Hepatocellular carcinoma progression during bridging before liver transplantation

Bridging locoregional treatment prior to liver transplantation for cirrhotic patients with hepatocellular carcinoma within the Milan criteria: a systematic review and meta-analysis

Background

We performed a meta-analysis to assess the benefit of bridging locoregional treatment (LRT) before liver transplantation for cirrhotic patients with hepatocellular carcinoma (HCC) already within the Milan criteria at diagnosis.

Methods

We included original studies with HCC cases within the Milan criteria at diagnosis, comparing patients with and without bridging LRT before liver transplantation.

Results

Twenty-six retrospective original studies were included. Out of the 9068 patients within the Milan criteria, 6435 (71%) received bridging LRT and 2633 (29%) did not. The most frequent LRTs were transarterial chemoembolization, radiofrequency ablation, and microwave ablation. Most of the patient and tumor characteristics were similar between the 2 groups. Maximum tumor diameter on scans was slightly larger in the LRT arm (mean difference: 0.36 cm, 95% confidence interval [CI] 0.11-0.61; I2=79%). The LRT group also had multifocal disease slightly more frequently (risk ratio [RR] 1.21, 95%CI 1.04-1.41; I2=0%) and disease extent outside the Milan criteria (RR 1.3, 95%CI 1.03-1.66; I2=0%) on pathological examination of explanted livers. There was no difference between the 2 arms in the waiting time for transplant, dropout rates, disease-free survival at 1, 3, 5 years after transplant, or overall survival at 3 and 5 years after transplant. However, cases with LRT had better overall survival at 1 year after transplant (hazard ratio 0.54, 95%CI 0.35-0.86; I2=0%).

Conclusions

The precise benefit of bridging LRT for cirrhotic patients with HCC within the Milan criteria at diagnosis is unclear. There may be an advantage regarding short-term overall survival after liver transplantation.

How important is the role of iterative liver direct surgery in patients with hepatocellular carcinoma for a transplant center located in an area with a low rate of deceased donation?

Introduction

Hepatocellular carcinoma (HCC) accounts for nearly 90% of primary liver cancers, with estimates of over 1 million people affected by 2025. We aimed to explore the impacting role of an iterative surgical treatment approach in a cohort of HCC patients within the Milan criteria, associated with clinical risk factors for tumor recurrence (RHCC) after liver transplant (LT) and loco-regional therapies (LRT), as well as liver resection (LR) and/or microwave thermal ablation (MWTA).

Methods

We retrospectively analyzed our experience performed during an 8-year period between January 2013 and December 2021 in patients treated for HCC, focusing on describing the impact on preoperative end-stage liver disease severity, oncologic staging, tumor characteristics, and surgical treatments. The Cox model was used to evaluate variables that could predict relapse risks. Relapse risk curves were calculated according to the Kaplan–Meier method, and the log-rank test was used to compare them.

Results

There were 557 HCC patients treated with a first-line approach of LR and/or LRTs (n = 335) or LT (n = 222). The median age at initial transplantation was 59 versus 68 for those whose first surgical approach was LR and/or LRT. In univariate analysis with the Cox model, nodule size was the single predictor of recurrence of HCC in the posttreatment setting (HR: 1.61, 95% CI: 1.05–2.47, p = 0.030). For the LRT group, we have enlightened the following clinical characteristics as significantly associated with RHCC: hepatitis B virus infection (which has a protective role with HR: 0.34, 95% CI: 0.13–0.94, p = 0.038), number of HCC nodules (HR: 1.54, 95% CI: 1.22–1.94, p < 0.001), size of the largest nodule (HR: 1.06, 95% CI: 1.01–1.12, p = 0.023), serum bilirubin (HR: 1.57, 95% CI: 1.03–2.40, p = 0.038), and international normalized ratio (HR: 16.40, 95% CI: 2.30–118.0, p = 0.006). Among the overall 111 patients with RHCC in the LRT group, 33 were iteratively treated with further curative treatment (12 were treated with LR, two with MWTA, three with a combined LR-MWTA treatment, and 16 underwent LT). Only one of 18 recurrent patients previously treated with LT underwent LR. For these RHCC patients, multivariable analysis showed the protective roles of LT for primary RHCC after IDLS (HR: 0.06, 95% CI: 0.01–0.36, p = 0.002), of the time relapsed between the first and second IDLS treatments (HR: 0.97, 95% CI: 0.94–0.99, p = 0.044), and the impact of previous minimally invasive treatment (HR: 0.28, 95% CI: 0.08–1.00, p = 0.051).

Conclusion

The coexistence of RHCC with underlying cirrhosis increases the complexity of assessing the net health benefit of ILDS before LT. Minimally invasive surgical therapies and time to HCC relapse should be considered an outcome in randomized clinical trials because they have a relevant impact on tumor-free survival.

Liver Transplant Oncology: Towards Dynamic Tumor-Biology-Oriented Patient Selection

While liver transplantation was initially considered as a curative treatment modality only for hepatocellular carcinoma, the indication has been increasingly extended to other tumor entities over recent years, most recently to the treatment of non-resectable colorectal liver metastases. Although oncologic outcomes after liver transplantation (LT) are consistently good, organ shortage forces stringent selection of suitable candidates. Dynamic criteria based on tumor biology fulfill the prerequisite of an individual oncological prediction better than traditional morphometric criteria based on tumor burden. The availability of specific (neo-)adjuvant therapies and customized modern immunosuppression may further contribute to favorable post-transplantation outcomes on the one hand and simultaneously open the path to LT as a curative option for advanced stages of tumor patients. Herein, we provide an overview of the oncological LT indications, the selection process, and expected oncological outcome after LT.

Role of Pretransplant Treatments for Patients with Hepatocellular Carcinoma Waiting for Liver Transplantation

Simple Summary

Hepatocellular carcinoma (HCC) is the fifth most common cancer in men worldwide and the second leading cause of cancer death. Liver transplantation (LT) is one of the treatment options for patients with HCC. Recently, there have been many reports of the usefulness of locoregional therapy, such as transarterial chemoembolization and radiofrequency ablation, for HCC as pretreatment before LT. In Western countries, locoregional therapy is used to bridge until transplantation to prevent drop-outs from the waiting list or for downstaging to treat patients with advanced HCC who initially exceed the criteria for LT. With the progress of locoregional therapy, new reports on the effects of bridging and downstaging locoregional therapy as pretransplant treatment are increasing in number.

Abstract

Recently, there have been many reports of the usefulness of locoregional therapy such as transarterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma (HCC) as pretreatment before liver transplantation (LT). Locoregional therapy is performed with curative intent in Japan, where living donor LT constitutes the majority of LT due to the critical shortage of deceased donors. However, in Western countries, where deceased donor LT is the main procedure, LT is indicated for early-stage HCC regardless of liver functional reserve, and locoregional therapy is used for bridging until transplantation to prevent drop-outs from the waiting list or for downstaging to treat patients with advanced HCC who initially exceed the criteria for LT. There are many reports of the effect of bridging and downstaging locoregional therapy before LT, and its indications and efficacy are becoming clear. Responses to locoregional therapy, such as changes in tumor markers, the avidity of FDG-PET, etc., are considered useful for successful bridging and downstaging. In this review, the effects of bridging and downstaging locoregional therapy as a pretransplant treatment on the results of transplantation are clarified, focusing on recent reports.

[Influence of molecular pathology on oncological surgery of liver and bile duct tumors]

BACKGROUND

Molecular pathology is increasingly being used to guide treatment in oncology. Approximately 25% of all hepatocellular carcinomas (HCC) and 50% of cholangiocarcinomas (CCA) present with known cancer-relevant mutations; however, the impact of the mutations on the treatment of these tumors is not yet sufficiently understood.

PURPOSE

To evaluate the current literature on molecular pathological advances in HCC/CCA and the potential impact on oncological surgery.

MATERIAL AND METHODS

A comprehensive search of the available literature on currently known molecular biomarkers in HCC/CCA was performed in PubMed and clinitrials.gov. Following review, the potential impact of these biomarkers on oncological surgery was analyzed and is discussed.

CONCLUSION

Molecular pathological investigations can be used to support the classification of tumors and to determine the dignity of HCC/CCA. Predictive molecular biomarkers are not yet established in routine diagnostics but can be used to individualize advanced oncological treatment.

Liver transplantation in malignant disease

Liver transplantation for malignant disease has gained increasing attention as part of transplant oncology. Following the implementation of the Milan criteria, hepatocellular carcinoma (HCC) was the first generally accepted indication for transplantation in patients with cancer. Subsequently, more liberal criteria for HCC have been developed, and research on this topic is still ongoing. The evident success of liver transplantation for HCC has led to the attempt to extend its indication to other malignancies. Regarding perihilar cholangiocarcinoma, more and more evidence supports the use of liver transplantation, especially after neoadjuvant therapy. In addition, some data also show a benefit for selected patients with very early stage intrahepatic cholangiocarcinoma. Hepatic epithelioid hemangioendothelioma is a very rare but nonetheless established indication for liver transplantation in primary liver cancer. In contrast, patients with hepatic angiosarcoma are currently not considered to be optimal candidates. In secondary liver tumors, neuroendocrine cancer liver metastases are an accepted but comparability rare indication for liver transplantation. Recently, some evidence has been published supporting the use of liver transplantation even for colorectal liver metastases. This review summarizes the current evidence for liver transplantation for primary and secondary liver cancer.