黃俊銘 葉俊杰 陳德鴻 許士超 許家豪 楊宏仁 楊美都 鄭隆賓 Treatment strategies and prognosis of hepatocellular carcinoma (HCC) in patients with end - stage renal disease (ESRD) 黃俊銘 葉俊杰 陳德鴻 許士超 許家豪 楊宏仁 楊美都 鄭隆賓 Jyun-Ming Huang, Chun-Chieh Yeh, Te-Hung Chen, Shih-Chao Hsu, Chia-Hao Hsu, Horng-Ren Yang, Mei-Due Yang, L-B Jeng Division of General Surgery, Department of Surgery, China Medical University Hospital 座長，各位醫師大家好。我是中國醫藥大學附設醫院一般外科研究醫師黃俊銘。今天要跟各位報告末期腎病(ESRD)對肝細胞癌治療策略及疾病預後的影響。

USRDS 2016 Annual Data Report Geographic variations in the incidence rate of treated ESRD (per million population/year), by country, 2014 根據美國腎臟資料登錄系統 ( United States Renal Data System, USRDS ) 2016年的報告 ( 2014年登錄資料 )，我們可以看到紅色的區域是ESRD發生率最高的地區，而臺灣也是其中之一。 USRDS 2016 Annual Data Report

High incidence and prevalance 再依國家及地區來看ESRD發生率及盛行率的排名，臺灣皆是位於第一位。 USRDS 2016 Annual Data Report

依據衛生福利部104年十大癌症死因統計，肝癌位列十大癌症死因的第二位。 衛生福利部 104年死因統計結果分析

不管在男性或女性，十大癌症死因的第一位及第二位皆是肺癌及肝癌。 衛生福利部 104年死因統計結果分析

ESRD : risk factor ? affect the treatment strategies and survival outcomes of HCC in Taiwan? ESRD及肝癌皆是臺灣地區盛行的疾病。因此我們想探討ESRD是否會對HCC的治療策略及疾病預後造成影響。

Treatment strategies of HCC Liver transplantation Hepatic resection Radiofrequency ablation (RFA) Percutaneous ethanol injection (PEI) Transarterial chemoembolization (TACE) 目前肝細胞癌的治療方式主要有liver transplantation, hepatic resection, RFA, PEI 以及TACE. 前述四種治療方式屬於Curative treatment，其中hepatic resection 仍是目前的 standard curative management。

ESRD should not be a contraindication of hepatic resection in HCC patients. Comparable overall survival and disease-free survival can be achieved in selected ESRD-HCC patients 這篇文章是長庚醫院比較接受hepatic resection的肝癌患者有無合併ESRD的比較。結論顯示在selected 的ESRD患者接受hepatic resection的overall survival 及disease-free survival並沒有比較差。 1982 to 2001 were retrospectively reviewed; 1224 surgically resected HCC patients, 26 (4.2%) were ESRD-HCC. World J Gastroenterol 2005;11(14):2067-2071

這篇文章同樣是比較有無ESRD的肝癌患者接受hepatic resection的outcome。這篇文章是利用健保資料庫來分析。結果顯示，在其survival outcome並不因有無ESRD而產生差異。 Using Taiwan’s National Health Institute Research Database, 149 uremia-HCC patients who underwent hepatic resection between 1996 and 2008 were enrolled. The control group comprised 596 HCC patients who also received hepatic resection during the same time period. As for perioperative complications, the uremia- HCC cohort had a higher risk of postoperative infections requiring invasive interventions as well as an increased risk of life-threatening heart-associated complications, compared to the HCC cohort. World J Surg (2013) 37:2402–2409

Journal of Gastroenterology and Hepatology 28 (2013) 348–356 Baseline demographics between 30 dialysis versus 2472 non-dialysis patients, and versus 90 matched controls 由前述文章的結果可知，有無ESRD並不影響肝癌患者接受hepatic resection的outcome。 而這篇台北榮總發表在hepatology的文章探討ESRD是否會增加肝癌的mortality。 比較30位肝癌合併ESRD的患者及match control 90位非ESRD的肝癌患者。 Taipei Veterans General Hospital A total of 2502 HCC patients, including 30 dialysis patients and 90 age, sex, and treatment-matched controls were retrospectively analyzed. Match control: gender, treatment modality Journal of Gastroenterology and Hepatology 28 (2013) 348–356

Journal of Gastroenterology and Hepatology 28 (2013) 348–356 兩組患者在治療方式的分佈並無差異。結論也顯示有肝癌合併有ESRD的患者並不會有較差的 long-term survival。 Journal of Gastroenterology and Hepatology 28 (2013) 348–356

Materials and Methods Taiwan National Health Insurance Research Database (NHIRD), HCC diagnosed between 2003 and 2009. ESRD vs Non-ESRD : 560 : 35041 (Total: 35601) 我們同樣是利用健保資料庫，搜尋2003到2009的肝癌患者共35601位。其中ESRD與非ESRD患者分別是560位及35041位。

我們是用1:10的match control. 兩組間control了 性別，年齡以及腫瘤期別。

ESRD vs Non-ESRD No statistically significant differences in economic status, residence area, and treatment strategies Significant difference in variables, including HBV, ACS, CVA, DM, HTN, ESRD and times of abdominal echo. 結果顯示兩組間在經濟狀況，居住區域，以及治療方式上無顯著的差異。 而兩組間在B型肝炎，冠心症，腦血管意外，糖尿病，高血壓，末期腎病以及腹部超音波的檢查次數上有顯著差異。 因此我們可知在臺灣，ESRD並不影響肝癌的治療方式。

Treatent strategies 我們再由不同的腫瘤期別來看，有無ESRD在不同的cancer stage對治療方式的選擇並無影響；但隨著 cancer stage 上升，hepatic resection的比例有下降的趨勢 。

Overall survival

ESRD vs Non-ESRD P value: <0.001

Stage I P value: <0.001 Stage II P value: 0.001 Stage III P value: 0.184 Stage IV P value: 0.974

Overall survival In cancer staging I or II in cancer staging III or IV Non-ESRD > ESRD in cancer staging III or IV No significant difference 在stage I 及 stage II，HCC without ESRD患者的overall survival明顯優於合併ESRD的患者。但在 stage III 及 stage IV兩組間則無顯著差異。因此我們推測隨著肝癌期別上升，ESRD對overall survival的影響逐漸降低，而腫瘤本身的影響則逐漸上升。

Disease-free survival

ESRD vs Non-ESRD P value: 0.014

Stage I P value: 0.064 Stage II P value: 0.130 Stage III P value: 0.462 Stage IV P value: -

Disease-free survival In different cancer staging no significant difference in disease free survivals between both groups ESRD was an independent risk factor for mortality 在不同的癌症期別，ESRD都沒有對disease-free survival產生影響。這顯示對肝癌的治療有相當良好的治療品質。

Conclusion ESRD did not alter clinical decision on treatment options for HCC. Higher comorbid status may account for inferior overall survival outcomes in HCC patients with ESRD. 我們的結果顯示合併ESRD並不影響肝癌的臨床治療策略及疾病預後。顯示臺灣在肝癌治療上的優良品質。 ESRD患者有較高的comorbidity，這可能是影響overall survival的原因。因此對合併ESRD的肝癌患者，我們需要更注重underlying disease的控制。

Thanks for your attention