Primary liver resection and salvage transplantation or primary liver transplantation in patients with single, small hepatocellular carcinoma and preserved liver function: an outcome-oriented decision analysis

Transarterial chemoembolization versus surgery/radiofrequency ablation for recurrent hepatocellular carcinoma with or without microvascular invasion

BACKGROUND/AIMS

Microvascular invasion (MVI) is a well-known prognostic factor of postoperative recurrence and of overall survival (OS) in patients with hepatocellular carcinoma (HCC). We compared the treatment outcomes of transarterial chemoembolization (TACE) and surgery/radiofrequency ablation (RFA) according to the presence of MVI in patients with early or late recurrent HCC that presented as Barcelona Clinical Liver Cancer (BCLC) stage 0 or A after curative resection for HCC.

METHODS

A consecutive 68 patients with recurrent HCC of BCLC stage 0 or A at our institution between 1998 and 2012 were retrospectively enrolled. We compared the outcomes of patients treated by TACE or surgery/RFA. Tumor recurrence after curative resection was classified as early (≤ 12 months) or late (> 12 months) recurrence.

RESULTS

Median tumor size was 1.5 cm (range, 1-10 cm), and 67 (98.5%) had HCCs within the Milan criteria. Median post-retreatment follow-up duration was 27 months (range, 1-109 months). Of the 68 patients, 19 (27.9%) underwent surgery/RFA, 47 (69.1%) TACE, and 2 (2.9%) were lost to follow-up. After retreatment, TACE showed significantly higher OS and recurrence-free survival rates than surgery/RFA in MVI-positive patients (P = 0.03 and P = 0.05, respectively), but not in MVI-negative patients (P = 0.95 and P = 0.98, respectively). In particular, in early recurred MVI-positive patients, TACE had a significantly higher OS rate than surgery/RFA (P = 0.01).

CONCLUSIONS

TACE may be the more effective treatment option for recurrent HCC of BCLC stage 0 or A than surgery/RFA in MVI-positive patients, especially in those that recur early after curative resection.

The postresection alpha-fetoprotein in cirrhotic patients with hepatocellular carcinoma. An independent predictor of outcome

BACKGROUND

The postresection alpha-fetoprotein (AFP) in cirrhotic patients with hepatocellular carcinoma (HCC) may predict overall survival (OS) and recurrence beyond Milan criteria (MC) among the subgroup of initially transplantable patients.

METHODS

All patients with cirrhosis resected for HCC between January 1990 and December 2010 in a single institution and presenting a serum AFP value > 15 ng/ml at diagnosis were included. The postresection AFP was analyzed as a dichotomized variable: normalization (norm + group) or not (norm - group) within the 90-day postresection period.

RESULTS

Among 271 resected patients, 141 patients (52%) had a level of serum AFP ≥ 15 ng/ml at diagnosis. Five-year OS and median survival were 42% and 52 months in group norm + versus 20% and 23 months in the group norm - (P = 0.009). On multivariate analysis, the absence of AFP normalization was an independent factor of poor OS as well as microvascular invasion, and satellites nodules. Among theoretically transplantable patients, independent predictors of recurrence beyond MC were the absence of AFP normalization (risk ratio (RR) 5.02 [1.53-16.34]) and microvascular invasion (RR 4.76 [1.42-15.34]).

CONCLUSION

The postresection AFP has an independent prognostic value. Transplantable patients resected for HCC without 90-day AFP normalization should be discussed for early liver transplantation.

Liver Transplantation for Hepatocellular Carcinoma beyond Milan Criteria: Multidisciplinary Approach to Improve Outcome

The implementation of the Milan criteria (MC) in 1996 has dramatically improved prognosis after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Liver transplantation has, thereby, become the standard therapy for patients with "early-stage" HCC on liver cirrhosis. The MC were consequently adopted by United Network of Organ Sharing (UNOS) and Eurotransplant for prioritization of patients with HCC. Recent advancements in the knowledge about tumor biology, radiographic imaging techniques, locoregional interventional treatments, and immunosuppressive medications have raised a critical discussion, if the MC might be too restrictive and unjustified keeping away many patients from potentially curative LT. Numerous transplant groups have, therefore, increasingly focussed on a stepwise expansion of selection criteria, mainly based on tumor macromorphology, such as size and number of HCC nodules. Against the background of a dramatic shortage of donor organs, however, simple expansion of tumor macromorphology may not be appropriate to create a safe extended criteria system. In contrast, rather the implementation of reliable prognostic parameters of tumor biology into selection process prior to LT is mandatory. Furthermore, a multidisciplinary approach of pre-, peri-, and posttransplant modulating of the tumor and/or the patient has to be established for improving prognosis in this special subset of patients.

Resection and transplantation for hepatocellular carcinoma: factors influencing surgical options

ABSTRACT: 

The management of hepatocellular carcinoma within the Milan criteria and with well-compensated cirrhosis is a topic of debate. Recent surveillance programs in patients with hepatitis C and cirrhosis have allowed some patients to be diagnosed with early, potentially curable, disease via liver resection (LR), liver transplantation (LT) or liver ablation. LT has excellent outcomes with 5–year survival rates >70% for patients within the Milan criteria. However, its utilization is limited by increasing organ shortages. LR is also effective with 5–year survival outcomes between 50–70% and safe in light of advances in surgical technique, preresection optimization and patient selection. Patients with solitary tumors and well-preserved liver function are good candidates for LR, whereas LT is best reserved for patients with compromised liver function and multifocal disease. LT and LR should not be viewed as competing tools but as complementary tools in the current armamentarium to treat early hepatocellular carcinoma.

[Therapy of hepatocellular carcinoma before liver transplantation]

Liver transplantation is the optimal therapy for patients with non-resectable early stage hepatocellular carcinoma (HCC) which is limited to the liver. During the sometimes long waiting period patients usually receive neoadjuvant bridging therapy to avoid tumor progression. The armamentarium of bridging therapies includes local ablative and systemic therapies as well as liver resection. The oncological benefit of neoadjuvant therapy for patients who receive a liver transplantation is unclear; however, bridging therapy keeps patients eligible for transplantation in the formal framework of current allocation rules. Moreover, response to therapy may serve as a surrogate marker for favorable tumor biology and may therefore help to guide the selection process for patients undergoing liver transplantation for HCC.

Salvage liver transplantation for recurrent hepatocellular carcinoma after liver resection: retrospective study of the Milan and Hangzhou criteria

Background

Salvage liver transplantation (SLT) has recently been proposed for recurrent hepatocellular carcinoma after liver resection; however, criteria for candidate assessment in SLT have not been thoroughly evaluated.

Methods and Findings

We retrospectively analyzed outcomes and factors affecting survival of 53 recipients who received SLT in the Liver Transplantation Center, The First Affiliated Hospital of Zhejiang University between 2004 and 2012. Thirty recipients fulfilled the Hangzhou criteria, of which 16 also fulfilled the Milan criteria, while the remaining 23 exceeded both criteria. The 1-year, 3-year and 5-year overall survival rates and tumor-free survival rates were both superior in patients fulfilling Milan or Hangzhou criteria compared with those exceeding the criteria. For recipients outside Milan criteria but within Hangzhou criteria, the 1-year, 3-year overall survival rates were 70.1%, 70.1%, similar to recipients within Milan criteria, with the 1-year, 3-year and 5-year overall survival of 93.8%%, 62.1% and 62.1% (P = 0.586). The tumor-free survival rates were also similar between these two subgroups, with 51.9% and 51.9% vs. 85.6%, 85.6% and 64.2% during the same time interval, respectively (P = 0.054). Cox regression analysis identified Hangzhou criteria (within vs. outside, hazard ratio (HR) 0.376) and diameter of the largest tumor (HR 3.523) to be independent predictors for overall survival. The only predictor for tumor-free survival was diameter of the largest tumor (HR 22.289).

Conclusions

Hangzhou criteria safely expanded the candidate pool and are feasible in assessment of candidates for SLT. This is helpful in donor liver allocation in transplant practice.

Primary surgical resection versus liver transplantation for transplant-eligible hepatocellular carcinoma patients

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of mortality worldwide. Existing studies comparing outcomes after liver transplantation (LT) versus surgical resection among transplant-eligible patients are conflicting.

AIM

The purpose of this study was to compare long-term survival between consecutive transplant-eligible HCC patients treated with resection versus LT.

METHODS

The present retrospective matched case cohort study compares long-term survival outcomes between consecutive transplant-eligible HCC patients treated with resection versus LT using intention-to-treat (ITT) and as-treated models. Resection patients were matched to LT patients by age, sex, and etiology of HCC in a 1:2 ratio.

RESULTS

The study included 171 patients (57 resection and 114 LT). Resection patients had greater post-treatment tumor recurrence (43.9 vs. 12.9 %, p < 0.001) compared to LT patients. In the as-treated model of the pre-model for end stage liver disease (MELD) era, LT patients had significantly better 5-year survival compared to resection patients (100 vs. 69.5 %, p = 0.04), but no difference was seen in the ITT model. In the multivariate Cox proportional hazards model, inclusive of age, sex, ethnicity, tumor stage, and MELD era (pre-MELD vs. post-MELD), treatment with resection was an independent predictor of poorer survival (HR 2.72; 95 % CI, 1.08-6.86).

CONCLUSION

Transplant-eligible HCC patients who received LT had significantly better survival than those treated with resection, suggesting that patients who can successfully remain on LT listing and actually undergo LT have better outcomes.

Suppressing N-Myc downstream regulated gene 1 reactivates senescence signaling and inhibits tumor growth in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most lethal malignancy worldwide with no curative therapies. To discover potentially novel therapeutic targets for HCC, we previously studied the gene expression profiles of HCC patients and identified that significant upregulation of N-Myc downstream regulated gene 1 (NDRG1) is associated with more aggressive phenotypes and poorer overall survival of HCC patients. In this study, we further used a loss-of-function approach (RNA interference) to understand the role of NDRG1 in hepatocarcinogenesis. We found that suppression of NDRG1 significantly impaired HCC cell growth through inducing extensive cellular senescence of HCC cells both in vitro and in vivo, accompanied by cell cycle arrest at the G1 phase. The observed antitumor effects of NDRG1 suppression were correlated with activation of major senescence-associated signaling pathways, such as upregulation of tumor suppressors p53, p21 and p16, and decreased phosphorylated Rb. To obtain further insights into the clinical significance of NDRG1-modulated senescence in HCC patients, immunohistochemistry staining of 92 cases of HCC patients was done. We found that high NDRG1 expression (n = 66) is associated with low p21 (n = 82; P < 0.001) and low p16 (n = 86; P < 0.001) levels. In conclusion, this study demonstrated that NDRG1 is a potential therapeutic target for HCC because its suppression triggers senescence of HCC cells through activating glycogen synthase kinase-3β-p53 pathway, thereby inhibiting tumor progression.

Expression and prognostic value of VEGFR-2, PDGFR-β, and c-Met in advanced hepatocellular carcinoma

BACKGROUND

We explore the clinical and prognostic significance of expression of vascular endothelial growth factor receptor (VEGFR)-2, platelet-derived growth factor receptor (PDGFR)-β, and c-Met in patients with hepatocellular carcinoma (HCC).

METHODS

The expression of VEGFR-2, PDGFR-β, and c-Met were determined by immunohistochemical examination of the tissues of 93 HCC patients. The relationships of these markers with clinicopathological factors and prognosis were then analyzed.

RESULTS

High expression of VEGFR-2, PDGFR-β, and c-Met was found in 86%, 19.4%, and 80.6% of patients, respectively. Expression of VEGFR-2 correlated with gender (P = 0.044), hepatitis B surface antigen positivity (P = 0.024), degree of tumor differentiation (P = 0.023), and hepatic cirrhosis (P = 0.026). Expression of PDGFR-β correlated with alpha-fetoprotein level (P = 0.029), tumor size (P = 0.033), and hepatic cirrhosis (P = 0.023). No significant correlations were identified between expression of c-Met and clinicopathological factors. Expression of PDGFR-β correlated with overall survival (P = 0.046) and expression of c-Met correlated with progression-free survival (P = 0.01).

CONCLUSIONS

We found that in patients with HCC, high expression of VEGFR-2 correlates with chronic hepatitis B virus infection and hepatic cirrhosis. High expression of PDGFR-β is a predictor of poor prognosis. High expression of C-Met may predict therapeutic effectiveness of sorafenib in HCC patients.

Liver transplantation for hepatocellular carcinoma recurrence after liver resection: why deny this chance of cure?

INTRODUCTION

Liver transplantation (LT) after liver resection (LR) for hepatocellular carcinoma (HCC) recurrence may be associated with poor patient long-term results and higher perioperative patient morbidity and mortality. This study focused on short-term and long-term outcomes of LT recipients due to HCC recurrence after LR in a single-institution cohort, and in highly comparable case-matched subgroups.

METHODS

Between 2000 and 2009, 570 consecutive patients with documented HCC underwent LR (n=355, 62.2%) or LT (n=215, 37.8%) at our Institute. The case-matched analysis was between 2 groups: group A1, LT recipients who had already undergone LR (n=26); group B1, LT recipients who had not already undergone LR (n=26).

RESULTS

Patient morbidity was higher in the A1 group in terms of packed red blood cell units transfused, fresh frozen plasma units transfused, median operative time, postoperative bleeding, and postoperative reoperations. No differences were detected in terms of patient mortality, patient survival, and patient recurrence-free survival at the univariate and multivariate analysis.

CONCLUSIONS

Although LT among patients who have already undergone LR is associated with higher risk of patient morbidity, patient long-term survival and recurrence-free survival is not impaired. Therefore, there do not seem to be any valid reasons to deny the chance of LT to patients who have already undergone LR.

Infection with hepatitis C virus is an adverse prognostic factor after liver resection for early-stage hepatocellular carcinoma: implications for the management of hepatocellular carcinoma eligible for liver transplantation

INTRODUCTION

Recent data support liver resection (LR) as first-line approach in patients with preserved liver function who have resectable/transplantable hepatocellular carcinoma (HCC). This study was designed to evaluate the outcome of LR in patients with transplantable HCC.

METHODS

Between 1998 and 2009, 75 patients (65 men, mean age 61 ± 11 years) with HCC eligible for liver transplantation (LT) underwent LR. The underlying hepatic disease was related to hepatitis C (HCV) in 30 (40 %) patients, hepatitis B (HBV) in 15 (20 %) patients, alcohol abuse in 26 patients (36 %) and other in 10 patients (13 %). Fifty-five (73 %) patients had cirrhosis. Intermittent clamping of the hepatic pedicle was used in 41 (55 %) patients. Treatment of recurrence by salvage LT was performed in 6 (8 %) patients.

RESULTS

Operative morbidity and mortality rates were 37 and 5 % respectively. At 1, 3, and 5 years, overall (OS) and disease-free (DFS) survival rates were 81, 69,55 and 56, 31, and 21 %, respectively. On multivariate analysis, HCV infection was the only independent factor associated with decreased OS (p = 0.02). On multivariate analysis, HCV infection (p = 0.05) and intermittent hepatic pedicle clamping (p = 0.003) were associated with decreased DFS. The 1-, 3-, and 5-year OS and DFS rates in patients with HCV-related HCC were 69, 53, 38 and 50, 18, and 9% respectively.

CONCLUSIONS

Overall and disease-free survival after liver resection in patients with HCV-related HCC and preserved liver function is poor. Primary LT should be offered to these patients.

Hepatocellular cancer and liver transplantation: a Western experience

Orthotopic liver transplantation is the preferred treatment option in patients with hepatocellular carcinoma developing in chronic liver disease. Unfortunately, based on classical transplantation criteria (Milan criteria), only a minority of patients with hepatocellular carcinoma are candidate to orthotopic liver transplantation. Major improvements in treatment strategy and surgical technique including the use of neoadjuvant locoregional therapies and progresses of post-transplant immunosuppressive treatment have contributed to safely expand transplantation criteria preserving acceptable surgical morbidity-mortality and good oncologic outcome. Further extension of transplantation criteria may have advantages including an increase in the number of transplant candidates and improvement of the prognosis of the disease and also disadvantages including an increase of surgical morbidity and deterioration of global oncologic outcome of orthotopic liver transplantation in hepatocellular carcinoma. In the future, identification of imaging or molecular prognostic markers could help to better define transplantation criteria.

Hepatocellular carcinoma--resection or transplant?

Resection and liver transplantation are considered effective treatments for early-stage hepatocellular carcinoma (HCC). As data from randomized trials are lacking, the choice of technique is controversial. Retrospective analyses suggest that for patients with suboptimal liver function, transplantation is the preferred treatment. For patients with preserved liver function and HCC within the Milan criteria, the overall survival rate is similar for both techniques; therefore resection is the preferred treatment. For tumours beyond the Milan criteria but within acceptable expanded criteria, transplantation has a more favourable outcome than resection. As liver grafts are in short supply, resection followed by transplantation once intrahepatic recurrence is detected would spare patients with favourable or very aggressive tumours from transplantation and enable patients with moderately aggressive tumours to undergo timely transplantation. Currently, resection and transplantation are considered complementary in the management of HCC. Expanding the transplantation and resection criteria of HCC needs to be investigated.

Salvage liver transplantation for recurrent hepatocellular carcinoma within UCSF criteria after liver resection

Background

Salvage liver transplantation (SLT) is restricted to patients who develop hepatocellular carcinoma (HCC) recurrence within Milan criteria (MC). Little is known about outcomes for SLT in patients with recurrent HCC within University of California San Francisco (UCSF) criteria after liver resection (LR).

Methods

Between January 2001 and December 2011, 380 patients with HCC meeting UCSF criteria, 200 of which were resected (LR group) from a perspective of SLT in case of recurrence, and 180 directly underwent LT (PLT). We compared patient characteristics, perioperative and long-term outcomes between SLT and PLT groups. We also assessed the outcome of LR and PLT groups.

Results

Among the 200 patients in LR group, 86 (43%) developed HCC recurrence and 15/86 (17%) of these patients presented HCC recurrence outside UCSF criteria. Only 39 of the 86 patients underwent SLT, a transplantation rate of 45% of patients with HCC recurrence. Compared with PLT group, LR group showed lower overall survival rate (P = 0.005) and higher recurrence rate (P = 0.006). Although intraoperative blood loss and required blood transfusion were more frequent in SLT group, the perioperative mortality and posttransplant complications were similar in SLT and PLT groups. The overall survival and recurrence rates did not significantly differ between the two groups. When stratifying by graft type in the SLT group, overall survival and recurrence rates did not significantly differ between deceased donor LT (DDLT) and living donor LT (LDLT) groups. In the subgroup analysis by MC, similar results were observed between patients with recurrent HCC meeting MC and patients with recurrent HCC beyond MC but within UCSF criteria.

Conclusion

Our single institution experience demonstrated that prior hepatectomy and SLT for recurrent HCC within UCSF criteria was feasible and SLT could achieve the same outcome as PLT.

Contemporary strategies in the management of hepatocellular carcinoma

Liver transplantation is the treatment of choice for selected patients with hepatocellular carcinoma (HCC) on a background of chronic liver disease. Liver resection or locoregional ablative therapies may be indicated for patients with preserved synthetic function without significant portal hypertension. Milan criteria were introduced to select suitable patients for liver transplant with low risk of tumor recurrence and 5-year survival in excess of 70%. Currently the incidence of HCC is climbing rapidly and in a current climate of organ shortage has led to the re-evaluation of locoregional therapies and resectional surgery to manage the case load. The introduction of biological therapies has had a new dimension to care, adding to the complexities of multidisciplinary team working in the management of HCC. The aim of this paper is to give a brief overview of present day management strategies and decision making.

Recipient outcomes of salvage liver transplantation versus primary liver transplantation: a systematic review and meta-analysis

Salvage liver transplantation (SLT), or liver transplantation after liver resection (LR), has been performed after primary LR for many years. However, the true outcomes and risks of SLT versus primary liver transplantation (PLT) remain unclear. We performed a systematic review and meta-analysis to evaluate the survival rate of SLT recipients and the incidence of postoperative complications. Among 2799 screened references, 7 eligible studies were identified. The results of the meta-analysis indicated no statistically significant differences in the overall survival rates of SLT and PLT: the pooled relative risk (RR) was 0.99 [95% confidence interval (CI) = 0.90-1.09, P = 0.87] at 1 year, 0.97 (95% CI = 0.83-1.13, P = 0.68) at 3 years, and 0.96 (95% CI = 0.81-1.13, P = 0.61) at 5 years. As for postoperative complications, there were no statistically significant differences in the incidence of sepsis and biliary complications between SLT and PLT, but there was a significantly higher incidence of bleeding with SLT (RR = 2.84, 95% CI = 1.57-5.13, P = 0.001). In conclusion, the overall survival associated with SLT is similar to that associated with PLT. Because of the limited organ donor pool, SLT might be an acceptable therapy for patients undergoing primary LR for hepatocellular carcinoma.

Salvage liver transplantation in the treatment of hepatocellular carcinoma: a meta-analysis

AIM

To evaluate survival and recurrence after salvage liver transplantation (SLT) for the treatment of hepatocellular carcinoma (HCC) compared with primary liver transplantation (PLT) using a meta-analysis.

METHODS

Literature on SLT versus PLT for the treatment of HCC published between 1966 and July 2011 was retrieved. A meta-analysis was conducted to estimate pooled survival and disease-free rates. A fixed or random-effect model was established to collect the data.

RESULTS

The differences in overall survival and disease-free survival rates at 1-year, 3-year and 5-year survival rates were not statistically significant between SLT group and PLT group (P > 0.05). After stratifying the various studies by donor source and Milan criteria, we found that: (1) Living donor liver transplantation recipients had significantly higher 1-year survival rate, lower 3-year and 5-year survival rates compared with deceased-donor liver transplantation (DDLT) recipients. And in DDLT recipients they had better 1-year and 5-year disease-free survival rate in SLT group; and (2) No difference was seen in 1-year, 3-year and 5-year survival rates between two groups who beyond Milan criteria at the time of liver transplantation.

CONCLUSION

SLT can be effectively performed for patients with recurrence or deterioration of liver function after hepatectomy for HCC. It does not increase the perioperative mortality and has a similar long-term survival rates compared to PLT.

Is resection equivalent to transplantation for early cirrhotic patients with hepatocellular carcinoma? A meta-analysis

BACKGROUND

Whether liver resection or liver transplantation is optimal therapy for patients with hepatocellular carcinoma (HCC) remains undefined. A meta-analysis was conducted to answer this question.

STUDY DESIGN

This study performed a systematic review of the published literature between January 2000 and April 2012.

RESULTS

Nine retrospective studies, totaling 2,279 patients (989 resected and 1,290 transplanted), met the selection criteria. Older patients with larger tumors and less severe cirrhosis were identified in the resection group. At 1 year, resection demonstrated significantly higher overall [odds ratio (OR) = 1.54; 95 % confidence interval (CI), 1.19-1.98; p = 0.001], but equivalent disease-free survival (OR = 0.93; 95 % CI, 0.53-1.63; p = 0.80). At 5 years, there was no difference in overall survival (OR = 0.86; 95 % CI, 0.61-1.21; p = 0.38), but a higher disease-free survival in transplanted patients was observed (OR = 0.39; 95 % CI, 0.24-0.63; p < 0.001). When limiting our analysis to studies conducted in an intent-to-treat fashion, there was no difference in 5 year overall survival (OR = 1.18; 95 % CI, 0.92-1.51; p = 0.19), but a significantly higher disease-free survival (OR = 0.76; 95 % CI, 0.57-1.00; p = 0.05) in transplanted patients. At 10 years, transplantation had higher overall and disease-free survival rates.

CONCLUSION

Liver transplantation in patients with HCC results in increased late disease-free and overall survival when compared with liver resection. Nonetheless, the benefit of liver transplantation is offset by higher short-term mortality, donor organ availability, and long transplant wait times associated with more patient deaths. Understanding these differences in survival is helpful in guiding treatment. However, a properly controlled prospective trial is needed to define how best to treat HCC patients who are candidates for either therapy.

Liver resection and transplantation in hepatocellular carcinoma

Liver resection is the most available, efficient treatment for patients with hepatocellular carcinoma. Better liver function assessment, increased understanding of segmental liver anatomy using more accurate imaging studies, and surgical technical progress are the most important factors that have led to reduced mortality, with an expected 5 year survival of 70%. Impairment of liver function and the risk of tumor recurrence lead to consideration of liver transplantation (LT) as the ideal treatment for removal of the existing tumor and the preneoplastic underlying liver tissue. However, LT, which is not available in many countries, is restricted to patients with minimum risk of tumor recurrence under immunosuppression. Limited availability of grafts as well as the risk and the cost of the LT procedure has led to considerable interest in combined treatment involving resection and LT. An increasing amount of evidence has shown that initial liver resection in transplantable patients with a single limited tumor and good liver function is a valid indication. Histological analysis of specimens allows identification of the subgroup of patients who could benefit from follow-up with LT in case of recurrence.

Liver transplantation for hepatocellular cancer: UCL experience in 137 adult cirrhotic patients. Alpha-foetoprotein level and locoregional treatment as refined selection criteria

Liver transplantation (LT) is a validated treatment for selected cirrhotics with hepatocellular cancer (HCC). A retrospective single center study including 137 recipients having proven HCC was done to refine inclusion criteria for LT as well as to look at impact of locoregional treatment (LRT) on outcome. At pre-LT imaging, 42 (30.6%) patients were Milan criteria (MC)-OUT; 28 (20.4%) were University of California San Francisco criteria (UCSFC)-OUT. Pre-LT LRT was performed in 109 (79.6%) patients. Multivariate analysis identified four factors to be independently predictive of recurrence: tumour number >3, AFP level ≥400 ng/ml, microvascular invasion and rejection needing anti-lymphocytic antibodies. When considering pre-transplant variables only, AFP level ≥400 ng/ml (HR = 5.13; P < 0.0001) was the unique risk factor for recurrence; conversely, application of LRT was protective (HR = 0.42; P = 0.04). MC-IN patients having LRT (n = 79) had the best 5-year tumour-free survival (TFS) (91.6%). MC-IN patients without LRT (n = 16) and MC-OUT patients with LRT (n = 30) had similar good TFS (72.7% vs.77.5%); finally MC-OUT patients without LRT (n = 12) had the worst results (45.0%; vs. 1st group: P < 0.0001). Immediate pre-LT AFP and aggressive pre-transplant LRT strategy, especially in MC-OUT patients, are both important elements to further expand inclusion criteria without compromising long-term results of HCC liver recipients.

Salvage liver transplantation for patients with recurrent hepatocellular carcinoma after curative resection

Objective

To summarize the experience with salvage liver transplantation (SLT) for patients with recurrent hepatocellular carcinoma (HCC) after primary hepatic resection in a single center.

Methods

A total of 376 adult patients with HCC underwent orthotopic liver transplantation (OLT) at Organ Transplantation Center, the First Affiliated Hospital of Sun Yat-sen University, between 2004 and 2008. Among these patients, 36 underwent SLT after primary liver curative resection due to intrahepatic recurrence. During the same period, one hundred and forty-seven patients with HCC within Milan criteria underwent primary OLT (PLTW group), the intra-operative and post-operative parameters were compared between these two groups. Furthermore, we compared tumor recurrence and patient survival of patients with SLT to 156 patients with HCC beyond Milan criteria (PLTB group). Cox Hazard regression was made to identify the risk factors for tumor recurrence.

Results

The median interval between initial liver resection and SLT was 35 months (1–63 months). The intraoperative blood loss (P<0.05) and transfusion volume (P<0.05) were larger in the SLT group than in the PLTW group. The operation time was longer in the SLT group (P<0.05). The post-operative complications incidence, tumor recurrence rate, patients' survival rate, and tumor-free survival rate were comparable between these two groups (all P>0.05). When compared to those patients with HCC beyond Milan criteria undergoing primary OLT, patients undergoing SLT achieved a better survival and a lower tumor recurrence. Cox Proportional Hazards model showed that vascular invasion, including macrovascular and microvascular invasion, as well as AFP level >400 IU/L were risk factors for tumor recurrence after LT.

Conclusions

In comparison with primary OLT, although SLT is associated with increased operation difficulties, it provides a good option for patients with HCC recurrence after curative resection.

Hepatic resection can provide long-term survival of patients with non-early-stage hepatocellular carcinoma: extending the indication for resection?

BACKGROUND

Indications for resection of non-early-stage hepatocellular carcinoma (HCC) remain controversial. This study aimed to identify factors that affect outcome of patients with Barcelona Clinical Liver Cancer Classification (BCLC) stage B or stage C HCC after hepatic resection.

METHODS

From 1991 to 2006, 478 patients with HCC (BCLC stage B, n = 318 and BCLC stage C, n = 160) who underwent resection were enrolled. Factors in terms of overall survival and recurrence were analyzed.

RESULTS

After a median follow-up of 29.5 months, 304 patients had died. The cumulative overall survival rate at 5 years was 46.5% in BCLC stage B patients and 29.1% in stage C patients (P < .001). Multivariate analysis disclosed that serum albumin levels ≤4 g/dL, indocyanine green retention rate at 15 minutes >10%, serum creatinine >1.2 mg/dL, multinodularity, Edmondson stage III or IV in tumor cell differentiation, and the presence of macroscopic vascular invasion were independent risk factors of poor overall survival. There were 331 patients with tumor recurrence after resection. Recurrence rate was less in BCLC stage B than that in BCLC stage C (P = .001). Multivariate analysis showed that serum albumin level ≤4 g/dL, multinodularity, cut margin ≤1 cm, and Edmondson stage III or IV were associated with the recurrence of HCC.

CONCLUSION

Hepatic resection can provide long-term survival benefit in selected BCLC stage B or C patients with compensated liver function, especially in those presenting with a single neoplasm without vascular invasion.

What is the probability of being too old for salvage transplantation after hepatocellular carcinoma resection?

BACKGROUND

The strategy of salvage transplantation for patients with hepatocellular carcinoma is based on the premise that tumour recurrence will be still transplantable at the time of recurrence. However, patients can not only present non-transplantable recurrence but can also be over the age limit accepted for transplantation.

AIMS

To measure the risk of being too old for salvage transplantation of patients resected for hepatocellular carcinoma within Milan criteria.

METHODS

A Markov simulation model was developed on the basis of published literature.

RESULTS

The risk of being too old for salvage transplantation depends on the time-span between age at hepatic resection and age limit, and the expected median waiting-time. Patients resected at an age 2 or 3 years below the age limit carry a risk of being too old that overcomes the probability of receiving transplantation. Salvage strategy can cause harm that depends on the tumour characteristics and degree of portal hypertension, becoming maximal for patients with multiple tumours, clinical signs of portal hypertension and increased bilirubin levels.

CONCLUSIONS

The best strategy to adopt should be balanced between the risk of being too old and the expected transplant benefit, but salvage strategy could be pursued if it did not turn into significant harm in comparison to primary transplantation.

Current opinion on the role of resection and liver transplantation for hepatocellular cancer

Hepatocellular carcinoma (HCC) represents one of the most common cancers worldwide with rising incidence in developed countries. The best treatment options with curative intent for patients with HCC are liver resection or transplantation, although the role of hepatic ablative therapies has also been recognized. Surgical resection has emerged as the primary treatment in carefully selected patients of HCC. With the advances in surgical and radiological techniques, the perioperative mortality has been reduced to less than 5 % depending on the extent of resection and hepatic reserve. The role of liver transplantation (LT) as the mainstay of treatment for the majority of patients with HCC has evolved in the last few decades. Historically, the Milan criteria have been considered the gold standard for selecting patients; more expanded selection criteria to include those with more advanced tumors have been implemented in recent years. Living donor liver transplantation (LDLT) has emerged as a way to expand the donor pool and has influenced the role of transplantation for HCC, especially in communities with little access to cadaveric transplantation. Salvage transplantation is an alternative option as it allows a window for the biologically less favorable lesions to declare tumor behavior. Salvage transplantation also decreases the burden on transplant resources. Sirolimus, a novel immunosuppressant drug with anti-tumor effect, may have a role in limiting the severity of recurrent disease after transplantation for HCC, and play an important role in the future management of transplant recipients. This article examines the literature on current status of management of HCC.

Survival advantage of primary liver transplantation for hepatocellular carcinoma within the up-to-7 criteria with microvascular invasion

PURPOSE

Microvascular invasion of hepatocellular carcinoma (HCC) is considered a poor prognostic factor of liver resection (LR) and liver transplantation (LT), but its significance for lesions within the up-to-7 criteria is unclear. This study investigated the survival benefit of primary LT against LR for HCC with microvascular invasion and within the up-to-7 criteria.

METHODS

Adult patients who underwent LR or LT as the primary treatment for HCC were included for study. Patients with prior local ablation, neoadjuvant systemic chemotherapy, targeted therapy, positive resection margin, or metastatic spread were excluded.

RESULTS

There were 471 LR patients and 95 LT recipients (70 with living donor, 25 with deceased donor). Seventy-seven (81.1%) LT recipients had HCC within the up-to-7 criteria. Twenty-five (26.3%) LT recipients had HCC with either macrovascular (n = 4) or microvascular (n = 21) invasion. The 5-year survival rate was 85.7% for LT recipients with HCC within the up-to-7 criteria, unaffected by the presence or absence of vascular invasion (88.2 vs. 85.1%). The rate was comparable with that of LR patients with HCC without vascular invasion (81.2%, p 0.227), but far superior to that of LR patients with lesions with vascular invasion (50.0%, p < 0.0001). Overall survivals were compromised by multiple tumors [odds ratio (OR) 1.902, confidence interval (CI) 1.374-2.633, p = 0.0001], vascular invasion (OR 2.678, CI 1.952-3.674, p < 0.0001), blood transfusion (OR 2.046, CI 1.337-3.131, p = 0.001), and being beyond the up-to-7 criteria (OR 1.457, CI 1.041-2.037, p = 0.028). LT was a favorable factor for survival (OR 0.243, CI 0.130-0.454, p < 0.0001).

CONCLUSION

Primary LT for HCC with microvascular invasion and within the up-to-7 criteria doubled the chance of cure as compared with LR.

Salvage liver transplantation in the treatment of hepatocellular carcinoma: A Meta-analysis

AIM: To evaluate survival and recurrence after salvage liver transplantation (SLT) for the treatment of hepatocellular carcinoma (HCC) compared with primary liver transplantation (PLT) using a meta-analysis.

METHODS: Literature on SLT versus PLT for the treatment of HCC published between 1966 and July 2011 was retrieved. A meta-analysis was conducted to estimate pooled survival and disease-free rates. A fixed or random-effect model was established to collect the data.

RESULTS: The differences in overall survival and disease-free survival rates at 1-year, 3-year and 5-year survival rates were not statistically significant between SLT group and PLT group (P > 0.05). After stratifying the various studies by donor source and Milan criteria, we found that: (1) Living donor liver transplantation recipients had significantly higher 1-year survival rate, lower 3-year and 5-year survival rates compared with deceased-donor liver transplantation (DDLT) recipients. And in DDLT recipients they had better 1-year and 5-year disease-free survival rate in SLT group; and (2) No difference was seen in 1-year, 3-year and 5-year survival rates between two groups who beyond Milan criteria at the time of liver transplantation.

CONCLUSION: SLT can be effectively performed for patients with recurrence or deterioration of liver function after hepatectomy for HCC. It does not increase the perioperative mortality and has a similar long-term survival rates compared to PLT.

Hepatic resection for transplantable hepatocellular carcinoma for patients within Milan and UCSF criteria

BACKGROUND

Liver transplantation is believed to be the best treatment option for selected patients with hepatocellular carcinoma (HCC). However, the shortage of organs and the risk of tumor progression while on the waiting list has hampered this effective treatment modality from being routinely offered. Hence, the second option of hepatic resection must be considered. The aim of this study is to report the results of hepatic resection in transplantable patients.

METHODS

From 1991 to 2009, 97 patients underwent liver resection for HCC. Thirty patients (31%) met transplant criteria [(Milan/University of California San Francisco (UCSF) Liver Transplant Criteria]. Outcomes after hepatic resection were evaluated with disease-free survival (DFS) and overall survival as the endpoints by stratification of transplant eligibility.

RESULTS

There were 30 patients within the UCSF transplant criteria and 16 patients within the Milan transplant criteria. By using either transplant criteria, patients survived an actuarial median survival of 102 months. Patients selected based on the Milan criteria had a median DFS of 55 months and patients selected based on the UCSF criteria had a median DFS of 42 months. Patients who were Child Pugh B (UCSF criteria P<0.001) and with cirrhosis had a poorer outcome after hepatic resection (UCSF criteria P=0.011, Milan criteria P=0.002).

CONCLUSIONS

Long-term DFS and overall survival may be achieved through hepatic resection for transplantable HCC. This is an effective option and may be regarded as a first-line treatment option. Patients with Child Pugh B or are cirrhotics may benefit more from a transplantation than a resection.

Salvage liver transplantation is a reasonable option for selected patients who have recurrent hepatocellular carcinoma after liver resection

Background

Salvage liver transplantation (SLT) has been reported as being feasible for patients who develop recurrent hepatocellular carcinoma (HCC) after primary liver resection, but this finding remains controversial. We retrospectively studied the clinical characteristics of SLT recipients and conducted a comparison between SLT recipients and primary liver transplantation (PLT) recipients.

Methodology and Principal Findings

A retrospective study examined data from the China Liver Transplant Registry (CLTR) for 6,975 transplants performed from January 1999 to December 2009. A total of 6,087 patients underwent PLT and 888 patients underwent SLT for recurrence. Living donor liver transplantation (LDLT) was performed in 389 patients, while 6,586 patients underwent deceased donor liver transplantation (DDLT). Kaplan-Meier curves were used to compare survival rates. The 1-year, 3-year, and 5-year overall survival of SLT recipients was similar to that of PLT recipients: 73.00%, 51.77%, and 45.84% vs. 74.49%, 55.10%, and 48.81%, respectively (P = 0.260). The 1-year, 3-year and 5-year disease-free survival of SLT recipients was inferior to that of PLT recipients: 64.79%, 45.57%, and 37.78% vs. 66.39%, 50.39%, and 43.50%, respectively (P = 0.048). Similar survival results were observed for SLT and PLT within both the LDLT and DDLT recipients. Within the SLT group, the 1-year, 3-year, and 5-year overall survival for LDLT and DDLT recipients was similar: 93.33%, 74.67%, and 74.67% vs. 80.13%, 62.10%, and 54.18% (P = 0.281), as was the disease-free survival: 84.85%, 62.85%, and 62.85% vs. 70.54%, 53.94%, and 43.57% (P = 0.462).

Conclusions

Our study demonstrates that for selected patients, SLT has similar survival to that of PLT, indicating that SLT is acceptable for patients with recurrent HCC after liver resection. Given the limited organ donor pool, salvage LDLT might be considered as a possible treatment.

Poor Prognostic Factors after Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma in the Modern Era

The purpose of this study was to determine the poor prognostic factors after repeat hepatectomy (Hx) in patients with recurrent hepatocellular carcinoma (HCC). Overall survival rates and clinicopathological variables in 112 patients with repeat Hx from 1992 to 2010 were compared with those in 531 patients who underwent a primary Hx. To clarify the poor prognosis factors after repeat Hx, survival data among 112 patients were univariately and multivariately analyzed. Overall survival after repeat Hx was similar for that of the patients who underwent a primary Hx. The mean age of repeat Hx group was significantly higher, and a well-preserved liver function was recognized than the primary Hx group. Multivariate analysis revealed that: 1) indocyanine green retention rate at 15 minutes; 2) disease-free interval; 3) tumor size; 4) portal vein invasion at primary Hx; 5) gender; and 6) estimated blood loss to be an independent and significant poor prognostic factors. The overall 3-year postrecurrence overall survival rates were 100, 91.3, 59.6, and 0 per cent at risk number (R) R0, R1/2, R3, R4, respectively ( P < 0.05). Repeat Hx provided a good compatible prognosis with primary Hx. In our findings, five risk factors to predict poor outcomes after repeat Hx were useful. Patients with recurrent HCC do not have universally poor outcomes, and our simple scoring system using five poor prognostic factors could serve to advise the prognosis and the potential benefit for patient selection about repeat Hx.

Cost-effectiveness analysis on the surveillance for hepatocellular carcinoma in liver cirrhosis patients using contrast-enhanced ultrasonography

AIM

  Sonazoid is a new contrast agent for ultrasonography (US). Contrast-enhanced ultrasonography (CEUS) using Sonazoid enables Kupffer imaging, which improves the sensitivity of hepatocellular carcinoma (HCC) detection. However, there are no studies on the cost-effectiveness of HCC surveillance using Sonazoid.

METHODS

  We constructed a Markov model simulating the natural history of HCV-related liver cirrhosis (LC) patients, and compared three strategies (no surveillance, US surveillance and CEUS surveillance). The transition probability and cost data were obtained from published data. The simulation and analysis were performed using TreeAge pro 2009 software.

RESULTS

  When compared to the no surveillance group, the US and CEUS surveillance groups increased the life expectancy by 1.67 and 1.99 quality-adjusted life-years (QALY), respectively, and the incremental cost effectiveness ratio (ICER) were 17 296 $US/QALY and 18 384 $US/QALY, respectively. These results were both less than the commonly-accepted threshold of $US 50 000/QALY. Even if the CEUS surveillance group was compared with the US surveillance group, the ICER was $US 24 250 and thus cost-effective. Sensitivity analysis showed that the annual incidence of HCC and CEUS sensitivity were two critical parameters. However, when the annual incidence of HCC is more than 2% and/or the CEUS sensitivity is more than 80%, the ICER was also cost-effective.

CONCLUSIONS

  Contrast-enhanced ultrasonography surveillance for HCC is a cost-effective strategy for LC patients and gains their longest additional life years, with similar degree of ICER in the US surveillance group. CEUS surveillance using Sonazoid is expected to be used not only in Japan, but also world-wide.

Surgical management of hepatocellular carcinoma

Hepatocellular carcinoma is the sixth most common cancer worldwide and its incidence is rising in Western countries. Liver resection is the treatment of choice in noncirrhotic patients and in cirrhotic patients with well-preserved liver function. Postresection survival rates are in the range of 41-74% at 5 years. Predictors of recurrence include tumor grade, vascular invasion, tumor size, number of tumors, presence of satellites, alpha-fetoprotein level, transfusion, and positive surgical margin. Second hepatic resection for recurrent hepatocellular carcinoma is applicable in about 15% of patients with recurrence. Liver transplantation has become an important element of the therapeutic strategy for hepatocellular carcinoma. Liver transplantation provides excellent outcomes applying the Milan criteria with 5-year survival rates of 70% and low recurrence rates. Intention-to-treat analysis has shown that wide extended indications lead to 25% 5-year survival rates. Expansion of indications beyond the Milan Criteria and use of bridging/downstaging procedures, to convert intermediate advanced stages of hepatocellular cancer within the Milan criteria limits, are counterbalanced by graft shortage and increasing use of marginal donors. Living donor transplantation is an alternative that can eliminate the waiting time and the attendant risk of drop-out.

Benefit of initial resection of hepatocellular carcinoma followed by transplantation in case of recurrence: an intention-to-treat analysis

Liver resection (LR) for hepatocellular carcinoma (HCC) as the first-line treatment in transplantable patients followed by "salvage transplantation" (ST) in case of recurrence is an attractive concept. The aim was to identify patients who gain benefit from this approach in an intention-to-treat study. From 1998 to 2008, among 329 potential candidates for liver transplantation (LT) with HCC within the Milan criteria (MC), 138 with good liver function were resected (LR group) from a perspective of ST in case of recurrence, and 191 were listed for LT first (LT group). The two groups were compared on an intention-to-treat basis with special reference to management of recurrences and transplantability after LR. Univariate and multivariate analyses were performed to identify resected patients who developed recurrence beyond MC. Five-year overall and disease-free survival was similar in both groups: LT versus LR group, 60% versus 77% and 56% versus 40%, respectively. Among the 138 patients in the LR group, 20 underwent LT before recurrence, 39 (28%) had ST, and 51 (37%) with recurrence were not transplanted including 21 within MC who were excluded for advanced age, acquired comorbidities, or refusal and 30 (22%) with recurrence beyond MC. Predictive factors for nontransplantability due to recurrence beyond MC included microscopic vascular invasion (hazard ratio [HR] 2.38 [range, 1.10-7.29]), satellite nodules (HR 2.46 [range, 1.01-6.68]), tumor size > 3 cm (HR 1.34 [range, 1.03-3.12]), poorly differentiated tumor (HR 3.18 [range, 1.31-7.70]), and liver cirrhosis (HR 1.90 [range, 1.04-3.12]).

CONCLUSION

The high risk of failure of ST after initial LR for HCC within MC suggests the use of tissue analysis as a selection criterion. The salvage LT strategy should be restricted to patients with favorable oncological factors.

Survival after radiofrequency ablation and salvage transplantation in patients with hepatocellular carcinoma and Child-Pugh A cirrhosis

BACKGROUND & AIMS

In patients with hepatocellular carcinoma (HCC) within the Milan criteria, liver transplantation (LT) may be the best therapeutic option. However, the shortage of grafts, leads to attempt liver resection (LR) or radiofrequency ablation (RFA) as a first-line treatment for patients with Child-Pugh A cirrhosis.

METHODS

We report results, obtained between 2000 and 2007 from a single center, involving 67 patients (mean age: 57 years) eligible for LT, who were treated with RFA, followed by LT if there was recurrence or liver failure.

RESULTS

Eighty three tumors were treated (mean size: 29±9 mm; 16 binodular forms). RFA achieved complete ablation in 96% of nodules. No mortality occurred. During a post-RFA median follow-up of 48 months, 38 patients experienced recurrence, corresponding to a 5-year recurrence rate of 58%. Of these, 14 patients did not receive a transplant because they fell outside the Milan criteria, 21 were transplanted, and 3 were treated by RFA after refusing LT. Binodularity (95% CI HR=2, 1.0-4.0; p=0.049) was the unique risk factor for recurrence. By the study's end-point, 24 patients had undergone LT (21 for HCC recurrence and three for liver failure). No HCC recurrence occurred after LT. Among the 43 non-transplant patients, 12 died due to HCC progression, and 27 were alive without detectable viable tumor. The probability rates for 5-year overall and tumor-free survival were 74% and 69%, respectively.

CONCLUSIONS

First line RFA followed by salvage LT allows survival figures that are at least as good as a first-line LT, while limiting the number of grafts.

Toward optimizing the indications for orthotopic liver transplantation in hepatocellular carcinoma

1. Liver transplantation is currently an effective therapy for patients with HCC who meet the Milan criteria. 2. The proportion of patients on waiting lists for liver transplantation who have HCC has increased substantially in recent years. HCC is currently one of the major indications for liver transplantation; it is the indication for approximately one-third of liver transplants. 3. If the Milan criteria are not met, the survival rates after liver transplantation for HCC tend to decrease, mainly because of the catastrophic consequences of HCC recurrence. 4. A few studies have supported liver transplantation when the Milan criteria are exceeded, but extensions beyond the Milan criteria remain controversial. Even if an individual patient with HCC who does not meet the Milan criteria might benefit from liver transplantation, the limited number of currently available donor organs limits the indications for liver transplantation to those patients with HCC who have the greatest likelihood of survival after the procedure. 5. To patients with early-stage HCC, surgical resection can be offered if the hepatocellular function is well maintained and severe portal hypertension is not present. 6. To enable patients with HCC to have access to liver transplantation that is similar to the access for other patients without HCC in the MELD allocation system, additional points based on the number and size of HCC lesions are assigned to patients on the waiting list. However, this system requires further refinement to ensure that it is as fair as possible. 7. Liver transplantation for HCC should be restricted to those patients who are expected to have the same posttransplant survival as that of patients with nonneoplastic end-stage chronic liver disease. 8. On the basis of these considerations, a 5-year survival rate of 50% after liver transplantation for HCC seems too low.

Comparison between observed survival after resection of transplantable hepatocellular carcinoma and predicted survival after listing through a Markov model simulation

There is still some debate on whether hepatic resection or liver transplantation should be the initial treatment for hepatocellular carcinoma (HCC) in compensated cirrhosis. Clinical data and observed survivals of 150 transplantable patients (within Milan criteria) resected for HCC were reviewed and their predicted survival after listing for liver transplantation was calculated using a Markov model simulation. Differences between observed and predicted survival estimates were explored by standardized differences (d). The mean observed survival within 5 years after surgery was 45.35 months, and the predicted survival after listing was 49.18 months (d = 0.265). The largest gain in life-expectancy with liver transplantation would be obtained in patients with Model for End-stage Liver Disease (MELD) score >9 (d = 0.403); conversely, observed and predicted survivals were similar in HCV+ patients (d = -0.002) and in patients with MELD ≤9 (d = -0.057). For T1 tumors, the observed mean estimate of survival after hepatic resection was higher than that predicted by the simulation (d = -0.606). In conclusion, in HCV patients and in those with very well compensated cirrhosis, hepatic resection could lead to results similar to those of transplantation strategy for HCC within Milan criteria; HCC T1 patients are probably best served by resection as first-line therapy rather than listing for transplantation.

Early Hepatocellular Carcinoma: Transplantation versus Resection: The Case for Liver Resection

The optimal surgical treatment of hepatocellular carcinoma on well-compensated cirrhosis is controversial. Advocates of liver transplantation cite better long-term survival, lower risk of recurrence, and the ability of transplantation to treat both the HCC and the underlying liver cirrhosis. Transplantation, however, is not universally available to all appropriate-risk candidates because of a lack of sufficient organ donors and in addition suffers from the disadvantages of requiring a more complex pre- and postoperative management associated with risks of inaccessibility, noncompliance, and late complications. Resection, by contrast, is much more easily and widely available, avoids many of those risks, is by many accounts as effective at achieving similar long-term survival, and still allows for safe, subsequent liver transplantation in cases of recurrence. Here, arguments are made in favor of resection being easier, safer, simpler, and comparably effective in the treatment of HCC relative to transplantation, and therefore being the optimal initial treatment in cases of hepatocellular carcinoma on well-compensated cirrhosis.

Comparison of survival rates between patients treated with transcatheter arterial chemoembolization and hepatic resection for solitary hepatocellular carcinoma

The present study aimed to retrospectively compare the survival rates between patients treated with transcatheter arterial chemoembolization and hepatic resection for solitary hepatocellular carcinoma (HCC). According to our database, derived from three affiliated hospitals, the inclusion criteria for this study were: solitary HCC [Child-Pugh class A and International Union Against Cancer (UICC) stage T1-3N0M0] treated between July 1990 and October 2001. Subsequently, hepatic resection (149 patients) as well as chemoembolization (102 patients) groups were selected. Following stratification according to tumor stage [UICC, Cancer of the Liver Italian Program (CLIP) and Milan criteria], survival rates were compared between the treatment groups. Survival rates were calculated using the Kaplan-Meier method. Age, gender and size of the HCC did not differ significantly between the groups. Moreover, no significant difference in the survival rates (average hepatic resection, 58.9 months; average chemoembolization, 45 months; P=0.1697) was observed between the groups. In the subgroup analysis, according to tumor stage, the survival rate was significantly higher for the hepatic resection group than for the chemoembolization group in the UICC T3N0M0 (P=0.017) subgroup. However, no significant differences in survival rates were observed between the hepatic resection and chemoembolization groups for UICC T1 (P=0.7329), T2N0M0 (P=0.5741), CLIP0 (P=0.3593), CLIP1-2 (P=0.3287) and within (>5 cm; P=0.4429) and beyond Milan criteria (≤5 cm; P=0.4003) subgroups. Chemoembolization is as effective as hepatic resection in treating solitary HCC in subpopulations with UICC T1-2N0M0 or CLIP 0-2 HCC or Milan criteria and adequate liver function. In the subgroup with UICC T3N0M0 HCC, hepatic resection is superior to chemoembolization.

The survival benefit of liver transplantation in hepatocellular carcinoma patients

BACKGROUND

There are no studies evaluating the survival benefit of liver transplantation over alternative therapies for patients with hepatocellular carcinoma.

METHODS

The short- to mid-term survival benefit (study group=135 aggressively treated patients with hepatocellular carcinoma, 52% beyond Milan criteria at pathology) was calculated by comparing the mortality rates of liver transplantation vs alternative therapies patients. A Markov prediction model was then created to estimate the long-term survival benefit of liver transplantation (gain in life expectancy) over alternative therapies. The long-term survival rates in the liver transplantation group were calculated using the Metroticket website calculator (http://89.96.76.14/metroticket/calculator/).

RESULTS

The short- to mid-term analysis indicated that liver transplantation afforded no significant survival benefit in the group of patients with hepatoma as a whole (hazard ratio=1.229, 95% confidence interval 0.544-2.773, p=.6200). The benefit was concentrated in patients with a poor initial response to alternative therapies (hazard ratio=3.137, 95% confidence interval 1.428-6.891, p=.0044). In the long-term analysis, the gain in life expectancy of liver transplantation vs alternative therapies was 6.115 years (base-case analysis) and the main determinants of gain in life expectancy were the 5-year survival prospects after alternative therapies and the patient's age.

CONCLUSIONS

The survival benefit of liver transplantation for patients with hepatocellular carcinoma is strongly related to the patient's age and the effectiveness of available alternative therapies.

Surgical treatment for early hepatocellular carcinoma: comparison of resection and liver transplantation

PURPOSE

The optimum strategy, hepatic resection (HR) or liver transplantation (LT), for treatment of early hepatocellular carcinoma (HCC) associated with liver diseases of Child-Pugh A is far from established. The aim of this study was to compare and determine which strategy is optimal for HCC fulfilling the Milan criteria.

METHODS

Consecutive data were collected in 1,018 HCC patients treated with HR and 89 HCC patients listed for LT (1 drop out for HCC progression) between January of 2003 and December of 2007.

RESULTS

The independent prognostic factors identified by multivariate analysis were tumor size-plus-number, microscopic venous invasion, and operation type (LT or HR). When tumor size-plus-number was < or =4 or microscopic venous invasion was absent, there was no significant difference in overall survival (OS) between the LT and HR group. When tumor size-plus-number was >4 or microscopic venous invasion was present, OS was higher in the LT group.

CONCLUSIONS

Since the pathological microscopic venous invasion was not easily available before operation which is limitation for widespread clinical use, thus in practice, we concluded that, for early HCC associated with Child-Pugh A cirrhosis, when tumor size-plus-number is >4, LT provides the best cure; when it is < or =4, HR remains the initial treatment of choice.

Response to therapy as a criterion for awarding priority to patients with hepatocellular carcinoma awaiting liver transplantation

BACKGROUND

How to prioritize patients with hepatocellular carcinoma (HCC) for liver transplantation (LT) remains controversial. This study was designed to assess the effectiveness of a policy for prioritizing HCC patients according to their response to pre-LT therapy.

METHODS

The study period was from 2000 to 2008. Dropout criteria included macroscopic vascular invasion, metastases, and poorly differentiated grade at pre-LT biopsy. A specific treatment algorithm was adopted to treat HCC before LT, and the effect of treatment was evaluated 3 months after listing or after the diagnosis of HCC for patients diagnosed while already on the waiting list. Patients were divided into two groups: group 1, patients with disease that completely or partially responded to therapy; and group 2, patients with stable, progressive, or untreatable disease. Group 2 patients were prioritized for LT unless full restaging and repeat biopsy identified dropout criteria.

RESULTS

At the 3-month visit, 62 HCC patients (42%) were assigned to group 2 and 85 (58%) to group 1. Eleven of 12 dropouts due to tumor progression came from group 2 (P < 0.01). Response to therapy was the sole predictor of dropout probability, independent of tumor stage (competing risk analysis). The 42 patients in group 2 who were transplanted had much the same 3-year post-LT survival rate as the 57 transplanted patients in group 1 (with survival rates of 82% and 83%, respectively; P > 0.05), but a slightly higher risk of post-LT HCC recurrence (13% and 2%, respectively; P = 0.04).

CONCLUSIONS

Response to therapy is a potentially effective tool for prioritizing HCC patients for LT.

Current approach to hepatocellular carcinoma

Hepatocellular carcinoma (HCC) accounts for 80% of all primary liver cancers and ranks globally as the fourth leading cause of cancer-related death. Partial hepatectomy remains the best treatment option for select patients with HCC without cirrhosis. Liver transplantation is well established as the gold standard for patients with HCC and cirrhosis in the absence of extrahepatic spread and macrovascular invasion. Local regional therapy is indicated in select patients who are not surgical candidates, and its role as adjuvant therapy remains to be clarified by prospective studies.

The challenges of liver transplantation for hepatocellular carcinoma on cirrhosis

Hepatocellular carcinoma (HCC) is a major cause of cancer mortality worldwide and liver transplantation (LT) has potentials to improve survival for patients with HCC. However, expansion of indications beyond Milan Criteria (MC) and use of bridging/downstaging procedures to convert intermediate-advanced stages of HCC within MC limits are counterbalanced by graft shortage and increasing use of marginal donors, partially limited by the use of donor-division protocols applied to the cadaveric and living-donor settings. Several challenges in technique, indications, pre-LT treatments and prioritization policies of patients on the waiting list have to be precised through prospective investigations that have to include individualization of prognosis, biological variables and pathology surrogates as stratification criteria. Also, liver resection has to be rejuvenated in the general algorithm of HCC treatment in the light of salvage transplantation strategies, while benefit of LT for HCC should be determined through newly designed composite scores that are able to capture both efficiency and equity endpoints. Innovative treatments such as radioembolization for HCC associated with portal vein thrombosis and molecular targeted compounds are likely to influence future strategies. Accepting this challenge has been part of the history of LT and will endure so also for the future.

Harm and benefits of primary liver resection and salvage transplantation for hepatocellular carcinoma

Primary transplantation offers longer life-expectancy in comparison to hepatic resection (HR) for hepatocellular carcinoma (HCC) followed by salvage transplantation; however, livers not used for primary transplantation can be reallocated to the remaining waiting-list patients, thus, the harm caused to resected patients could be balanced, or outweighed, by the benefit obtained from reallocation of livers originating from HCC patients first being resected. A Markov model was developed to investigate this issue based on literature data or estimated from the United Network for Organ Sharing database. Markov model shows that primary transplantation offers longer life-expectancy in comparison to HR and salvage transplantation if 5-year posttransplant survival remains higher than 60%. The balance between the harm for resected patients and the benefit for the remaining waiting list depends on (a) the proportion of HCC candidates, (b) the percentage shifted to HR and (c) the median expected time-to-transplant. Faced with a low proportion of HCC candidates, the harm caused to resected patients was higher than the benefit that could be obtained for the waiting-list population from re-allocation of extra livers. An increased proportion of HCC candidates and/or an increased median time-to-transplant could lead to a benefit for waiting-list patients that outweighs this harm.

[Practice guidelines for management of hepatocellular carcinoma 2009]

Hepatocellular carcinoma (HCC) is a major cancer in Korea, typically has a poor prognosis, and constitutes the majority of primary hepatic malignancies. It is the number one cause of death among people in their 50s in Korea. The five-year survival rate of liver cancer is poor; at 18.9%. Efforts to increase the survival rate through early diagnosis of HCC and optimal treatments are keenly needed. Western guideline for the management of HCC were developed, but these guidelines are somewhat unsuitable for Korean patients. Thus, the Korean Liver Cancer Study Group (KLCSG) and the National Cancer Center (NCC), Korea jointly produced the Clinical Practice Guidelines for HCC for the first time in Korea in 2003. Owing to medical advances over the following six years, diagnosis and treatment of HCC has changed considerably. As more national and foreign data are accumulated, KLCSG and NCC, Korea recently revised the Clinical Practice Guidelines for HCC. Forty or more specialists in the field of hepatology, general surgery, radiology and radiation oncology participated, and meticulously reviewed national and foreign papers, and collected opinions through advisory committee conferences. These multidisciplinary, evidence-based guidelines summarized diagnosis, surgical resection, liver transplantation, local treatments, transarterial chemoembolization, radiation therapy, chemotherapy, preemptive antiviral treatments, and response evaluation of HCC. These Korean guidelines are expected to be useful for clinical management of and research on HCC.

Liver transplantation versus liver resection for the treatment of hepatocellular carcinoma

PURPOSE

Liver resection (LR) and liver transplantation (LT) are considered the only two potentially curative treatments for hepatocellular carcinoma (HCC). Recently, there has been an intense debate as to whether LR or LT is the optimal initial treatment for patients with Child A or B cirrhosis. The aim of this study was to compare the results of LR and LT in patients with HCC and with Child A or B cirrhosis in a single center over a 10-year period.

METHOD

Seventy-eight patients were treated with LT and 130 were treated with LR. We evaluated patient characteristics, short-term results such as hospital stay, postoperative complication, mortality, and long-term results such as overall and recurrence-free survival and recurrence.

RESULTS

The hospital stay of the LT group was significantly longer than that of the LR group (P < 0.001). The postoperative complication rate and the early operative mortality rate were similar between the two groups. The overall survival rate was higher after LT than it was after LR, but not to a statistically significant degree (P = 0.267). The recurrence-free survival rate was significantly higher after LT than it was after LR (P = 0.002). Within and beyond the Milan criteria, the overall survival rate was higher after LT than it was after LR, but not to a statistically significant degree. The recurrence-free survival rate was significantly higher after LT than it was after LR in the patients within Milan criteria (P < 0.001). HCC recurred more frequently after resection (51.5%) than it did after transplantation (29.5%) (P < 0.001), and HCC recurrence developed in the liver more frequently after LR than it did after LT (P = 0.002). However, after recurrence, LR had better survival than LT did, but not to a statistically significant degree (P = 0.177).

CONCLUSION

LT should be considered as the primary treatment in patients with HCC within the Milan criteria. LR is recommended for patients with HCC beyond the Milan criteria. The LT group showed a significantly lower recurrence rate than the LR group. However, in the case of recurrence, the LT group showed a poorer long-term outcome than the LR group.