健康肝硬化肝肝细胞癌手术治疗标准是否有标准？八项指南

StephenW

BMJ Open Gastro 2017; 4:e000129 doi:10.1136/bmjgast-2016-000129
Is there a standard for surgical therapy of hepatocellular carcinoma in healthy and cirrhotic liver? A comparison of eight guidelines
Giulia Manzini1, Doris Henne-Bruns1, Franz Porzsolt2, Michael Kremer1
Author Affiliations
Received:
13 December 2016
Accepted:
13 February 2017
Published Online:
24 March 2017
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

   
Background and aims

Liver resection (LR) and transplantation are the most reliable treatments for hepatocellular carcinoma (HCC). Aim was to compare different guidelines regarding indication for resection and transplantation because of HCC with and without underlying cirrhosis.
Methods

We compared the following guidelines published after 1 January 2010: American (American Association for the Study of Liver Diseases (AASLD)), Spanish (Sociedad Espanola de Oncologia Medica (SEOM)), European (European Association for the study of liver-European Organization for Research and Treatment of Cancer (EASL-EORTC) and European Society for Medical Oncology-European Society of Digestive Oncology (ESMO-ESDO)), Asian (Asian Pacific Association for the Study of Liver (APASL)), Japanese (Japan Society of Hepatology (JSH)), Italian (Associazione Italiana Oncologia Medica (AIOM)) and German (S3) guidelines.
Results

All guidelines recommend resection as therapy of choice in healthy liver. Guidelines based on the Barcelona Clinic Liver Cancer staging system recommend resection for single HCC<2 cm and Child-Pugh A cirrhosis and for HCC≤5 cm with normal bilirubin and portal pressure, whereas transplantation is recommended for multiple tumours between Milan criteria and for single tumours ≤5 cm and advanced liver dysfunction. Patients with HCC and Child-Pugh C cirrhosis are not candidates for transplantation. JSH guidelines recommend LR for patients with Child-Pugh A/B with HCC without tumour size restriction; APASL guidelines in general exclude patients with Child-Pugh A from transplantation. In patients with Child-Pugh B, transplantation is the second-line therapy, if resection is not possible for patients within Milan criteria. German and Italian guidelines recommend transplantation for all patients within Milan criteria.
Conclusions

Whereas resection is the standard therapy of HCC in healthy liver, a standard regarding the indication for LR and transplantation for HCC in cirrhotic liver does not exist, although nearly all guidelines claim to be evidence based. Surprisingly, despite European guidelines, Germany and Italy use their own national guidelines which partially differ from the European. Possible solutions of the problems are discussed.
Keywords: CIRRHOSIS, LIVER TRANSPLANTATION, HEPATOCELLULAR CARCINOMA, SURGICAL RESECTION
Article summary
▸   

Surgery is the only curative option for hepatocellular carcinoma (HCC).
   

Several guidelines exist that provide recommendations regarding indication for resection and transplantation.
   

Although nearly all guidelines claim to be evidence-based, we only find consensus in regard to indication for liver resection and transplantation for HCC in healthy liver, but a standard for the treatment of HCC with underlying liver cirrhosis does not exist.
   

Traditional guidelines are based on efficacy but not yet effectiveness data.
   

Only when outcomes, conditions, patient characteristics and interventions are described transparently, it will be possible to discuss possible reasons for different guidelines in different countries.
   

Traditional guidelines are based on efficacy but not yet effectiveness of data.
   

Progress in the development of guidelines will be made when the reasons that explain the differences in the existing guidelines can be identified.
   

Promising prognostic factors considering tumor biology as well as liver function tests should be included in future guidelines.

StephenW

BMJ Open Gastro 2017; 4：e000129 doi：10.1136 / bmjgast-2016-000129
健康肝硬化肝肝细胞癌手术治疗标准是否有标准？八项指南的比较
Giulia Manzini1，Doris Henne-Bruns1，Franz Porzsolt2，Michael Kremer1
作者联盟
收到：
2016年12月13日
公认：
2017年2月13日
在线发布：
2017年3月24日
这是根据知识共享署名非商业性（CC BY-NC 4.0）许可发布的开放获取文章，允许其他人分发，混搭，适应，非商业性的工作，并对其衍生作品进行不同的许可条款，原始作品被正确引用，使用非商业性。见：http://creativecommons.org/licenses/by-nc/4.0/

   
背景和目的

肝切除术（LR）和移植是肝细胞癌（HCC）最可靠的治疗方法。目的是比较不同的指南，用于切除和移植的指征，因为肝癌伴有和没有潜在的肝硬化。
方法

我们比较了2010年1月1日以后发布的以下指南：美国（美国肝脏疾病研究协会（AASLD）），西班牙语（Societad Espanola de Oncologia Medica（SEOM）），欧洲（欧洲肝脏欧洲组织研究协会癌症研究与治疗（EASL-EORTC）和欧洲肿瘤学协会 - 欧洲消化科肿瘤学会（ESMO-ESDO）），亚洲（亚太地区肝脏研究协会（APASL）），日本（日本社会学会肝病学（JSH）），意大利语（意大利医学博士（AIOM））和德国（S3）指南。
结果

所有指南都建议切除术作为健康肝脏选择的治疗方法。基于巴塞罗那诊所肝癌分期系统的指南建议切除单次HCC <2 cm和Child-Pugh A肝硬化，HCC≤5cm，正常胆红素和门静脉压，而移植建议用于米兰标准和单次肿瘤≤5cm，晚期肝功能不全。 HCC和Child-Pugh C型肝硬化患者不是移植的候选者。 JSH指南为没有肿瘤大小限制的HCC患儿的Child-Pugh A / B患者推荐LR; APASL指南一般排除移植患儿Child-Pugh A患者。在Child-Pugh B患者中，移植是二线治疗，如果不能在米兰标准范围内进行切除手术。德国和意大利指南建议移植米兰所有患者的标准。
结论

而切除术是肝健康肝脏的标准治疗方法，肝硬化肝脏肝硬化指征和肝移植手段不存在标准，尽管几乎所有的指导原则都以证据为依据。令人惊讶的是，尽管有欧洲的指导方针，德国和意大利则使用自己的国家指南，与欧洲部分不同。讨论可能的问题解决方案。
关键词：胆囊切除术，肝移植，肝细胞癌，外科治疗
文章摘要
▸

手术是肝细胞癌（HCC）的唯一治疗方案。


有几个准则提供了关于切除和移植指征的建议。


虽然几乎所有的指导原则都被证明是基于证据的，但是我们在健康肝脏中仅获得HCC肝切除术和移植指征方面的共识，但是不存在用于治疗潜在肝硬化的HCC的标准。


传统指南是基于有效性，但尚未成效的数据。


只有当结果，条件，患者特征和干预措施被透明地描述时，才有可能讨论不同国家不同指导方针的可能原因。


传统的指导方针是基于有效性，但尚未成效的数据。


当解释现有指南的差异的原因可以确定时，将制定指导方针的进展。


考虑肿瘤生物学和肝功能检查的有希望的预后因素应包括在未来的指南中。

MP4

无奈，手术竟然是唯一。应该快速批准新的治疗方法