Purpose: This study was designed to elucidate the various new classifications and the use of LDLT and bridging therapy for HCC in this context beyond the Milan criteria (MC). Methods: The clinical data of patients with HCC outside the MC who underwent LT at Jena University between January 2007 and August 2023 were retrospectively analysed. Eligible patients were classified according to various classification systems. Clinicopathological features, overall and disease-free survival rates were compared between LT and LDLT within the context of bridging therapy. The Results: Among the 245 patients analysed, 120 patients did not meet the MC, and 125 patients met the MC. Moreover, there were comparable overall survival rates between patients outside the MC for LT versus LDLT (OS 44.3 months vs. 28.3 months; 5-year survival, 56.4% vs. 40%;p= 0.84). G3 tumour differentiation, the presence of angioinvasion and lack of bridging were statistically significant risk factors for tumour recurrence according to univariate and multivariate analyses (HR 6.34;p= 0.0002; HR 8.21;p< 0.0001; HR 7.50;p= 0.0001). Bridging therapy before transplantation provided a significant survival advantage regardless of the transplant procedure (OS:p= 0.008; DFS:p< 0.001). Conclusions: Patients with HCC outside the MC who underwent LT or LDLT had worse outcomes compared to those of patients who met the MC but still had a survival advantage compared to patients without transplantation. Nevertheless, such patients remain disadvantaged on the waiting list, which is why LDLT represents a safe alternative to LT and should be considered in bridged HCC patients because of differences in tumour differentiation, size and tumour marker dynamics.
目的：本研究旨在阐明超出米兰标准（MC）的肝细胞癌（HCC）患者中，活体肝移植（LDLT）及桥接治疗的各种新分类及其应用。方法：回顾性分析了2007年1月至2023年8月期间在耶拿大学接受肝移植（LT）的超出米兰标准的HCC患者的临床资料。根据不同的分类系统对符合条件的患者进行分类。在桥接治疗的背景下，比较了肝移植与活体肝移植患者的临床病理特征、总生存率和无病生存率。结果：在分析的245例患者中，120例患者不符合米兰标准，125例患者符合米兰标准。此外，超出米兰标准接受肝移植与活体肝移植的患者总生存率相当（OS 44.3个月 vs. 28.3个月；5年生存率，56.4% vs. 40%；p=0.84）。根据单变量和多变量分析，G3级肿瘤分化、血管侵犯的存在以及缺乏桥接治疗是肿瘤复发的统计学显著危险因素（HR 6.34；p=0.0002；HR 8.21；p<0.0001；HR 7.50；p=0.0001）。无论采用何种移植手术，移植前的桥接治疗均提供了显著的生存优势（OS：p=0.008；DFS：p<0.001）。结论：与符合米兰标准的患者相比，超出米兰标准接受肝移植或活体肝移植的HCC患者预后较差，但与未接受移植的患者相比仍具有生存优势。然而，此类患者在等待名单上仍处于不利地位，因此活体肝移植是肝移植的安全替代方案，并且由于肿瘤分化、大小和肿瘤标志物动态的差异，应在接受桥接治疗的HCC患者中予以考虑。
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