Child-Pugh B，C评分预测肝癌监测失败

StephenW

Child-Pugh B, C scores predict failure in liver cancer surveillance

Mancebo A, et al. J Gastroenterol Hepatol. 2017;doi:10.1111/jgh.14108.
January 31, 2018

Child-Pugh B and C, and elevated alpha-fetoprotein, at diagnosis of hepatocellular carcinoma corresponded with a diagnosis outside Milan criteria and surveillance failure during a surveillance program of patients with cirrhosis.

“HCC surveillance in cirrhotic patients aims to detect tumors in the initial stages of the disease to offer treatments that increase patient survival,” Alejo Mancebo, MD, from the Hospital Universitario Central de Asturias, Spain, and colleagues wrote. “Although the usefulness of screening programs remains controversial, several studies have shown survival improvement in patients under surveillance.”

To assess the frequency and risk factors associated with HCC surveillance failure, the researchers prospectively followed 1,242 patients with cirrhosis enrolled in an HCC surveillance program with quarterly or semi-annual ultrasonography and alpha-fetoprotein (AFP) screening tests.

During a median follow-up of 48 months, 188 patients developed HCC who comprised the study. The patients were mostly men (85.1%) and developed cirrhosis due to alcohol use (50%), hepatitis C (39.8%), hepatitis B (6.9%) or other cause.

At the time of HCC diagnosis, median patient age was 62.6 years, most patients had Child-Pugh class A (69.7%) and the mean AFP level was 8.8 ng/mL (range, 1-18,430). Twenty-eight patients had an AFP level of 100 ng/mL or higher, 9 patients had an AFP level higher of 1,000 ng/mL or higher, and 50 of the 188 tumors were outside Milan criteria.

“HCC surveillance is not recommended for Child-Pugh class C patients, except for those included in a waiting list for liver transplantation,” Mancebo and colleagues wrote. “In our series, 12 patients were in this class at the time of tumor detection, but all of them had been in class A or B in the previous screening round, suggesting that the development of the tumor could have contributed to the liver function impairment.”

Patients with tumors outside Milan criteria had significantly more nodules at diagnosis (2.8 vs. 1.2; P < .001) than patients within Milan criteria, as well as higher diameters among the larger tumors (4.8 vs. 2.4 cm; P < .001), higher levels of AFP (659.4 vs. 48.5 ng/mL; P < .001) and shorter survival after diagnosis (7.6 vs. 33.9 months; P < .001).

Multivariate analysis showed that Child-Pugh B or C (HR = 3.15; 95% CI, 1.78-5.55) and AFP levels of 100 ng/mL or higher (HR = 2.8; 95% CI, 1.37-5.71) at HCC diagnosis correlated with surveillance failure.

“Variables collected before HCC diagnosis, such as Child-Pugh class B at inclusion or the development of portal hypertension-related complications during follow-up, are more useful in selecting patients with a higher risk of program failure,” the researchers concluded. “Current screening strategies are probably not suitable for these patients, and different modalities should be investigated.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.

StephenW

Child-Pugh B，C评分预测肝癌监测失败

Mancebo A等人。 J Gastroenterol Hepatol。 2017; DOI：10.1111 / jgh.14108。
2018年1月31日

Child-Pugh B和C以及甲胎蛋白升高在诊断肝细胞癌时符合米兰标准以外的诊断标准，并且在肝硬化患者监测计划期间的监测失败。

西班牙阿斯图里亚斯大学医学院的Alejo Mancebo博士及其同事写道：“肝硬化患者的HCC监测旨在检测疾病初期的肿瘤，提供可提高患者生存率的治疗方法。 “虽然筛查方案的实用性仍然存在争议，但是一些研究显示，监测患者的生存率有所提高。”

为了评估与HCC监测失败相关的频率和风险因素，研究人员前瞻性地随访了1242名肝硬化患者参加了HCC监测计划，每季度或每半年一次的超声检查和甲胎蛋白（AFP）筛查试验。

在中位随访48个月期间，有188名患者发展为HCC组成的研究。以酒精使用（50％），丙型肝炎（39.8％），乙型肝炎（6.9％）或其他原因引起的肝硬化患者多为男性（85.1％）。

在HCC诊断时，患者中位年龄为62.6岁，大多数患者Child-Pugh A级（69.7％），平均AFP水平为8.8ng / mL（范围1-18,430）。 28例AFP水平为100 ng / mL或更高，9例AFP水平高于1000 ng / mL或更高，188例肿瘤中50例超出米兰标准。

Mancebo和他的同事写道：“对于Child-Pugh C级患者，除肝移植候选名单中的患者外，不建议对HCC进行监测。 “在我们的系列研究中，有12名患者在肿瘤检测时在这个类别中，但是在之前的筛查中他们都在A或B级，这表明肿瘤的发展可能导致了肝功能损害“。

米兰标准以外的肿瘤患者的诊断结节明显多于米兰标准患者（2.8比1.2; P <0.001），而大肿瘤直径更大（4.8比2.4cm; P <0.001） ，AFP水平较高（659.4 vs. 48.5 ng / mL; P <0.001），诊断后生存期较短（7.6 vs. 33.9个月; P <0.001）。

多变量分析显示HCC诊断时Child-Pugh B或C（HR = 3.15; 95％CI，1.78-5.55）和AFP水平为100ng / mL或更高（HR = 2.8; 95％CI，1.37-5.71）监视失败。

研究人员总结说：“HCC诊断前收集的变量，如Child-Pugh B级，随访期间发生门静脉高压相关并发症，对选择程序失败风险更高的患者更为有用。 “目前的筛查策略可能不适合这些患者，应该调查不同的方式。” - Talitha Bennett

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