meeting that "if the patient and donor well understand the risk and they are eager to receive a transplant, then we cannot say no."

This study was funded by the Japanese Ministry of Health. Dr. Takada has no conflicts of interest to report.

11th Annual Congress ILTS: Abstract 109. Presented July 22, 2005.

Reviewed by Gary D. Vogin, MD

    
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