本帖最後由 lsc0019 於 2009-7-29 21:58 編輯
作者：Laura Newman, MA
出處：WebMD醫學新聞
July 14, 2009 (紐約) – 移植外科醫師在國際肝臟移植協會第15屆國際研討會中發表指出，肝細胞腫瘤(HCC)進行肝臟移植之後，相較於無治療者，無線射頻消融術(RFA)與顯著較高的5年病患存活有關。另一篇研究發現，相較於HCC而無治療者，動脈栓塞化學療法(TACE)更有效，可以減少腫瘤大小，適用於那些不符合米蘭規約的病患。
新的輔助治療被廣泛用於降低肝細胞腫瘤以及延緩腫瘤惡化，以減少在等待移植時死亡的病患人數。德州Baylor大學醫學中心Baylor地區移植研究中心主任Goren Klintmalm博士向Medscape Transplantation表示，有趣的是，移植學界使用新的輔助治療來降低疾病分期，以讓極重症病患可以符合米蘭規約(1個腫瘤小於5公分或者最多3個腫瘤且每個小於3公分)，那是HCC病患要考量肝臟移植時必須符合的標準。
與會者表示，擔心那些HCC病患未及時進行輔助治療，導致病重而無法接受移植或降低成功機會。
Klintmalm博士表示，有許多學派考慮進行新的輔助治療，新的輔助治療選擇，某些程度上是機構特定或醫師特定的。
Klintmalm博士等人分析HCC病患在肝臟移植前的登記資料，以確認新的輔助治療在病患結果上的效果。
整體來說，有143名病患接受TACE，92人接受RFA，53人未接受治療。就移植後存活來看，這三組都沒有明顯的利益。範圍從67.3%到78.8% (P= .3213)。
在那些超出米蘭規約者中，52人接受TACE，31人接受RFA，10人未接受治療；這三組之間在治療效果方面有統計上的顯著差異。TACE的5年存活率為56.1%、RAF為86%、無治療者為30%(P= .0123)。RFA存活優於無治療者(P= .0017)，但是TACE則無。
Klintmalm博士表示，RFA是我們幫助病患準備肝臟移植時的最重要工具之一，它與你的執行狀況相當有關— 如果有較高的細胞殺傷率的話 — 也和癌症的侵犯性多寡密切有關。就我們的經驗，RFA很好。我們使用多個探針在大腫瘤上進行。唯一的限制在於解剖上— 它得避免靠近大血管。
Klintmalm博士表示，該研究與其他多個研究結果一致，認為米蘭規約對於達到好的病患存活太過限制。如果我們擴大納入規範，之後採用新的輔助治療，RFA顯示優於化學栓塞療法。
Klintmalm博士表示，他在約5到6公分大小的腫瘤使用RFA獲得好的結果，如同在日本、韓國、辛辛那提與芝加哥的報告。一般來說，給予新的輔助治療之後幾個月，Baylor研究團隊再看腫瘤的生物學是否惡化。
由紐約市紐約大學醫學中心肝臟移植研究員Vincent Peyregne醫師發表的另一篇研究，比較TACE與沒有治療者，也對超過米蘭規約者進行分析。總共納入在2002年3月至2007年12月間在紐約大學醫學中心治療的85名HCC病患；59人接受TACE，26人沒有。
該研究由紐約大學外科副教授Lewis Teperman醫師所領導，回溯回顧進行TACE之前與肝臟移植後立即進行的病理報告和核磁共振造影(MRI)，評估腫瘤大小的變化和米蘭規約的狀態。
Peyregne醫師表示，病理報告比MRI更能提供準確的腫瘤壞死狀態。TACE對於腫瘤縮小與不符米蘭規約的病患更有效。
根據Peyregne醫師表示，MRI和病理報告皆顯示，TACE引起壞死。不過，兩組的疾病復發、無復發存活、病患存活等都沒有差異。
Peyregne醫師表示，根據他們的發現，可以論證TACE能在使那些不符規約者改善之後適合肝臟移植，也就是以治療來降低分期。
賓州愛因斯坦醫學院肝病與移植中心、愛因斯坦中心肝臟移植計畫醫療主任暨肝臟科主任Victor Araya醫師在Medscape Transplantation的訪問中對這個新的輔助治療提出評論，認為它對肝臟科醫師來說，是幫助等待肝臟移植病患降低分期和延緩腫瘤生長的一個重要工具。
他指出，HCC病患應及早轉診給肝臟科醫師，肝臟移植團隊可以評估適當治療，包括新的輔助治療。雖然紐約大學團隊偏好TACE，而Baylor團隊偏好RFA，Araya醫師相信，兩種方法都有可用之處。一般而言，他表示，對於大的多發的腫瘤，他偏好TACE勝過RFA；不過，對於較小的腫瘤，RFA或許比較合適。
兩篇研究都未接受商業補助。Klintmalm、Peyregne、Araya等醫師都宣告無相關財務關係。
國際肝臟移植協會(ILTS)第15屆國際研討會：摘要P-79和P-88。發表於2009年7月8日。
Neoadjuvant Therapies Can Improve Access to Liver Transplantation for Patients With Liver Cancer
By Laura Newman, MA
Medscape Medical News
July 14, 2009 (New York, New York) – Radiofrequency ablation (RFA) is associated with a significantly higher 5-year patient survival after liver transplantation for hepatocellular carcinoma (HCC) than no treatment, transplant surgeons announced here at the International Liver Transplantation Society 15th Annual International Congress. A separate study found that transarterial chemoembolization (TACE) is more effective than no treatment in patients with HCC, resulting in reduced tumor size, and it is viable in patients who do not meet Milan criteria.
Neoadjuvant therapies are widely used to downstage hepatocellular tumors and slow the progression of tumors so that fewer patients die while waiting for transplants. Increasingly, the transplant community is using neoadjuvant therapy to downstage patients so that extremely sick patients are brought within Milan criteria (1 tumor <5?cm or up to 3 tumors <3?cm each), which is the standard that patients with HCC must meet to be considered for liver transplantation, Goren Klintmalm, MD, PhD, chair and chief of the Baylor Regional Transplant Institute at Baylor University Medical Center in Dallas, Texas, told Medscape Transplantation.
Attendees expressed concern that patients with HCC are not being referred for neoadjuvant therapy soon enough and therefore get too sick to undergo a transplant or have lower odds of a successful outcome.
There are many schools of thought on choice of neoadjuvant therapy, Dr. Klintmalm commented, noting that "the choice of neoadjuvant therapy is somewhat institution- and physician-specific."
Dr. Klintmalm and colleagues analyzed data from a registry of patients with HCC known prior to liver transplantation to determine the effects of neoadjuvant therapies on patient outcomes.
Of the total, 143 patients underwent TACE, 92 underwent RFA, and 53 received no treatment.
No significant advantages for any of the 3 strategies were shown in terms of posttransplant survival. It ranged from 67.3% to 78.8% (P?= .3213).
In the subset of patients who exceeded Milan criteria, 52 underwent TACE, 31 underwent RFA, and 10 received no treatment; there was a statistically significant difference in treatment effect among the 3 groups. Five-year survival was 56.1% with TACE, 86% with RFA, and 30% with no treatment (P?= .0123). RFA survival was superior to no treatment (P?= .0017), but TACE was not.
"RFA is one of the most important tools we have in preparing HCC patients for liver transplantation.?.?.?. It really depends on how well you do it — if you have a higher kill rate — and it is very much dependent on how aggressive the cancer is," said Dr. Klintmalm. "In our hands, RFA is superior. We do it in huge tumors, using several probe sticks. The only restriction is anatomical — that it is not near a big vessel."
"This study is consistent with several other studies showing that using the Milan criteria is too restrictive to achieve good patient survival," continued Dr. Klintmalm. "If we are to expand inclusion criteria, then neoadjuvant therapy is feasible, and RFA appears preferable to chemoembolization."
Dr. Klintmalm said that he has had good results with RFA in tumors as large as 5 and 6?cm, as has been shown by reports from Japan, Korea, Cincinnati, and Chicago. Typically, the neoadjuvant therapy is delivered and the Baylor team will wait several months to see whether the biology of the tumor is aggressive or not.
A separate study, reported by investigator Vincent Peyregne, MD, liver transplant fellow at NYU Medical Center in New York City, compared TACE with no treatment, again in the setting of patients who exceeded Milan criteria. A total of 85 HCC patients treated at NYU Medical Center between March 2002 and December 2007 were included; 59 underwent TACE and 26 did not.
This study, led by Lewis Teperman, MD, associate professor of surgery at NYU, was a retrospective review showing changes in size and Milan criteria status on magnetic resonance imaging (MRI) and pathology reports done before TACE and immediately before liver transplantation.
"Pathology reports proved more accurate in showing tumor necrosis than MRI," said Dr. Peyregne. TACE proved more effective with an objective decrease in tumor size and in patients beyond Milan criteria.
Both MRI and pathology reports showed that TACE induced necrosis, according to Dr. Peyregne. However, there were no differences in disease recurrence, recurrence-free survival, or patient survival in the 2 groups.
Dr. Peyregne said that, based on their findings, one could argue that TACE might improve access to liver transplantation after being made eligible for exception points, as a result of treatment-induced downstaging.
Victor Araya, MD, chief of hepatology and medical director of the Liver Transplant Program at the Albert Einstein Center for Liver Disease and Transplantation of Albert Einstein College of Medicine in Philadelphia, Pennsylvania, commented in an interview with Medscape Transplantation that neoadjuvant therapies are an important tool for hepatologists in downstaging and slowing tumor growth in patients waiting for liver transplants.
He added that patients with HCC should be referred early in their disease course to hepatologists and liver transplant teams for evaluation of appropriate therapies, including neoadjuvant therapy. Whereas the NYU group favors TACE and the Baylor group favors RFA, Dr. Araya believes there is a place for each modality. In general, he said that he favors TACE over RFA for large, multiple tumors; however, for smaller tumors, RFA might be most appropriate.
Neither study received commercial support. Dr. Klintmalm, Dr. Peyregne, and Dr. Araya have disclosed no relevant financial relationships.
International Liver Transplantation Society (ILTS) 15th Annual International Congress: Abstracts P-79 and P-88. Presented July 8, 2009. |
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