Predictors of Outcome of Living Donor Liver Transplantation for Hepatocellular Carcinoma

Current role and perspectives of living donor liver transplantation for hepatocellular carcinoma: systematic review of the past 20 years

Hepatocellular carcinoma (HCC) poses a significant global health challenge, and liver transplantation (LT) remains the best curative option. Living donor liver transplantation (LDLT) emerged as a potential solution to organ scarcity, reducing waitlist times. This comprehensive review explores LDLT practices, focusing on patient selection criteria and oncologic outcomes. A systematic review following PRISMA guidelines included 50 studies (2004-2023) with 8062 patients. Data encompassed baseline characteristics, HCC features, and oncologic outcomes. Further analysis categorized results by geography and publication year. Heterogeneity in patient demographics, tumor burden, and transplant characteristics was observed. Recent LDLT series demonstrated a shift towards refined selection criteria, increased neoadjuvant treatment, and improved oncologic outcomes. Geographic disparities revealed unique challenges in Eastern and Western practices. LDLT proves effective for HCC, addressing donor shortages. Evolving practices highlight the importance of refining inclusion criteria and optimizing tumor management. While geographic differences exist, LDLT, when judiciously applied, offers promising outcomes.

Successful use of venous graft from native liver with hepatocellular carcinoma during living donor liver transplantation with no impact on recurrence rate: A retrospective cohort study

INTRODUCTION

There are still debates regarding using portal vein (PV) from liver with hepatocellular carcinoma (HCC) for vascular reconstruction. This study aimed to assess the feasibility and patency of PV venous graft from an explanted liver with HCC for the reconstruction of the hepatic veins tributaries or PV in living donor liver transplantation (LDLT) and to see if it has any risk on recurrence of HCC.

PATIENT AND METHODS

We conducted a retrospective study on 81 patients with HCC who underwent LDLT from April 2004 to July 2022.

RESULTS

Venous graft from native liver PV was used for vascular reconstruction in 31 patients as follows; reconstruction of V5 in 7 patients, V8 in 4 patients, V6 in 3 patients, combined V5 and V8 in 4 patients, V6 with V5/V8 in 5 patients, and as Y shape venous graft for 2 PV reconstruction in 8 patients. The implantation of the new conduit PV graft after reconstruction of the anterior sector tributaries was direct to the IVC in 8 patients, and to the common orifice of the left and middle hepatic veins in 12 patients. The 1 month, 3 months, and 1-year overall patency of the venous graft was 93.5%, 90.3%, and 84%, respectively. Nine patients had recurrent HCC. In multivariate analysis, the independent risk factors for HCC recurrence were AFP >400 ng/mL (HR = 1.47, 95% CI: 1.69-2.31, P = 0.01), moderate/poor differentiated tumor (HR = 3.06, 95% CI: 2.58-6.29, P = 0.02), and microvascular invasion (HR = 2.51, 95% CI: 1.05-1.93, P = 0.01). Using a PV venous graft had no risk factor for HCC recurrence (P = 0.9).

CONCLUSION

The use of PV venous graft of native liver with HCC for venous reconstruction is a feasible and valuable option in LDLT with good patency rates and no risk of HCC recurrence.

Life Expectancy after Liver Transplantation for Non-Cirrhotic Hepatocellular Carcinoma

BACKGROUND

Hepatocelluar carcinoma typically occurs with underlying cirrhosis. However roughly 20% of cases arise in a non-cirrhotic liver. There is limited literature that addresses the long-term survival of the narrow subgroup who received transplantation. For such patients we sought to calculate life expectancies both at time of transplant and several years later, stratified by key risk factors, and to determine if survival has improved in recent years. Such information can be helpful in making treatment decisions.

METHODS

Data on 4,373 non-cirrhotic HCC patients who underwent liver transplantation in the MELD era (2002-2018) from the United States OPTN database were analyzed using the Cox proportional hazards regression model and life table methods.

RESULTS

Demographic and past medical history factors related to survival were patient age, donor age over 20, and the presence of ascites or severe hepatic encephalopathy. Survival did not vary by race or sex. HCC-specific factors significantly related to survival were the total number of tumors, extrahepatic spread, lymph node involvement, satellite lesions, micro- or macrovascular invasion, tumor differentiation (grade), and pre-transplant treatment. Survival improved over the study period, at 4% per calendar year during the first 5 years post transplant and 1% per year thereafter.

CONCLUSIONS

Life expectancy in non-cirrhotic HCC transplant patients is much reduced from normal, and varies according to age and tumor-related factors. Survival improved modestly over the study period.

Total tumor volume as a prognostic value for survival following liver resection in patients with hepatocellular carcinoma. Retrospective cohort study

BACKGROUND

Total tumor volume (TTV) can provide a simplified parameter in describing the tumor burden by incorporating the size and number of tumor nodules into one continuous variable. The aim of the study was to evaluate the prognostic value of TTV in resection of hepatocellular carcinoma (HCC).

METHODS

Patients who underwent liver resection for HCC between 2012 and 2017 were retrospectively analyzed. Patients were divided into a group with TTV ≤65.5 cm³ (which nearly equal to a single tumor with a diameter of 5 cm), and another group with TTV > 65.5 cm³.

RESULTS

Two hundred and four patients were included in this study (108 patients had TTV ≤ 65.5cm3, and 96 patients had TTV > 65.5 cm³). Ninety patients (44.1%) were within Milan and 114 patients (55.9%) were beyond Milan criteria. Eighteen patients (15.8%) of beyond Milan criteria had TTV ≤ 65.5 cm³, with a median survival of 32 months which is comparable to a median survival of patients with TTV< 65.5 cm³ (38 months, P = 0.38). TTV-based Cancer of Liver Italian Program (CLIP) score gained the highest value of likelihood ratio 114.7 and the highest Concordance-index 0.73 among other prognostic scoring and staging systems. In multivariate analysis, independent risk factors for diminished survival were serum AFP level >400 ng/ml, TTV >65.5 cm³, microvascular invasion, postoperative decompensation (all P values < 0.05).

CONCLUSION

TTV is a feasible prognostic measure to describe the tumor burden in patients with HCC. TTV-CLIP score may provide good prognostic value for resection of HCC than other staging systems.

Alpha-fetoprotein level to total tumor volume as a predictor of hepatocellular carcinoma recurrence after resection. A retrospective cohort study

Background

Total tumor volume (TTV) and serum alfa fetoprotein (AFP) level are important risk factors linked with the high possibility of hepatocellular carcinoma (HCC) recurrence. The aim of the study was to evaluate the role of AFP/TTV ratio, as a prognostic marker, in the prediction of HCC recurrence after resection.

Methods

Patients who underwent liver resection for HCC between 2010 and 2018 were retrospectively analyzed. Patients were divided into 2 groups; a group with AFP/TTV ≤2 and another group with AFP/TTV >2. Risk factors for HCC recurrence were recorded.

Results

A total of 286 HCC patients underwent liver resection (184 patients with AFP/TTV ≤ 2, and 102 patients with AFP/TTV > 2). There was a significant difference between the 2 groups in the preoperative total bilirubin level, serum AFP level, mean tumor diameter, TTV, operative blood loss, microvascular invasion and hospital stay (all P values < 0.05). The 1-, 3-, and 5-year tumor recurrence rates were 24.1%, 43%, and 57.6% respectively. The independent risk factors for tumor recurrence were AFP/TTV >2 (HR = 1.62, 95% CI = 1.29–1.98, P = 0.042), Macrovascular invasion (HR = 2.03, 95% CI = 2.17–2.38, P = 0.021, and microvascular invasion (HR = 1.36, 95% CI = 1.08–1.77, P = 0.019).

Conclusion

AFP/TTV ratio is a feasible prognostic marker for prediction of HCC recurrence after resection so, it can help in providing an intensive postoperative surveillance program to high risk patients for early detection and management of any recurrence.

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AFP/TTV ratio is a feasible surrogate for prediction of HCC recurrence.

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It can help in providing an intensive postoperative surveillance program to high risk patients.

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By knowing the high risk patients for HCC recurrence, we can provide appropriate preventive measures.

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The appropriate preventive measures like loco-regional or new-adjuvant therapy, still need another study to clarify.

Is It Justified to Use Liver Grafts From Living Donors for Retransplant? A Single-Center Experience

OBJECTIVES

Liver retransplant is considered the only hope for patients with irreversible graft failure after primary transplant. In most Western centers, retransplantis done mainly from deceased donors; so far, only few published studies have reported on outcomes of liver retransplant with living donors. In this study, our aim was to analyze the outcomes of living-donor liver retransplant.

MATERIALS AND METHODS

Patients who underwent liver retransplant between February 2011 and February 2019 were included in the study. Preoperative, operative, and postoperative data were analyzed. Results from 2 patient groups were compared: liver retransplant with living donors and liver retransplant with deceased donors.

RESULTS

Thirty-two patients underwent liver retransplant (21 adult and 11 pediatric patients). The most common indications for liver retransplant were hepatic artery thrombosis (28.5%) and primary graft nonfunction (23.8%) in adults and hepatic artery thrombosis (45.5%) and chronic rejection (36.4%) in pediatric patients. Seventeen retransplant patients (53.1%) required early retransplant (within 1 mo), mainly due to hepatic artery thrombosis (52.9%) and primary graft nonfunction (35.3%). Late retransplant was mainly due to chronic rejection (40%) and recurrence of primary disease (26.7%). Seventeen patients (53.1%) underwent living-donor retransplant, and 5 donors underwent robotic right hepatectomy. Graft and patient survival rates at 1, 3, and 5 years were 81.3% for living-donor and 51.4% for deceased-donor liver retransplant recipients (P = .08). On multivariate analyses, we observed significant differences between both groups in pretransplant Model for End-Stage Liver Disease and Pediatric End-Stage Liver Disease scores (P = .05), preoperative international normalized ratio (P = .012), and cold ischemia time (P = .046).

CONCLUSIONS

The use of living donors for liver retransplant, despite its technical demand, was shown to be a safe and feasible option, especially when there is scarcity of deceased donors.

Quantitative evaluation of blood perfusion in hepatocellular carcinoma after transcatheter arterial chemoembolization by contrast-enhanced ultrasound

AIM

To evaluate the blood perfusion status of residual hepatocellular carcinoma (HCC) tumors after transcatheter arterial chemoembolization (TACE) by contrast-enhanced ultrasound (CEUS) as well as the application value of CEUS.

METHODS

A total of 45 HCC patients with a total of 57 tumors who underwent TACE at our hospital were selected. CEUS was performed one day before treatment and one month after treatment. The blood perfusion parameters of residual tumors before and after TACE were compared.

RESULTS

The sensitivity, accuracy, and specificity of CEUS in the diagnosis of residual HCC lesions were 95.45%, 94.74%, and 92.31%, respectively. The enhanced intensity (56.87% ± 4.15%) of residual HCC tumors after TACE decreased significantly compared with that (75.09% ± 6.42%) before TACE (P < 0.05). The peak time (25.26 s ± 3.83 s) of HCC residual tumors after TACE was significantly longer than that (21.02 s ± 3.70 s) before TACE (P < 0.05). The area under the curve (581.29 ± 86.43) for residual HCC tumors decreased significantly compared with that (1017.83 ± 111.76) before TACE (P < 0.05).

CONCLUSION

CEUS can directly reflect the residual state of HCC after TACE and quantitatively evaluate the blood perfusion change of residual tumors, which can provide hemodynamic information for further clinical treatment.