Download - SB-04
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HEPATOSELLÜLER KANSERLİ HASTALARDA CANLI VERİCİLİ
KARACİĞER NAKLİ: MİLAN KRİTERLERİ ÖTESİNDE
Deniz BALCITaner B, Dayangac M, Akin B, Yaprak O, Duran C, Uraz S,
Ayanoglu Ö, Killi R, Şentürk H, Yüzer Y, Tokat Y
Florence Nightingale Hastanesi İstanbul Bilim Üniversitesi
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El-Serag H and Mason A. N Engl J Med 1999;340:745-750
Age-Specific Incidence of Hepatocellular Carcinoma (ICD-O Code 8170) SEER Data Base, 1981-1995,
İnsidansı artmakta
3%/yıl- USA 7%/yıl - Japan per 100,000
Yılda 1 milyon kişinin ölümünden sorumlu
UNOS Database www.unos.org
HEPATOSELLÜLER KARSİNOMA (HCC)
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MILAN KRITERLERI
•Tek tumor ≤ 5 cm • n < 3 nodül, •herbiri ≤ 3 cm
Mazzaferro et al. N Engl J Med 1996;334: 693-9
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Japonya deneyimi Kore deneyimi
Todo S et al. AnnSurg 2004;240:451–9
HCC İÇİN CANLI VERİCİLİ KARACİĞER NAKLİ
Lee SY et al.Transpl Proceed 2004:36; 2289–90
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Milan Kriterleri Genişletilebilir mi? UCSF Kriterleri
UCSF KRITERLERI
•Tek tumor ≤ 6.5 cm • 3 nodül ≤ 4.5 cm• Toplam ≤ 8 cm
Yao FY. Liver Transpl 12:1189-1191, 2006
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Şu an ABD de yaklaşım
Kleek et al. J Clin Gastroenterol (40)7; 2006
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MK genişletilebilir
Onaca N , Klintmalm. Liver Transpl 13:391-399, 2007
International Registry of HepaticTumors in Liver Transplantation from 1,206 patients with HCC.
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Istanbul Bilim Üniversitesi Karaciğer Nakli deneyimi
Temmuz.2004 - Temmuz.2007
153 ardışık Karaciğer Nakli 115 Canlı vericili
38 Kadavradan
44/153 nakil HCC nedeniyle
32 Canlı vericili
12 Kadavradan
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ÇALIŞMA
AMAÇ:
Milan Kriterlerini aşan ve aşmayan tümör özelliklerine göre ayrılan HCC li hastalarda survinin karşılaştırılması
INKLUZYON KRITERLERI:
Ekstrahepatik hastalık yokToraks + Abdominopelvik CT
Tüm vucut kemik sintigrafisi
Preoperatif portal ven trombozu saptanan 2 hastada çalışmaya dahil edildi.
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HastalarTemmuz 2004 – Temmuz 2007
Patoloji sonucu HCC
32 hasta
Milan K İÇİ 15 hasta
Milan K DIŞI15 hasta
2 perioperatif exitus
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Demografik Veriler
Ort. yaş
(yıl)
55
(40-72)
Cins ( E / K ) 23 / 7
Peak AFP 178 (2-2271)
MELD Skoru (hesaplanmış
ort)
MILAN
İçi: 16
Dışı: 14
0
1
2
3
4
5
6
A B C
MILAN ICI
MILAN DISI
CHILD
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Etyoloji
02468
101214161820
HBV HCV ALCHL CRYPTG
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Cerrahi Tedavi
32 canlı vericili karaciğer nakli
Exploratif laparotomi ---- Extrahepatik hastalık
Portal LN örneklemesi ---- Frozen (MK ni aşan hastalara)
Standard hepatektomi ---- Piggyback tekniği
Sağ lob transplantasyonu
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Postoperatif İzlem
Abdomen USG Her 3 ayda - ilk yıl
Her 6 ayda – takiben
Abdomen CT / MR1. yıl
Yılda bir kez
AFPAyda bir – ilk yıl
Her 3 ayda bir- takiben
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SONUÇLAR
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SONUÇLAR
Patoloji sonuçlarına göre 32 hastada HCC
4 hastada insidental HCC (12.5%)
Mortalite 2 hasta
Pnömoni- Sepsis 2.ay
Şiddetli Gastroenterit-dehidratasyon- inferior vena cava trombozu
exitus (dış merkez)
2 hastada Ana portal vende tümör
2 hastada İntrahepatik PV tümör
1 hastada hepatik vende tümör
Lenf nodu metastazı yok
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Tumor Karakteristikleri
Milan İçi (n=15)
Milan Dışı (n=15)
p
Multipl lezyon (n) 5 15 ns
Bilateral tumor 1 7 0,015
Preop peak AFP 126±96 229±569 ns
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Tümör Karakteristikleri
Multifokalite
50%50%
unifokal multifokal
Tümör Differansiasyonu
23%20%
57%
iyi orta kötü
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Postop izlem
Ortalama izlem 16 ay ( 2 – 36 )
Median: 12.8 ay28/30 (93%) hayatta
27/30 (90%) hastalıksız
Rekürrens 3/30 (10%)
intrahepatik 0
extrahepatik 1
Herikiside 2
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Tümor Özellikleri
0123456789
10
multifokal soliter
MILAN ICI
MILAN DISI
P=0.073
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Rekürrens / Vasküler Invazyon
Vasküler invazyon
VAR
N:4
Vasküler İnvazyon
YOK
N:26
REKURRENS VAR
1 2
REKURRENS YOK
3 24
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Genel Sağkalım
Estimated mean: 33 ay
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HASTALIKSIZ SAĞKALIM
Means and Medians for Survival Time
32.000 2.119 27.846 36.154 . .Estimate Std. Error Lower Bound Upper Bound
95% Confidence Interval
Estimate Std. Error
Meana Median
Estimation is limited to the largest survival time if it is censored.a.
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Milan içi-dışı Sağkalım
Overall Comparisons
.503 1 .478
.794 1 .373
Log Rank (Mantel-Cox)
Breslow (GeneralizedWilcoxon)
Chi-Square df Sig.
Test of equality of survival distributions for the different levels ofMILAN.
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Recurrence-free survival
Overall Comparisons
.010 1 .919
.048 1 .826
Log Rank (Mantel-Cox)
Breslow (GeneralizedWilcoxon)
Chi-Square df Sig.
Test of equality of survival distributions for the different levels ofdifferans2.
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SONUÇ
Günümüzde organ dağıtımında HCC li hastalarda MK’ ni kullanan sistemlerde bu kriterleri aşan tümörü olan hastaların tedavi imkanları sınırlı olmaktadır
Kadavra greft imkanının sınırlı olduğu bölgelerde CVKN bu grup hastaya da potansiyel olarak küratif tedavi imkanı
sunabilmektedir.
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Hangi durakta inersiniz?
Majno P and Mazzafero V. Liver Transplantation 12:896-898, 2006
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Sonuçlar
Sınırlı sayıda hasta
Sınırlı uzun dönemli takip süresi
Tümör differansiasyonu ve multifokalite ile sağkalım
arasında istatistiki olarak anlamlı ilişki saptanmadı
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HCC li hastalarda CVKN, Milan Kriterlerini aşan tümörü olan hastalarda da benzer sürvi ve
rekürrens oranları sunan efektif bir tedavi modalitesidir.