Stellenwert der ablativen Tumortherapie beim HCC: „eine reale Brücke“ zur Lebertransplantation?

 

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Zusammenfassung

Hintergrund: Interventionelle ablative Verfahren werden zunehmend zur lokoregionalen Therapie von hepatozellulären Karzinomen (HCCs) im Rahmen von Bridging- und/oder Downstaging-Konzepten vor Lebertransplantation eingesetzt. Das Ziel der vorliegenden Arbeit ist, einen Überblick über die Datenlage zum Einsatz von Bridging und Downstaging vor Lebertransplantation zu geben. Methodik: Die vorliegende Übersichtsarbeit beruht auf einer umfassenden Literaturrecherche in PubMed, welche die Ergebnisse aus kontrollierten Studien, Kohortenstudien, Metaanalysen und Übersichtsarbeiten einschließt. Ergebnisse: Bei insgesamt niedrigem Evidenzgrad besteht aktuell eine größenabhängige Empfehlung zum Bridging von hepatozellulären Karzinomen innerhalb der Milankriterien vor Lebertransplantation bei zu erwartender Wartezeit von mehr als 6 Monaten. Bei ebenfalls schwachem Evidenzgrad besteht eine Empfehlung zur Lebertransplantation nach erfolgreichem Downstaging von HCCs außerhalb der Milankriterien in die Milankriterien. Schlussfolgerung: Randomisierte kontrollierte Studien, die den Therapieerfolg von Bridging oder Downstaging eindeutig belegen könnten, liegen nicht vor und werden auch nicht erwartet. Aufgrund der unkomplizierten Anwendung und dem geringen Therapierisiko werden die interventionellen Verfahren zum Bridging und Downstaging aber anerkannt und empfohlen.

Abstract

Background: The utilisation of interventional ablation procedures in the context of bridging and downstaging plans for hepatocellular carcinomas before liver transplantation is increasing. The aim of the present study was to summarise current data for the application of bridging and downstaging procedures before liver transplantation. Methods: The present study is based on an extensive investigation of the literature in PubMed. Results of controlled trials, cohort studies, meta-analyses and reviews were included. Results: Recommendations for the usage of bridging procedures for hepatocellular carcinomas within the Milan criteria and an expected waiting time of more than 6 months until transplantation depend on the size of the lesions and have a low level of evidence. After successful downstaging of hepatocellular carcinomas beyond the Milan criteria into the range of the Milan criteria liver transplantation is recommended with a low level of evidence, as well. Conclusion: Randomised controlled trials, clearly proving the success of bridging and downstaging procedures, are not available at the time and are not awaited for ethical reasons. Due to the uncomplicated application and low risk for therapy-associated complications, interventional procedures for bridging and downstaging are accepted and recommended.

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