Experience of orthotopic liver transplantation and hepatic resection for hepatocellular carcinoma of less than 8 cm in patients with cirrhosis

Primary liver tumors

Many improvements have been made in the treatment of primary liver tumors, especially in hepatocellular carcinoma. Partial hepatectomy still remains the mainstay of therapy for resectable tumors, and it offers the potential of a cure. Total hepatectomy and liver transplantation may be applicable in selected patients. Palliative resection and tumor debulking operations are beneficial for some malignant tumors. Local ablative therapy can be tried on patients with small tumors who are not suitable candidates for open resectional surgery because of serious associated medical diseases or because of poor liver function. For patients with advanced malignancy, new treatment modalities in the form of hepatic artery transcatheter treatment or systemic therapy are on the horizon. Some of these treatment options show very promising results. Properly conducted randomized studies are required to evaluate these new treatment modalities, as well as those older treatment modalities for which there is insufficient data to determine their actual role in the management of patients with liver cancer.

Transplantation of autologous and allogeneic bone marrow with liver from a cadaveric donor for primary liver cancer

BACKGROUND

In histocompatibility mismatched experimental animals, a combination of T-cell-depleted autologous and allogeneic marrow may induce mixed chimerism and tolerance. Patients with large primary liver tumors have a poor outcome. We investigated whether it were possible to induce mixed chimerism and obtain an antitumor effect in a patient with a large primary liver cancer after combined liver and bone marrow transplantation (BMT).

METHODS

A 46-year-old female with a primary non resectable liver cancer received a liver transplant from a cadaveric donor. Subsequently, she was conditioned with 4x2 Gy of total lymphoid irradiation, 120 mg/kg cyclophosphamide, and 7.5 Gy total body irradiation. Twelve days after liver transplantation, she received T-cell-depleted autologous:cadaveric 5/6 antigen HLA-mismatched marrow in a proportion of CD34+ cells of 0.5:3.0x10(6)/kg. Chimerism status was determined with polymerase chain reaction amplification of variable number tandem repeats from DNA obtained from CD3+, CD19+, and CD45+ magnetic-bead-separated cells.

RESULTS

The early posttransplant period was uneventful; liver function was normal and the hematopoietic engraftment of donor and recipient origin was prompt. Alpha-fetoprotein levels dropped from 440 to 35 microg/l. One month after marrow transplantation, donor T-cells decreased markedly. Monoclonal antibody OKT-3 and 10(5)/kg donor T-cells were given. One month later, the patient developed diarrhea and abdominal pain. A colonoscopy showed moderate gastrointestinal acute graft-versus-host disease and a Cryptosporidium infection. Three months after BMT, she became a complete donor chimera. Chimera cells showed little, if any, reactivity in mixed lymphocyte cultures to recipient and donor cells, but reacted to third party. Five months after BMT, she developed progressive Aspergillus fumigatus pneumonia and died. No tumor was found at the autopsy.

CONCLUSION

We obtained mixed donor-recipient hematopoietic chimerism without severe acute graft-versus-host-disease, after combined T-cell depleted autologous and allogeneic BMT and a transplantation of a liver from an HLA-mismatched cadaveric donor. Additional donor T-cells enhanced donor bone marrow engraftment, but rejected the autograft. On the basis of this first attempt, further clinical studies are warranted.

Resection or transplantation for hepatocellular carcinoma in cirrhotic patients: outcomes based on indicated treatment strategy

BACKGROUND

Surgical resection has been the treatment of choice for hepatocellular carcinoma (HCC), but the resection rate remains low in cirrhotic patients and recurrence is common. Unfavorable results compared with benign disease and the shortage of organ donors have led to a restricted indication for orthotopic liver transplantation (OLT) for HCC.

STUDY DESIGN

The aim of this study was to analyze the results of our surgical approach to HCC in patients with cirrhosis. The first treatment strategy indicated in these patients was OLT. From January 1990 to May 1999, 85 patients underwent OLT and the remaining 35 had surgical resection.

RESULTS

One-, 3-, and 5-year survival rates were 84%, 74%, and 60% versus 83%, 57%, and 51%, respectively, in the OLT and resection groups (p = 0.34). Hepatic tumor recurrence was much less frequent in the OLT group than in the resection group. The 1-, 3-, and 5-year disease-free survival rates were 83%, 72%, and 60% versus 70%, 44%, and 31%, respectively (p = 0.027). In the multivariate Cox regression analysis, macroscopic vascular invasion was the only factor independently associated with death or recurrence after OLT (p = 0.006). After partial liver resection, the tumors significantly associated with mortality and recurrence in the multivariate analysis were solitary or multiple tumors greater than 2cm with microscopic vascular invasion (pathologic pT3) (p = 0.01).

CONCLUSIONS

Our results confirm that in cirrhotic patients, OLT may provide better outcomes than liver resection in carefully selected HCC and that longterm survival is similar to the results of OLT in cirrhotic patients without tumors.

[Hepatocellular carcinoma. Part 2. Treatment]

Recent improvements on the therapeutical management of hepatocellular carcinoma are revised with special attention to evaluate the role of surgery for the disease. Considering that definitive surgical intervention is not feasible in most cases because of extreme tumor extension, multiplicity of tumor foci, and associated advanced liver cirrhosis at the time of diagnosis, others forms of treatment are listed, such as transcatheterarterial chemoembolization, percutaneous ethanol and acetic acid injections, and chemotherapy only to a small portion of patients with no indication for standard treatments. The emerging role of retinoic acid metabolism blocking agents, was examined and may offer a significant new potential treatment for cancer, inclusive the possibility of combining other anticancer drugs with exogenous retinoids or modulation of endogenous retinoids as a real opportunity to advance our ability to treat or prevent human cancer effectively Octreotide, nitrosamine and other drugs are analyzed and is concluded that improves survival and is a valuable alternative in the treatment of inoperable hepatocellular carcinoma. The potential role of intersticial laser coagulation for patients with irresectable hepatic tumors was investigated, and in terms of experience, it has now been developed sufficiently to study its effect on these patients survival. The homeostatic control of angiogenesis and its influences on the tumor growth and for migration of metastatic cells, was focused in this concise review, given that hepatocytes are the source of much of the precursor pool, regulation of angiogenesis may be regarded as a new liver function with important consequences for tissue repair and cancer. Early hepatocellular carcinoma and its recognition in routine clinical practice contributes to improved patients survival. Recombinant-Interferon-alpha therapy surely prevents, the development of cirrhosis or hepatocellular carcinoma in about one-third of patients, with chronic hepatitis C, with sustained response. Finally, in individuals with life-threatening liver disease, such as those with cirrhosis and hepatocellular carcinoma, the liver transplantation, must be considered, besides controversial, however, with increasing experience the results of the procedure in these patients have improved, and may offer a better long-term survival than liver resection.

An active liver transplant programme for hepatocellular carcinoma in cirrhotic patients: is it justified?

Even at an early stage, hepatocellular carcinoma (HCC) in patients with cirrhosis is often deemed unresectable because of limited liver reserve. In these circumstances, liver transplantation (LTx) offers some hope for palliation or cure. The results of LTx for selected cirrhotic patients with HCC were analysed. The outcomes were compared with those of patients who underwent LTx for other forms of hepatic malignancy and those who underwent LTx for non-malignant conditions. Four hundred and eighty LTx were performed in 441 patients between January 1986 and December 1998. Twenty-eight LTx recipients (25 males, 3 females) of mean age 51 (14 63) yr had cirrhosis and HCC. Twenty-seven patients had underlying predisposing conditions (11 had hepatitis B, 10 had hepatitis C, 2 had hepatitis B and C, 1 had haemochromatosis, 1 had autoimmune hepatitis, 1 had alcoholic cirrhosis and 1 had alpha-1 antitrypsin deficiency). In 22 patients, HCC was diagnosed pre-LTx, and in 6 patients, the cancers were discovered incidentally. The average tumour size and number were 2.8 (0.4-11.5) cm and 1.3 (1-4), respectively. Two patients with known HCC died during and shortly after the LTx operation. Of the other patients, 3 died; 1 died of HCC recurrence 18 months post-LTx, 1 died of graft failure from recurrent hepatitis C and 1 died of fungal sepsis. Twenty-three (82%) patients survived to 22.5 (0.5-96) months post-LTx without HCC recurrence and with 1- and 3-yr actuarial patient survival rates of 87 and 76%, respectively. Equivalent survival rates of patients who underwent LTx for other malignancies (n = 11) were 82 and 46% (p = NS), and for those who underwent LTx for benign causes (n = 402), they were 77 and 73% (p = NS). All 15 patients with known HCC, who met the selection criteria now in use, survived. LTx can result in prolonged. cancer-free survival in a good proportion of patients with cirrhosis and HCC, particularly when the cancers are incidental, or when diagnosed pre-LTx, conforming to established selection criteria. An active LTx programme for this group of patients is justified.

Screening for hepatocellular carcinoma

Screening for hepatocellular carcinoma has become widely practised in the management of patients with end-stage liver disease. However, the theoretical basis for this practice is largely lacking. Issues such as the selection of the target population and the correct method of confirming positive screening tests have yet to be resolved. Complicating the assessment of screening strategies is the poor literature on comparing different forms of therapy. Nonrandomized, uncontrolled studies that do not account for lead-time bias make it frequently impossible to know whether an applied treatment has really improved survival. Despite these difficulties, screening is reality, and strategies have to be devised to efficiently screen patients, find small tumours and apply effective treatments. Some practical strategies are discussed.

Liver transplantation for hepatocellular carcinoma in cirrhotic patients

BACKGROUND

Hepatocellular carcinoma (HCC) in patients with cirrhosis, due to a limited liver reserve, is often deemed unresectable, even at an early stage.

METHODS

In order to evaluate the ongoing transplant programme for cirrhotic patients with HCC at Royal Prince Alfred Hospital, the results of liver transplantation (LTx) for HCC were analysed and the patient actuarial survival was compared with that of those LTx patients without malignancy.

RESULTS

A total of 441 LTx were performed in 404 patients between January 1986 and April 1998. Twenty-four LTx recipients (22 men; two women) of mean age 49 (15-62) years had HCC. Twenty-one had underlying aetiology for their cirrhosis (hepatitis B: n = 9; hepatitis C: n = 8; hepatitis B and C: n = 1; haemochromatosis: n = 1; autoimmune hepatitis: n = 1; alcoholism: n = 1), while three patients had cryptogenic cirrhosis. Six patients had incidental tumours and another two cases were of the fibrolamellar type. The average tumour size and tumour number were 2.9 (0.4-11.5) cm and 1.3 (1-4), respectively. Operative mortality was 4.2% (1/24). The HCC recurrence appeared in one (4.2%) patient (with a 11.5-cm HCC) who died 18 months after LTx. A further two patients died (one graft failure from recurrent hepatitis C and one from fungal sepsis) during follow-up. The overall 1- and 3-year actuarial patient survival rates were 87% and 76%, respectively, and that of patients with benign causes (n = 369) were 77% and 72% (P = NS).

CONCLUSION

With careful patient selection, long-term tumour-free patient survival can be achieved. The results support an active transplant programme for selected HCC.

Resection of hepatocellular carcinoma in cirrhotic patients: longterm results of a prospective study

BACKGROUND

Surgical resection of hepatocellular carcinoma in cirrhotic patients remains controversial because of a high reported recurrence rate. To assess the longterm results of resection, 37 patients included in a prospective study were followed for more than 5 years, with special interest in early detection of recurrence.

STUDY DESIGN

Resection was performed from 1986 to 1991 with the goal of sparing the functional liver parenchyma. The mean tumor diameter was 5.3 +/- 2.6 cm (range 2 to 11 cm). Nineteen patients had tumors smaller than 5 cm. No additional perioperative therapy was performed.

RESULTS

Evidence of intrahepatic recurrence was demonstrated in 26 of the 33 patients surviving the operation. Eight recurrences (31%) were diagnosed from the third to the fifth postoperative years. The recurrence-free survival rates at 1, 2, 3, 4, and 5 years were 68%, 40%, 26%, 13%, and 9%, respectively. Only 2 patients (7%) were alive and free of recurrence at 5 years. Some long survivals were observed after treatment of recurrence. The overall survival rates at 3 and 5 years were 35% and 24%, respectively. Tumor cell differentiation was the only significant prognostic factor for both recurrence and survival. Multifocal tumors were associated with a higher recurrence rate. Patients with good liver function had longer survivals that reached 38% in those with small solitary tumors. Study of the other dinicopathologic factors failed to demonstrate any prognostic value.

CONCLUSIONS

Only a few patients are alive and free of recurrence 5 years after resection. Some long survival can be observed after treatment. Assessment of prognostic factors remains difficult, but the best results of resection are obtained in patients with small solitary hepatocellular carcinoma function.

[Liver transplantation in the adult: who and when to transplant?]

INTRODUCTION

The shortage of cadaveric organ donors imposes a severe limit to the number of liver transplantations. A selection is thus necessary among patients: should the sickest be selected, or those who supposedly have the best chance to survive and recover? Optimizing the timing of transplantation during the course of the disease (not too early, but not too late) is another issue.

CURRENT KNOWLEDGE AND KEY POINTS

Suitable candidates for transplantation are patients suffering from an irreversible, symptomatic liver disease. The goals of therapy are: firstly, to favorably modify the natural outcome of the disease; and secondly, in an acceptable risk taking manner. Major criteria for indication in the most common liver diseases can be summarized as follows: a) for chronic parenchymal liver diseases, a Child-Pugh score of 9 or 10, or less if complications have already occurred, is a mandatory and often sufficient criterion; b) for cholestatic liver diseases, a serum bilirubin level higher than 100-150 mumol/L is generally required; c) apart from "small" hepatocellular carcinomas on cirrhotic parenchyma (less than three tumors of less than 5 cm in diameter), most cancers are considered contraindications; d) acute liver failure requires early referral to a liver transplant center for potential emergency indication.

FUTURE PROSPECTS AND PROJECTS

In an organ shortage situation which is likely to perdure, early consultative contact between the patient and the liver transplant team will allow improvement in the access to transplantation procedure.

Biphasic spiral computed tomography for detection of hepatocellular carcinoma before resection or orthotopic liver transplantation

RATIONALE AND OBJECTIVES

The authors correlate computed tomography (CT) findings in biphasic spiral technique with histopathology in patients with hepatocellular carcinoma (HCC) who had undergone liver resection (LR) or orthotopic liver transplantation (OLT).

METHODS

Preoperative biphasic spiral CT findings in 33 consecutive patients (23 men, 10 women, aged 43-74 years; LR group: n = 17; OLT group; n = 16) with liver cirrhosis and HCC were reviewed retrospectively by consensus of two radiologists and correlated with pathology from liver specimens.

RESULTS

Of the 16 patients in the OLT group with 1 to 5 confirmed HCC lesions (total lesions: 29; mean lesion diameter: 2 cm; range: 0.6-5.0 cm), CT before OLT depicted 22 lesions in 15 patients (sensitivity for lesions with a diameter of 0.5-1.0 cm, 20%; for lesions 1.1-2.0 cm, 82%; and for lesions 2.1-3.0 cm and > 3.0 cm, 86% and 100%, respectively). Among the 17 patients in the LR group (total lesions: 21; mean lesion diameter: 5.4 cm; range: 1.0-11.0 cm), CT detected 18 lesions. Lesion-by-lesion sensitivity, as correlated with pathology, was calculated at 76% and 86% in the OLT and LR groups, respectively (overall sensitivity, 80%). The diameter of CT detected lesions, compared with liver specimens, corresponded in 90% of lesions (maximum deviation, 15%). Characteristic CT findings of HCC included unenhanced hypoattenuating focal liver lesions (32 lesions), with hyperattenuation (38 lesions) in the arterial phase of contrast material administration.

CONCLUSIONS

Biphasic spiral CT for preoperative HCC detection correlated with pathology in 80%, thus proving this technique to represent a sensitive imaging modality for pretherapeutic evaluation of HCC.

Appraisal of transplantation for malignant tumours of the liver with special reference to early stage hepatocellular carcinoma

The enthusiasm to treat or even cure patients with unresectable hepatobiliary malignancy by total hepatectomy and liver transplantation has considerably diminished. Nowadays, due to organ-donor shortage, patients have to be selected with predictable likelihood for long-term survival. According to own experience and a review of the literature, liver transplantation may be considered in unresectable early stage hepatocellular and proximal bile duct carcinoma, the uncommon entities fibrolamellar carcinoma, epithelioid haemangioendothelioma and hepatoblastoma as well as in liver metastases from neuroendocrine tumours. At present, advanced stages of hepatocellular and proximal bile duct carcinoma, as well as intrahepatic bile duct carcinoma, haemangiosarcoma and metastases from nonendocrine tumours, should be excluded from transplantation. In order to cure the cancer-bearing disease, liver transplantation might be the ideal treatment for small but still resectable hepatocellular carcinoma with underlying cirrhosis. Our retrospective comparison of survival after resection and transplantation for early stage hepatocellular carcinoma does not reveal a significant difference. Although a tendency has been observed in favour of transplantation, resection of these tumours is still justifiable, not least because of donor organ shortage.

Liver resection or transplantation for hepatocellular carcinoma? Retrospective analysis of 215 patients with cirrhosis

BACKGROUND/AIMS

Currently, surgical treatment of hepatocellular carcinoma in patients with cirrhosis is not clearly defined. The objective of this study was, in patients with cirrhosis with hepatocellular carcinoma, to compare liver resection to transplantation assessed by patient survival and to determine whether the tumor recurrence might be influenced by prognostic factors.

METHODS

We have gathered all the available data from six French Medical Universities, for 215 patients with cirrhosis with hepatocellular carcinoma surgically treated either by liver resection (102) or by transplantation (113).

RESULTS

The overall 5-year survival rate was similar in the transplantation group and in the resection group (32% vs. 31%, p=0.7). However, the 5-year survival rate without recurrence was higher in the transplantation group than in the resection group (60% vs. 14%, p<0.001). Three independent prognostic factors influenced significantly the survival without recurrence: the surgical treatment by transplantation (p<0.001), the number of tumors (p<0.01) and the tumor size (p<0.001). With these factors we defined a prognostic index (Ip) which allowed assessment of the probability of survival without recurrence: Ip= (Xie. x 1.41)+(Nbr T. x 0.19)+(Size TV. x 0.16); Xie=surgical treatment (Xie=0 if transplantation, Xie=1 if resection), Nbr.T. and Size TV.=number of tumors and size of the most voluminous tumor, respectively, according to the histologic study.

CONCLUSIONS

These results and this prognostic index are encouraging for liver transplantation as treatment of hepatocellular carcinoma in selected patients with cirrhosis.

Cost-effectiveness of screening for detection of small hepatocellular carcinoma in western patients with Child-Pugh class A cirrhosis

BACKGROUND AND AIM

The incidence of hepatocellular carcinoma is increased in patients with cirrhosis. Therefore, surveillance for detection of small tumors has been proposed. The aim of this study was to determine the clinical and economical effects of screening for small hepatocellular carcinoma in Western patients with Child-Pugh class A cirrhosis.

METHODS

Based on a decision analysis model representing the natural history of cirrhosis and the continuing risk of developing cancer, we compared a strategy of performing ultrasound and alpha-fetoprotein dosage every 6 months with a strategy of seeking tumors only if they are clinically suspected. In both strategies, partial hepatectomy was performed for patients with compensated cirrhosis and diagnosed with resectable tumors. We did not consider orthotopic liver transplantation as a therapeutic option. Data were drawn from MEDLINE search.

RESULTS

For most patients seen in the daily practice, screening provides negligible benefits in life expectancy (< 3 months), even when the incidence of cancer is high (6% per year), and despite our choice of consistent biases in favor of screening. The cost-effectiveness ratios of systematic surveillance range between $48,000 and $284,000 for each additional life-year gained, more than other common medical practices. However, for a minority of patients with a predicted cirrhosis-related survival rate above 80% at 5 years (the "ideal" candidates) screening may increase mean life expectancy by 3 to 9 months depending on age, cancer incidence (1.5% to 6% per year), and survival rate after surgery (40% to 60% at 3 years). In this clinical setting, the cost-effectiveness ratios range between $26,000 and $55,000 for each additional life-year gained.

CONCLUSIONS

For most patients with cirrhosis seen in the daily practice, biannual screening to detect symptomless tumors accessible to surgical resection provides negligible benefit in life expectancy. In addition, the cost-effectiveness ratios incurred by this strategy is more important than that of many current medical practices. On the other hand, for well-targeted patients with the longest reported cirrhosis-related survival rate, screening may substantially increase mean life expectancy, at lower costs. Careful selection of these patients with a favorable cirrhosis-related prognosis requires further studies.

Etiology, screening, and treatment of hepatocellular carcinoma

The prognosis with large hepatocellular carcinomas is poor, and only palliative treatment is available. Small tumors are amenable to several modes of treatment, including liver transplantation, resection, or alcohol injection, with acceptable 5-year survival rates. Although the value of screening for hepatocellular carcinoma has yet to be shown, these data, coupled with the recognition of at-risk groups and useful diagnostic techniques, might encourage the clinician to screen at-risk patients in the clinic. New imaging techniques such as ultrasonographic angiography enhanced with CO2 microbubbles, or color Doppler ultrasound, may clarify the intratumoral blood flow of small tumors.

Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis

BACKGROUND

The role of orthotopic liver transplantation in the treatment of patients with cirrhosis and hepatocellular carcinoma is controversial, and determining which patients are likely to have a good outcome after liver transplantation is difficult.

METHODS

We studied 48 patients with cirrhosis who had small, unresectable hepatocellular carcinomas and who underwent liver transplantation. In 94 percent of the patients, the cirrhosis was related to infection with hepatitis B virus, hepatitis C virus, or both. The presence of tumor was confirmed by biopsy or serum alpha-fetoprotein assay. The criteria for eligibility for transplantation were the presence of a tumor 5 cm or less in diameter in patients with single hepatocellular carcinomas and no more than three tumor nodules, each 3 cm or less in diameter, in patients with multiple tumors. Thirty-three patients with sufficient hepatic function underwent treatment for the tumor, mainly chemoembolization, before transplantation. After liver transplantation, the patients were followed prospectively for a median of 26 months (range, 9 to 54). No anticancer treatment was given after transplantation.

RESULTS

The overall mortality rate was 17 percent. After four years, the actuarial survival rate was 75 percent and the rate of recurrence-free survival was 83 percent. Hepatocellular carcinoma recurred in four patients (8 percent). The overall and recurrence-free survival rates at four years among the 35 patients (73 percent of the total) who met the predetermined criteria for the selection of small hepatocellular carcinomas at pathological review of small hepatocellular carcinomas at pathological review of the explanted liver wer 85 percent and 92 percent, respectively, whereas the rates in the 13 patients (27 percent) whose tumors exceeded these limits were 50 percent and 59 percent, respectively (P=0.01 for overall survival; P=0.002 for recurrence-free survival). In this group of 48 patients with early-stage tumors, tumor-node-metastasis status, the number of tumors, the serum alphafetoprotein concentration, treatment received before transplantation, and 10 other variables were not significantly correlated with survival.

CONCLUSIONS

Liver transplantation is an effective treatment for small, unresectable hepatocellular carcinomas in patients with cirrhosis.