Prognosis for recipients with hepatocellular carcinoma of salvage liver transplantation versus those of primary liver transplantation: a retrospective single-center study

Surgical treatment for recurrent hepatocellular carcinoma: Current status and challenges

Primary liver cancer is the sixth most commonly diagnosed cancer and was the third leading cause of cancer deaths worldwide in 2020. It includes hepatocellular carcinoma (HCC) (representing 75%-85% of cases), intrahepatic cholangiocarcinoma (representing 10%-15% of cases), and other rare types. The survival rate of patients with HCC has risen with improved surgical technology and perioperative management in recent years; however, high tumor recurrence rates continue to limit long-term survival, even after radical surgical resection (exceeding 50% recurrence). For resectable recurrent liver cancer, surgical removal [either salvage liver transplantation (SLT) or repeat hepatic resection] remains the most effective therapy that is potentially curative for recurrent HCC. Thus, here, we introduce surgical treatment for recurrent HCC. Areas Covered: A literature search was performed for recurrent HCC using Medline and PubMed up to August 2022. Expert commentary: In general, long-term survival after the re-resection of recurrent liver cancer is usually beneficial. SLT has equivalent outcomes to primary liver transplantation for unresectable recurrent illness in a selected group of patients; however, SLT is constrained by the supply of liver grafts. SLT seems to be inferior to repeat liver resection when considering operative and postoperative results but has the major advantage of disease-free survival. When considering the similar overall survival rate and the current situation of donor shortages, repeat liver resection remains an important option for recurrent HCC.

Salvage versus Primary Liver Transplantation for Hepatocellular Carcinoma: A Twenty-Year Experience Meta-Analysis

(1) Background: Primary liver transplantation (PLT) for HCC represents the ideal treatment. However, since organ shortage increases the risk of drop-out from the waiting list for tumor progression, a new surgical strategy has been developed: Salvage Liver Transplantation (SLT) can be offered as an additional curative strategy for HCC recurrence after liver resection. The aim of this updated meta-analysis is to compare surgical and long-term outcomes of SLT versus PLT for HCC. (2) Materials and Methods: A systematic review and meta-analysis was conducted using the published papers comparing SLT and PLT up to January 2022. (3) Results: 25 studies describing 11,275 patients met the inclusion criteria. The meta-analysis revealed no statistical difference in intraoperative blood loss, overall vascular complications, retransplantation rate, and hospital stay in the SLT group compared with the PLT group. However, the SLT group showed a slightly significant lower 5-year OS rate and 5-year disease-free survival rate. (4) Conclusion: meta-analysis advocates the relative safety and feasibility of both Salvage LT and Primary LT strategies. Specifically, SLT seems to have comparable surgical outcomes but slightly poorer long-term survival than PLT.

Continuing five or more locoregional therapies before living donor salvage liver transplantation for hepatocellular carcinoma is related to poor recurrence-free survival

Purpose

This study was designed to analyze factors related to the success of salvage liver transplantation (SLT) in hepatocellular carcinoma (HCC). While liver resection (LR) is considered the best locoregional therapy in HCC, there is a high recurrence rate. SLT may be the best treatment option when feasible.

Methods

Patients who underwent living donor SLT for recurrent HCC after LR from November 1996 to May 2017 were included. Patient demographic data, clinical and pathologic characteristics, operative data, hospital course, and follow-up data regarding initial LR, locoregional therapy after recurrence and SLT were reviewed. Prognostic factors for recurrence were analyzed using Cox proportional hazard ratio.

Results

Eighty-five of 123 SLT patients were included. Patients who had five or more locoregional therapies prior to SLT (hazard ratio [HR], 3.74; 95% confidence interval [CI], 1.45-9.64, P = 0.006), hepatitis B (HR, 9.20; 95% CI, 1.13-74.89; P = 0.04), outside Milan criteria at the time of SLT (HR, 2.66, 95% CI, 1.26-5.63; P = 0.011) and an alpha-fetoprotein level above 1,000 ng/mL at the time of recurrence after initial LR (HR, 6.48; 95% CI, 1.83-22.92; P = 0.004) and at the time of transplantation (HR, 3.43; 95% CI, 1.26-5.63; P = 0.011) were related to significant risk of recurrence.

Conclusion

Continuing five or more locoregional therapies for recurrent HCC after LR is related to poor recurrence-free survival after SLT.

Salvage Liver Transplant versus Primary Liver Transplant for Patients with Hepatocellular Carcinoma

The strategy of salvage liver transplantation (SLT) originated for initially resectable and transplantable hepatocellular carcinoma (HCC) to preclude upfront transplantation, with SLT in the case of recurrence. However, SLT remains a controversial approach in comparison to primary liver transplant (PLT). The aim of our study was to conduct a systemic review and meta-analysis to assess the short-term outcomes, overall survival (OS), and disease-free survival (DFS) between SLT and PLT for patients with HCC, stratifying results according to the Milan criteria and donor types. A search of PubMed, EMBASE, and the Cochrane Library was conducted to identify studies comparing SLT and PLT. A fixed effects model and a random effects model meta-analysis were conducted to assess the short-term outcomes, OS, and DFS based on the evaluation of heterogeneity. SLT had superior 1-year, 3-year, and 5-year OS and DFS compared with that of PLT. After classifying data according to donor type and Milan criteria, our meta-analysis revealed: that for deceased-donor liver transplantation (DDLT) recipients, there were no significant differences in 1-year and 3-year OS rate between the SLT group and the PLT group. However, the 5-year OS rate was superior in the SLT group compared to the PLT group. Similarly, SLT had superior 1-year, 3-year, and 5-year OS rate compared to PLT in living-donor liver transplantation (LDLT) recipients. Moreover, 1-year, 3-year, and 5-year DFS were also superior in SLT compared to PLT in both the DDLT and LDLT recipients. In patients within Milan criteria there were no statistically significant differences in 1-year, 3-year, and 5-year OS and DFS between the SLT group and the PLT group. Similarly, in patients beyond Milan criteria, both SLT and PLT showed no significant difference for 1-year, 3-year, and 5-year OS rate. Our meta-analysis included the largest number of studies comparing SLT and PLT, and SLT was found to have significantly better OS and DFS. Moreover, this meta-analysis suggests that SLT has comparable postoperative complications to that of PLT, and thus, SLT may be a better treatment strategy for recurrent HCC patients and patients with compensated liver, whenever feasible, considering the severe organ limitation and the safety of SLT. However, PLT can be referred as a treatment strategy for HCC patients with cirrhotic and decompensated liver.

The surgical challenges of salvage living donor liver transplantation for Hepatocellular carcinoma; The cumulative experience of 100 cases - A retrospective cohort study and a propensity score analysis

BACKGROUND

Hepatocellular carcinoma (HCC) is increasingly managed by liver resection first then salvage liver transplantation in case of recurrence within accepted criteria. Many reports compared the safety of the salvage against the primary surgery in the setting of deceased donation but the difference in case of living donation is not sufficiently defined. Salvage living donor liver transplantation (SLDLT) is believed to be a more challenging surgery than primary living donor liver transplantation (PLDLT) due to operative field adhesions, in addition to the inherent difficulties particularly short vasculobiliary stumps. In this report, we compared both pathways from a surgical perspective in a homogenous LDLT-only cohort.

MATERIALS AND METHODS

Over 15 years, 448 LDLTs for HCC were performed in a single liver transplant institution in Taiwan, including PLDLT (n = 348) and SLDLT (n = 100). A retrospective comparative review of the surgical outcomes of both pathways using a propensity score matching model (1-1, 100 pairs) was performed with adjustment for age, Child score and MELD score. The surgical outcome and survival were compared across 2 time eras.

RESULTS

The operative data showed that SLDLT surgery encountered more extensive adhesions (57% vs. 0%, p < 0.001), longer operative duration (650 vs. 618 min, p=0.04), and was followed by more incidence of re-exploration (16% vs. 5%, p=0.01), than the PLDLT surgery. There was no significant difference regarding the incidence of in-hospital mortality, vascular and biliary complications, or overall survival (OS). The 1-year OS of SLDLT was inferior to PLDLT in the first 50 cases (90% vs. 98%, p=0.03), then the same OS was found in the 2nd 50 cases (96% vs. 96%, p=0.9).

CONCLUSIONS

The SLDLT surgery is a demanding lengthy procedure with extensive adhesions and possibility of frequent re-explorations. Significant case load and high centre volume are important factors for safe practice of SLDLT and better cumulative OS.

Liver transplantation for hepatocellular carcinoma

Over the last several years, liver transplantation has evolved to become a widely used treatment for hepatocellular carcinoma (HCC). The criteria used were developed in order to have acceptable outcomes for transplant with survival similar to other indications for transplant. These criteria are discussed in detail along with alternate options, including surgical resection and downstaging of HCC in cirrhotics. Technical considerations of liver transplantation must be considered, and living donor liver transplant is a possibility for treatment.