Liver transplantation for hepatocellular carcinoma: Improving eligibility without compromising outcomes

Background

In the context of liver transplantation for hepatocellular carcinoma (HCC), traditional transplant criteria appear restrictive. The objective of the current study was to determine risk factors for recurrence and improve transplant eligibility in patients with HCC.

Materials and methods

This was a retrospective study of patients who underwent living donor liver transplant (LDLT) for HCC (n = 219). Largest tumor diameter, tumor number, AFP and neutrophil to lymphocyte ratio were assessed. Multivariate analysis was performed to develop risk scores. The new model was compared with seven previously published transplant criteria using receiver operator curves.

Results

Largest tumor size >3.7 cm [HR:2.6, P = 0.02], and AFP > 600 ng/ml [HR:4.7, P = 0.001] were independent predictors of recurrence. Patients with risk scores of 0, 1–3, 4–6 and 7–9 had recurrence rate of 5.9%, 12.5%, 25% and 58.4% respectively. When compared with Milan criteria, Metro ticket 2.0, AFP model and Samsung criteria; transplant eligibility increased by 31.5%, 22.9%, 8.7%, and 7% respectively. Recurrence rate with the current model was 16/199 (8%) (P < 0.0001) and was comparable with other transplant criteria (6.9–9.1%). On ROC analysis, only Milan criteria (AUC = 0.7, P = 0.001) and the current model (AUC = 0.66, P = 0.01) showed significance for recurrence. All patients with high risk scores within Milan criteria had recurred at 3 years (P = 0.03).

Conclusions

Low AFP can be used to select patients for LDLT outside traditional criteria for HCC, with comparable recurrence rates.

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There is an unmet need to expand transplant pool for hepatocellular carcinoma.

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We developed a model, based on tumor size cutoff of 3.7 cm, any tumor number, and AFP cutoff of 600 ng/ml; and compared it with other transplant criteria.

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There was considerable expansion in transplant pool with comparable outcomes.

When to call it off: defining transplant candidacy limits in liver donor liver transplantation for hepatocellular carcinoma

Background

Living donor liver transplantation (LDLT) is an acceptable treatment option for hepatocellular carcinoma (HCC). Traditional transplant criteria aim at best utilization of donor organs with low risk of post transplant recurrence. In LDLT, long term recurrence free survival (RFS) of 50% is considered acceptable. The objective of the current study was to determine preoperative factors associated with high recurrence rates in LDLT.

Methods

Between April 2012 and December 2019, 898 LDLTs were performed at our center. Out of these, 242 were confirmed to have HCC on explant histopathology. We looked at preoperative factors associated with ≤ 50%RFS at 4 years. For survival analysis, Kaplan Meier curves were used and Cox regression analysis was used to identify independent predictors of recurrence.

Results

Median AFP was 14.4(0.7–11,326.7) ng/ml. Median tumor size was 2.8(range = 0.1–11) cm and tumor number was 2(range = 1–15). On multivariate analysis, AFP > 600 ng/ml [HR:6, CI: 1.9–18.4, P = 0.002] and microvascular invasion (MVI) [HR:5.8, CI: 2.5–13.4, P <  0.001] were independent predictors of 4 year RFS ≤ 50%. When AFP was > 600 ng/ml, MVI was seen in 88.9% tumors with poor grade and 75% of tumors outside University of California San Francisco criteria. Estimated 4 year RFS was 78% for the entire cohort. When AFP was < 600 ng/ml, 4 year RFS for well-moderate and poor grade tumors was 88 and 73%. With AFP > 600 ng/ml, RFS was 53% and 0 with well-moderate and poor grade tumors respectively (P <  0.001).

Conclusion

Patients with AFP < 600 ng/ml have acceptable outcomes after LDLT. In patients with AFP > 600 ng/ml, a preoperative biopsy to rule out poor differentiation should be considered for patient selection.

Cohort event monitoring of patients treated for uncomplicated malaria with artemisinin-based combination therapies in selected hospitals and community pharmacies in Nigeria

AIMS AND OBJECTIVES

The study was designed with the broad objective of determining the safety profile of artemisinin-based combination therapies amongst Nigerian population.

PATIENTS AND METHODS

This was a cohort event monitoring (CEM) programme involving monitoring adverse events (AEs) in malaria patients treated with either artemether-lumefantrine (AL) or artesunate-amodiaquine (AA) in healthcare facilities in Nigeria. The study involved continuous enrolment of patients with malaria and treated with either AL or AA at the various sites until a total cohort of 600 patients were enrolled at each site. Patients were monitored from the onset of therapy, and on days 3 and 7 from the first day of treatment to identify AEs that may occur.

RESULTS

A total of 6102 AEs were recorded in 10,259 patients monitored during the programme. Of 4896 patients who received AA, 4233 (86.5%) patients reported at least one AE while 1869 (34.8%) AEs out of 5363 patients who received AL were reported (P = 0.010). The predominant incidence of each specific AE reported in each group among the patients who received AA and AL includes body weakness 30.8%/7.5%, dizziness 10.3%/3.9%, restlessness 5.02/1.12%, vomiting 3.5/1.03% and drowsiness 3.1/1.5% for AA and AL, respectively. There were more AEs among patients with co-morbid conditions and patients in the younger age groups (9-<15 years), P = 0.000.

CONCLUSIONS

Various types of AEs were seen and documented during the CEM programme. The findings suggested that the AA/AL monitored during this programme was generally safe and remarkably well tolerated among the Nigerian populations.