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Undetectable Brain Metastasis of Hepatocellular Carcinoma by PET-CT After Liver Transplantation: a Case Report. J Gastrointest Cancer 2021; 54:270-274. [PMID: 34811649 DOI: 10.1007/s12029-021-00767-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Management of the unexplained AFP elevation after transplantation. F18 FDG PET/CT may not be helpful to detect post-transplant brain metastasis of hepatocellular carcinoma (HCC). CASE REPORT A-61-year old male patient with HBV related HCC have undergone living donor liver transplantation after successfully downstaging. AFP level started to increase on Post-transplant one year and there was no detectable metastases on PET/CT, abdominal thorax tomography. Patient admitted to hospital with confusion and seizure on post-transplant 16th month and diagnosed brain metastasis by brain tomography. Surgical resection was performed but the patientd died on post-transplant 20th month. CONCLUSION In the unexplained elevation of AFP after transplantation, it is beneficial to keep brain metastases in mind and perform cranial scanning with conventional imaging methods (CT, MRI) rather than FDG PET.
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Chen LC, Lin HY, Lee MS, Chiou WY, Huang LW, Chew CH, Hsu FC, Hung SK. Effectiveness of individual audio-visual coaching, respiratory modulated stereotactic body radiotherapy for localized hepatocellular carcinoma: Analysis of 29 cases from a single academic radiotherapy center. Tzu Chi Med J 2021; 33:380-387. [PMID: 34760635 PMCID: PMC8532585 DOI: 10.4103/tcmj.tcmj_247_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/22/2020] [Accepted: 03/04/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives: Recently, Stereotactic Body Radiotherapy (SBRT) has been suggested for managing hepatocellular carcinoma (HCC) curatively. Thus, we conducted this clinical study to evaluate retrospectively the effect of individualized audio-visual (AV) coaching, respiratory modulated SBRT. Materials and Methods: Between 2014 and 2018, 29 patients with inoperable Barcelona Clinic Liver Cancer (BCLC) stage 0-B HCC received AV coaching, respiratory-modulated SBRT. We constructed a task-oriented multidisciplinary team to establish a standard operation process of respiratory modulation procedures and developed our AV coaching devices. In the training period, a goodness-of-fit test was applied individually. SBRT was delivered with a total dose of 40–54 Gy in 5–6 fractions individually. Freedom from local progression (FFLP) and overall survival (OS) were estimated using SPSS (version 17, SPSS Inc., Chicago, IL, USA) life tables. Results: The patient characteristics were as follows: 32.7 ± 16 mm in maximum tumor diameter (range 11–94); BCLC stage 0: 3.4%, BCLC A: 48.3%, BCLC B: 48.3%; Child-Pugh classification A: 86.2%, Child-Pugh classification B: 13.8%, and a median of 2 prior liver-directed treatments (range 0–7). One-, 2-, and 3-year rates of FFLP of SBRT were 96.6%, 96.6%, and 96.6%, respectively. One-, 2-, and 3-year rates of OS were 81.5%, 72.4%, and 67.2%, respectively. No adverse event (AE) occurred in 41.4% of patients, 48.3% developed grade (G) 1–2 AE, 10.3% had G3 AE and none had G4-5 AE. Conclusion: Respiration-modulated SBRT is a promising noninvasive treatment option for patients with inoperable and localized HCC. Our data show that SBRT provides comparable tumor control to historical curative options like surgery and radiofrequency ablation of localized tumors. Thus, we are conducting a further prospective clinical trial with the intent to demarcate the clinical effectiveness of SBRT in a larger population of patients with HCC.
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Affiliation(s)
- Liang-Cheng Chen
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Hon-Yi Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan.,Institute of Molecular Biology, National Chung Cheng University, Chiayi, Taiwan
| | - Moon-Sing Lee
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Wen-Yen Chiou
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Li-Wen Huang
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Chia-Hui Chew
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Feng-Chun Hsu
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Shih-Kai Hung
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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53
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El-Domiaty N, Saliba F, Karam V, Sobesky R, Ibrahim W, Vibert E, Pittau G, Amer K, Saeed MA, Shawky JA, Cherqui D, Adam R, Samuel D. Impact of body mass index on hepatocellular carcinoma recurrence after liver transplantation through long-term follow-up. Hepatobiliary Surg Nutr 2021; 10:598-609. [PMID: 34760964 DOI: 10.21037/hbsn.2020.04.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 03/26/2020] [Indexed: 12/12/2022]
Abstract
Background Obesity is associated with increased oncological risk and outcomes but the evidence surrounding the effect of body mass index (BMI) on increased risk of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) is still questionable. The purpose of this retrospective study of a large cohort of adult patients transplanted for HCC was to investigate the effect of BMI on the incidence of HCC recurrence and outcome. Methods Data from 427 adult recipients transplanted for HCC between 2000 and 2017 were collected. Patients were classified at time of LT according to the World Health Organization BMI classification into 3 groups; group 1: BMI <25 (n=166), group 2: BMI 25-29.9 (n=150) and group 3: BMI ≥30 (n=111). Results There were no significant changes of mean BMI overtime 26.8±5.0 kg/m2 at time of LT and 28.8±23.1 at 5 years. The recurrence rates of HCC after LT in the three groups were 19%, 16% and 17% respectively. The 5, 10 and 15-year recurrence free survival (RFS) rates were respectively 68.6%, 47.3% and 40.8% in group 1, 73.3%, 66.2% and 49.5% in group 2 and 68.8%, 57.5% and 47.7% in group 3 (log rank P=0.47). Conclusions Recipient BMI at time of transplant and during follow-up didn't impact the incidence of HCC recurrence nor long-term patient survival, irrespective to the status of the patients and their tumor characteristic at time of LT. The present study clearly confirms that obesity should not be considered, when selecting patients with HCC to LT, as a predictive factor of recurrence.
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Affiliation(s)
- Nada El-Domiaty
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Centre, INSERM UMR 1193, Université Paris Saclay, Villejuif, France.,Tropical Medicine Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Centre, INSERM UMR 1193, Université Paris Saclay, Villejuif, France
| | - Vincent Karam
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Centre, INSERM UMR 1193, Université Paris Saclay, Villejuif, France
| | - Rodolphe Sobesky
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Centre, INSERM UMR 1193, Université Paris Saclay, Villejuif, France
| | - Wafaa Ibrahim
- Statistics Department, Faculty of Economics and Political Science, Cairo University, Cairo, Egypt
| | - Eric Vibert
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Centre, INSERM UMR 1193, Université Paris Saclay, Villejuif, France
| | - Gabriella Pittau
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Centre, INSERM UMR 1193, Université Paris Saclay, Villejuif, France
| | - Khaled Amer
- Hepato-Biliary and Liver Transplant Department, International Medical Center, Cairo, Egypt
| | - Maysaa A Saeed
- Tropical Medicine Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Jihan A Shawky
- Tropical Medicine Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Daniel Cherqui
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Centre, INSERM UMR 1193, Université Paris Saclay, Villejuif, France
| | - René Adam
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Centre, INSERM UMR 1193, Université Paris Saclay, Villejuif, France
| | - Didier Samuel
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Centre, INSERM UMR 1193, Université Paris Saclay, Villejuif, France
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54
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Liu S, Nalesnik MA, Singhi A, Wood-Trageser MA, Randhawa P, Ren BG, Humar A, Liu P, Yu YP, Tseng GC, Michalopoulos G, Luo JH. Transcriptome and Exome Analyses of Hepatocellular Carcinoma Reveal Patterns to Predict Cancer Recurrence in Liver Transplant Patients. Hepatol Commun 2021; 6:710-727. [PMID: 34725972 PMCID: PMC8948579 DOI: 10.1002/hep4.1846] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 10/06/2021] [Accepted: 10/10/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most lethal human cancers. Liver transplantation has been an effective approach to treat liver cancer. However, significant numbers of patients with HCC experience cancer recurrence, and the selection of suitable candidates for liver transplant remains a challenge. We developed a model to predict the likelihood of HCC recurrence after liver transplantation based on transcriptome and whole‐exome sequencing analyses. We used a training cohort and a subsequent testing cohort based on liver transplantation performed before or after the first half of 2012. We found that the combination of transcriptome and mutation pathway analyses using a random forest machine learning correctly predicted HCC recurrence in 86.8% of the training set. The same algorithm yielded a correct prediction of HCC recurrence of 76.9% in the testing set. When the cohorts were combined, the prediction rate reached 84.4% in the leave‐one‐out cross‐validation analysis. When the transcriptome analysis was combined with Milan criteria using the k‐top scoring pairs (k‐TSP) method, the testing cohort prediction rate improved to 80.8%, whereas the training cohort and the combined cohort prediction rates were 79% and 84.4%, respectively. Application of the transcriptome/mutation pathways RF model on eight tumor nodules from 3 patients with HCC yielded 8/8 consistency, suggesting a robust prediction despite the heterogeneity of HCC. Conclusion: The genome prediction model may hold promise as an alternative in selecting patients with HCC for liver transplant.
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Affiliation(s)
- Silvia Liu
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael A Nalesnik
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Aatur Singhi
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Parmjeet Randhawa
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bao-Guo Ren
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Peng Liu
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Yan-Ping Yu
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - George C Tseng
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - George Michalopoulos
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jian-Hua Luo
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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55
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Circulating Tumor Cell Is a Clinical Indicator of Pretransplant Radiofrequency Ablation for Patients with Hepatocellular Carcinoma. JOURNAL OF ONCOLOGY 2021; 2021:7776389. [PMID: 34712326 PMCID: PMC8548160 DOI: 10.1155/2021/7776389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/07/2021] [Accepted: 09/24/2021] [Indexed: 12/14/2022]
Abstract
Introduction It is of great significance to confirm reliable indicators for the guidance of pretransplant radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). In this study, we aim to investigate whether circulating tumor cell (CTC) status is a clinical indicator for RFA before liver transplantation (LT) in HCC patients. Method CTC analyses were measured in 79 HCC patients. Clinical outcomes including progression-free (PFS) and overall survival (OS) were compared and analyzed between patients with and without pretransplant RFA. Result Forty-two patients were detected as CTC-positive and 18 patients received pretransplant RFA. Recurrence was correlated with CTC count (P=0.024), tumor number (P=0.035), liver cirrhosis (P=0.001), Milan criteria (P=0.003), and University of California San Francisco (UCSF) criteria (P=0.001). Kaplan-Meier analysis revealed that patients with CTC-positive had a lower PFS rate (P=0.0257). For CTC-positive patients, the PFS rate of the pretransplant RFA group was significantly higher than the non-pretransplant RFA group (100% vs. 46.7%, P=0.0236). For CTC-negative patients, both PFS rate and OS rate were similar and without significant differences. In multivariate analysis, pretransplant RFA was the independent factor for PFS (P=0.025). Conclusion Pretransplant CTC status can guide the administration of pretransplant RFA in HCC patients which can improve PFS in CTC-positive HCC patients.
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56
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Muhammad H, Tehreem A, Ting PS, Gurakar M, Li SY, Simsek C, Alqahtani SA, Kim AK, Kohli R, Gurakar A. Hepatocellular Carcinoma and the Role of Liver Transplantation: A Review. J Clin Transl Hepatol 2021; 9:738-748. [PMID: 34722189 PMCID: PMC8516838 DOI: 10.14218/jcth.2021.00125] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/01/2021] [Accepted: 05/18/2021] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the leading causes of cancer deaths worldwide and liver transplantation (LT) is the only potentially curative treatment. Over the years, Milan criteria has been used for patient selection. There is ongoing research in this field with introduction of new biomarkers for HCC that can help guide future treatment. Furthermore, newer therapies for downstaging of the tumor are being implemented to prevent dropout from the transplant list. In addition, combination therapies for better outcome are under investigation. Interestingly, the concept of living-donor LT and possible use of hepatitis C virus-positive donors has been implemented as an attempt to expand the organ pool. However, there is a conflict of opinion between different centers regarding its efficacy and data is scarce. The aim of this review article is to outline the various selection criteria for LT, discuss the outcomes of LT in HCC patients, and explore future directions of LT for HCC. Therefore, a comprehensive PubMed/MEDLINE review was conducted. To expand our search, references of the retrieved articles were also screened for additional data. After selecting the studies, the authors independently reviewed them to identify the relevant studies. After careful evaluation 120 studies relevant to out topic are cited in the manuscript. Three tables and two figures are also included. In conclusion LT for HCC has evolved over the years. With the introduction of several expanded criteria beyond Milan, the introduction of bridging therapies, such as transcatheter arterial chemoembolization and radiofrequency ablation, and the approval of newer systemic therapies, it is evident that there will be more LT recipients in the future. It is promising to see ongoing trials and the continuous evolution of protocols. Prospective studies are needed to guide the development of a pre-LT criteria that can ensure low HCC recurrence risk and is not overly stringent, clarify the role of LDLT, and determine the optimal bridging therapies to LT.
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Affiliation(s)
- Haris Muhammad
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
| | - Aniqa Tehreem
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD, USA
| | - Peng-Sheng Ting
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Merve Gurakar
- Department of Medicine, Osler Residency Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Cem Simsek
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Saleh A. Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy K. Kim
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruhail Kohli
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Correspondence to: Ahmet Gurakar, Section of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Suite 918 Baltimore, MD 21205, USA. ORCID: https://orcid.org/0000-0002-2221-9148. Tel: +1-410-614-3369, Fax: +1-443-683-8349, E-mail:
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57
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Yilmaz S, Ince V. The Importance of the Immunosuppressive Regime on Hepatocellular Carcinoma Recurrence After Liver Transplantation. J Gastrointest Cancer 2021; 52:1350-1355. [PMID: 34611833 DOI: 10.1007/s12029-021-00716-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) occurs in approximately 20% of recipients and these patients have median about one year survival after diagnosis. Some immunosuppressive drugs can cause development of HCC recurrence, on the other hand some immunosuppressive drugs may have a positive effect for preventing HCC recurrence. Thus, immunosuppression (IS) modification may play a role in preventing HCC recurrence. METHODS In this review, we analyzed IS treatment strategy in two parts: before HCC recurrence following LT and after HCC recurrence following LT, and after HCC recurrence following LT. RESULTS There is no proven, optimal IS protocol to prevent HCC recurrence after transplantation. Therefore, individualized immunosuppressive treatments should be tailored to the biological behaviour of HCC. Forcing the immune tolerance in terms of recurrence can probably be expressed as the most appropriate post LT period. Once HCC recurrence has developed after transplantation, again, there is no commonly accepted, optimal IS treatment, but there is a tendency to switch to IS modifications that include mTORi by minimizing CNIs and MMF. CONCLUSION There is a need for well-designed, randomized, controlled clinical studies with larger numbers of patients on this subject.
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Affiliation(s)
- Sezai Yilmaz
- Department of Surgery, Liver Transplant Institute, Inonu University, Malatya, Turkey
| | - Volkan Ince
- Department of Surgery, Liver Transplant Institute, Inonu University, Malatya, Turkey.
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58
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L R, T I, Mpaw C, H M, G S. THE MANAGEMENT OF POST-TRANSPLANTATION RECURRENCE OF HEPATOCELLULAR CARCINOMA. Clin Mol Hepatol 2021; 28:1-16. [PMID: 34610652 PMCID: PMC8755475 DOI: 10.3350/cmh.2021.0217] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/03/2021] [Indexed: 11/15/2022] Open
Abstract
The annual incidence of hepatocellular carcinoma (HCC) continues to rise. Over the last two decades, liver transplantation (LT) has become the preferable treatment of HCC, when feasible and strict selection criteria are met. With the rise in HCC-related LT, compounded by downstaging techniques and expansion of transplant selection criteria, a parallel increase in number of post-transplantation HCC recurrence is expected. Additionally, in the context of an immunosuppressed transplant host, recurrences may behave aggressively and more challenging to manage, resulting in poor prognosis. Despite this, no consensus or best practice guidelines for post-transplantation cancer surveillance and recurrence management for HCC currently exist. Studies with adequate population sizes and high-level evidence are lacking, and the role of systemic and locoregional therapies for graft and extrahepatic recurrences remains under debate. This review seeks to summarize the existing literature on post-transplant HCC surveillance and recurrence management. It highlights the value of early tumour detection, re-evaluating the immunosuppression regimen, and staging to differentiate disseminated recurrence from intrahepatic or extrahepatic oligo-recurrence. This ultimately guides decision-making and maximizes treatment effect. Treatment recommendations specific to recurrence type are provided based on currently available locoregional and systemic therapies.
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Affiliation(s)
- Rajendran L
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ivanics T
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Surgery, Henry Ford Hospital, Detroit, MI, USA.,Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
| | - Claasen Mpaw
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - Muaddi H
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sapisochin G
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
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Kang I, Lee JG, Choi SH, Kim HJ, Han DH, Choi GH, Kim MS, Choi JS, Kim SI, Joo DJ. Impact of everolimus on survival after liver transplantation for hepatocellular carcinoma. Clin Mol Hepatol 2021; 27:589-602. [PMID: 34293849 PMCID: PMC8524068 DOI: 10.3350/cmh.2021.0038] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/09/2021] [Accepted: 07/22/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND/AIMS This study aimed to investigate whether everolimus (EVR) affects long-term survival after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). METHODS The data from 303 consecutive patients with HCC who had undergone LT from January 2012 to July 2018 were retrospectively reviewed. The patients were divided into two groups: 1) patients treated with EVR in combination with calcineurin inhibitors (CNIs) (EVR group; n=114) and 2) patients treated with CNI-based therapy without EVR (non-EVR group; n=189). Time to recurrence (TTR) and overall survival (OS) after propensity score (PS) matching were compared between the groups, and prognostic factors for TTR and OS were evaluated. RESULTS The EVR group exhibited more aggressive tumor biology than the non-EVR group, such as a higher number of tumors (P=0.003), a higher prevalence of microscopic vascular invasion (P=0.017) and exceeding Milan criteria (P=0.029). Compared with the PS-matched non-EVR group, the PS-matched EVR group had significantly better TTR (P<0.001) and OS (P<0.001). In multivariable analysis, EVR was identified as an independent prognostic factor for TTR (hazard ratio [HR], 0.248; P=0.001) and OS (HR, 0.145; P<0.001). CONCLUSION Combined with CNIs, EVR has the potential to prolong long-term survival in patients undergoing LT for HCC. These findings warrant further investigation in a well-designed prospective study.
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Affiliation(s)
- Incheon Kang
- Department of Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hoon Choi
- Department of Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Hyun Jeong Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Dai Hoon Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Gi Hong Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sub Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
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60
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Pelizzaro F, Gambato M, Gringeri E, Vitale A, Cillo U, Farinati F, Burra P, Russo FP. Management of Hepatocellular Carcinoma Recurrence after Liver Transplantation. Cancers (Basel) 2021; 13:cancers13194882. [PMID: 34638365 PMCID: PMC8508053 DOI: 10.3390/cancers13194882] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/19/2021] [Accepted: 09/24/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Hepatocellular carcinoma (HCC) is an increasingly important indication for liver transplantation (LT) worldwide. However, LT in the setting of liver cancer is burdened by the risk of tumor recurrence. The prognosis of patients with post-LT HCC recurrence is still very poor and several areas of uncertainty remain in the management of these patients. In this paper, we provide a comprehensive evaluation of available evidence regarding the management of HCC recurrence after LT, starting from the pre- and post-transplant stratification criteria and encompassing post-LT surveillance, preventive strategies and treatment. Much work has been done in the last several years but further effort is still needed in order to improve the outcome of these patients. Abstract Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT), occurring in 10–15% of cases, is a major concern. A lot of work has been done in order to refine the selection of LT candidates with HCC and to improve the outcome of patients with recurrence. Despite this, the prognosis of these patients remains poor, partly due to the several areas of uncertainty in their management. Even if surveillance for HCC recurrence is crucial for early detection, there is currently no evidence to support a specific and cost-effective post-LT surveillance strategy. Concerning preventive measures, consensus on the best immunosuppressive drugs has not been reached and not enough data to support adjuvant therapy are present. Several therapeutic approaches (surgical, locoregional and systemic treatments) are available in case of recurrence, but there are still few data in the post-LT setting. Moreover, the use of immune checkpoint inhibitors is controversial in transplant recipients considered the risk of rejection. In this paper, the available evidence on the management of HCC recurrence after LT is comprehensively reviewed, considering pre- and post-transplant risk stratification, post-transplant surveillance, preventive strategies and treatment options.
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Affiliation(s)
- Filippo Pelizzaro
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (M.G.); (F.F.); (P.B.)
| | - Martina Gambato
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (M.G.); (F.F.); (P.B.)
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (E.G.); (A.V.); (U.C.)
| | - Alessandro Vitale
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (E.G.); (A.V.); (U.C.)
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (E.G.); (A.V.); (U.C.)
| | - Fabio Farinati
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (M.G.); (F.F.); (P.B.)
| | - Patrizia Burra
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (M.G.); (F.F.); (P.B.)
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Francesco Paolo Russo
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (M.G.); (F.F.); (P.B.)
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
- Correspondence:
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Liu T, Shi Q, Yang L, Wang S, Song H, Wang Z, Xu X, Liu H, Zheng H, Shen Z. Long non-coding RNAs HERH-1 and HERH-4 facilitate cyclin A2 expression and accelerate cell cycle progression in advanced hepatocellular carcinoma. BMC Cancer 2021; 21:957. [PMID: 34445994 PMCID: PMC8390207 DOI: 10.1186/s12885-021-08714-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 08/18/2021] [Indexed: 12/11/2022] Open
Abstract
Background The advanced hepatocellular carcinoma (HCC), such as the recurrent tumor after liver transplantation (LT), is an obstacle of HCC treatment. The aim of this study was to discover the underlying mechanism of HCC progression caused by non-coding RNAs (ncRNAs). Methods To this end, we investigated the selected patient cohort of matching primary and recurrent HCC after receiving LT. The recurrent tumors after LT were regarded as clinical models of the advanced HCC. Microarrays were used to profile lncRNA and mRNA expression in HCC recurrent and primary tissue samples. The mRNA profile characteristics were analyzed by bioinformatics. Two cell lines, HepG2 and QGY-7703, were used as HCC cell models. The protein-coding potential, length, and subcellular location of the interested lncRNAs were examined by bioinformatics, Northern blot, fluorescent in situ hybridization (FISH), and quantitative RT-PCR (qRT-PCR) assays. HCC cell proliferation was detected by CCK-8, doubling time and proliferation marker gene quantitation assays. DNA replication during the cell cycle was measured by EdU/PI staining and flow cytometry analyses. Promoter activity was measured using a luciferase reporter assay. Interactions between DNA, RNA, and protein were examined by immunoprecipitation and pull-down assays. The miRNA-target regulation was validated by a fluorescent reporter assay. Results Both lncRNA and mRNA profiles exhibited characteristic alterations in the recurrent tumor cells compared with the primary HCC. The mRNA profile in the HCC recurrent tissues, which served as model of advanced HCC, showed an aberrant cell cycle regulation. Two lncRNAs, the highly expressed lncRNA in recurrent HCC (HERH)-1 and HERH-4, were upregulated in the advanced HCC cells. HERH-1/4 enhanced proliferation and promoted DNA replication and G1-S transition during the cell cycle in HCC cells. HERH-1 interacted with the transcription factor CREB1. CREB1 enhanced cyclin A2 (CCNA2) transcription, depending on HERH-1-CREB1 interaction. HERH-4 acted as an miR-29b/c sponge to facilitate CCNA2 protein translation through a competing endogenous RNA (ceRNA) pathway. Conclusions The oncogenic lncRNA HERH-1/4 promoted CCNA2 expression at the transcriptional and post-transcriptional levels and accelerated cell cycle progression in HCC cells. The HERH-1-CREB1-CCNA2 and HERH-4-miR-29b/c-CCNA2 axes served as molecular stimuli for HCC advance. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08714-7.
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Affiliation(s)
- Tao Liu
- National Health Commission's Key Laboratory of Critical Care Medicine, Tianjin First Central Hospital, School of Medicine, Nankai University, No. 24 Fukang Road, Nankai District, Tianjin, 300192, China. .,Key Laboratory of Transplant Medicine, Chinese Academy of Medical Sciences, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, 300192, China.
| | - Qiao Shi
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Lei Yang
- Department of Clinical Laboratory, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, 300192, China
| | - Shusen Wang
- National Health Commission's Key Laboratory of Critical Care Medicine, Tianjin First Central Hospital, School of Medicine, Nankai University, No. 24 Fukang Road, Nankai District, Tianjin, 300192, China.,Key Laboratory of Transplant Medicine, Chinese Academy of Medical Sciences, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, 300192, China.,Organ Transplant Center, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, 300192, China
| | - Hongli Song
- Organ Transplant Center, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, 300192, China
| | - Zhenglu Wang
- Biological Sample Resource Sharing Center (BSRSC), Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, 300192, China
| | - Xinnv Xu
- National Health Commission's Key Laboratory of Critical Care Medicine, Tianjin First Central Hospital, School of Medicine, Nankai University, No. 24 Fukang Road, Nankai District, Tianjin, 300192, China
| | - Hongsheng Liu
- National Health Commission's Key Laboratory of Critical Care Medicine, Tianjin First Central Hospital, School of Medicine, Nankai University, No. 24 Fukang Road, Nankai District, Tianjin, 300192, China
| | - Hong Zheng
- National Health Commission's Key Laboratory of Critical Care Medicine, Tianjin First Central Hospital, School of Medicine, Nankai University, No. 24 Fukang Road, Nankai District, Tianjin, 300192, China.,Key Laboratory of Transplant Medicine, Chinese Academy of Medical Sciences, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, 300192, China.,Organ Transplant Center, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, 300192, China
| | - Zhongyang Shen
- National Health Commission's Key Laboratory of Critical Care Medicine, Tianjin First Central Hospital, School of Medicine, Nankai University, No. 24 Fukang Road, Nankai District, Tianjin, 300192, China. .,Key Laboratory of Transplant Medicine, Chinese Academy of Medical Sciences, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, 300192, China. .,Organ Transplant Center, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, 300192, China.
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Wang H, Li W. Recent update on comprehensive therapy for advanced hepatocellular carcinoma. World J Gastrointest Oncol 2021; 13:845-855. [PMID: 34457190 PMCID: PMC8371518 DOI: 10.4251/wjgo.v13.i8.845] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/12/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in the world. The treatment methods for HCC are diverse, mainly including surgical resection, ablation, and liver transplantation. The curative effect can be achieved only for early stage HCC, and it is easy to recur and metastasize after surgery, with a 5-year recurrence rate as high as 70%. Most patients with HCC are in the middle and advanced stage at the time of diagnosis and lose the chance of surgical resection. In recent years, with the in-depth study of the pathogenesis of HCC and the progress of medical science and technology, the systemic treatment of advanced HCC has made a breakthrough. At present, multidisciplinary comprehensive treatment including targeted therapy and immunotherapy has become an effective strategy and inevitable trend for the treatment of advanced HCC. Combined therapy has greatly improved the prognosis of HCC patients and opened up a new milestone in the treatment of this malignancy. In this article, we focus on the treatment progress of advanced HCC to further guide clinical practice.
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Affiliation(s)
- Hui Wang
- Department of Hepatobiliary-Pancreatic Surgery, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Wei Li
- Department of Hepatobiliary-Pancreatic Surgery, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
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63
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Early Versus Late Hepatocellular Carcinoma Recurrence After Transplantation: Predictive Factors, Patterns, and Long-term Outcome. Transplantation 2021; 105:1778-1790. [PMID: 32890134 DOI: 10.1097/tp.0000000000003434] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is currently the first indication of liver transplantation (LT) in Europe and Asia-Pacific region and the third in the United States. HCC recurrence is the main complication affecting short- and medium-term outcomes after LT. METHODS A total of 433 consecutive adult recipients transplanted for HCC between 2000 and 2017 (mean age: 57.8 ± 8.5 y; 83.8% were males) with a mean follow-up of 74.6 ± 58.6 months were included. Patients had to meet Milan criteria and, since 2014, alpha-fetoprotein score to be listed. Patients with HCC recurrence were classified into early (≤2 y) and late recurrence (>2 y) and were retrospectively reviewed. RESULTS Patients who developed recurrence (75 patients, 17%) had more tumors outside Milan and University of California San Francisco criteria, high alpha-fetoprotein score, and microvascular invasion at pathology. Early recurrence developed in 46 patients (61.3%); the overall 5- and 10-year survival rates of these patients from time of LT were 6.7% and 0%, which were significantly lower than those with late recurrence 64.0% and 27.1%, respectively (P < 0.001). The median survival times from the diagnosis of HCC recurrence were 15 and 17 months, respectively, in the 2 groups (P < 0.001). Multivariable Cox regression analysis identified alcoholic cirrhosis as etiology of the underlying liver disease (hazard ratio [HR] = 3.074; P = 0.007), bilobar tumor at time of LT (HR = 2.001; P = 0.037), and a tumor size (>50 mm) in the explant (HR = 1.277; P = 0.045) as independent predictors of early recurrence. CONCLUSIONS Improving the prediction of early HCC recurrence could optimize patient selection for LT, potential adjuvant therapy with new targeted drugs and hence, improve long-term survival.
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64
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HCC: role of pre- and post-treatment tumor biology in driving adverse outcomes and rare responses to therapy. Abdom Radiol (NY) 2021; 46:3686-3697. [PMID: 34195886 DOI: 10.1007/s00261-021-03192-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022]
Abstract
Liver cancer is the fastest-growing cause of cancer deaths in the United States and is a complex disease. The response of hepatocellular carcinoma (HCC) to treatment can be variable. Predicting response to determine the most effective therapy is an active area of research. Our understanding of underlying factors which drive response to therapy is continually increasing. As more therapies for the treatment of this disease evolve, it is crucial to identify and match the ideal therapy for a particular tumor and patient. The potential predicative imaging features of tumor behavior, while of research interest, have not been validated for clinical use and do not currently inform treatment planning. If further validated though, prognostic features may be used in the future to personalize treatment plans according to individual patients and tumors. Unexpected post-treatment responses such as potential tumor biology changes and abscopal effect which are important to be aware of. This review is intended for radiologists who routinely interpret post treatment HCC imaging and is designed to increase their cognizance about how HCC tumor biology drives response to therapy and explore rare responses to therapy.
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65
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Nitta H, Younès A, El-Domiaty N, Karam V, Sobesky R, Vibert E, Coilly A, Maria Antonini T, De Martin E, Cherqui D, Baba H, Rosmorduc O, Adam R, Samuel D, Saliba F. High trough levels of everolimus combined to sorafenib improve patients survival after hepatocellular carcinoma recurrence in liver transplant recipients. Transpl Int 2021; 34:1293-1305. [PMID: 33932239 DOI: 10.1111/tri.13897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/19/2021] [Accepted: 04/21/2021] [Indexed: 12/21/2022]
Abstract
Recurrence of hepatocellular carcinoma (HCC) following liver transplantation (LT) occurs in 10%-20% of patients transplanted for HCC. The treatment of HCC recurrence after LT remains a challenge. Consecutive patients who underwent LT for HCC between 2005 and 2015 at our center were recruited. Characteristics of patients with recurrence, modalities of treatment and outcome were collected retrospectively. Patient survival was analyzed according to HCC recurrence therapeutic strategy. Among 306 transplanted patients, 43 patients (14.1%) developed recurrence with a median survival time after recurrence of 10.9 months (95%CI: 6.6-18.6). Survival of patients treated with Sorafenib (SOR) and everolimus (EVL) (n = 19) was significantly better than that of the group treated with other strategies (n = 24) (P = 0.001). Multivariable analysis demonstrated that SOR plus EVL therapy and absence of dissemination at diagnosis of recurrence were independent predictive factors of prolonged survival after recurrence. Among the patients who treated with EVL, survival of patients with controlled EVL blood trough levels ≥5 ng/ml was significantly better compared to those with EVL trough levels <5 ng/ml (P = 0.021). Combination therapy of sorafenib and everolimus was an independent predictor for better survival after HCC recurrence. Patients with controlled everolimus trough level ≥5 ng/ml might get the best survival benefit.
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Affiliation(s)
- Hidetoshi Nitta
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Aline Younès
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Nada El-Domiaty
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France.,Tropical Medicine Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Vincent Karam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Rodolphe Sobesky
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Eric Vibert
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Audrey Coilly
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Teresa Maria Antonini
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Daniel Cherqui
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Olivier Rosmorduc
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - René Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Didier Samuel
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris- Saclay, Villejuif, France
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Abstract
BACKGROUND Liver transplantation is the best treatment option for hepatocellular carcinoma (HCC). Although centers use strict selection criteria, there is a risk of recurrence, reaching up to 20% which are mostly observed within two years following the procedure. The survival after the recurrence is poor and it has been reported to be between 7-16 months. This poor prognosis is due to the systemic course of the recurrence even its presentation is local initially. RESULTS The clinical management and treatment algorithm of recurrence is challenging and there is no guideline regarding the situation. Staging of the disease and multi-disciplinary approach are important. The decision for choice of treatment is given depending on the localization and spread of the recurrence. Adjusting and switching the immunosuppressive therapy should be the first attempt. When the recurrence is limited or confined to resectable regions, surgery should be the choice of treatment. Multiple recurrence sites such as adrenal glands, lung, lymph nodes are not contraindication for curative surgery. Resection of the graft for intrahepatic recurrence is the most beneficial procedure for survival. If resection is not possible due to advanced hepatic disease, loco-regional therapies such as TACE, RF, microwave ablation should be considered. SBRT may be an alternative both for hepatic and extra-hepatic recurrence. In case of systemic disease, sorafenib should be the drug choice.
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Affiliation(s)
- Baris Sarici
- Departmant of Surgery, Liver Transplantation Institute, Inonu University, 44315, Malatya, Turkey.
| | - Burak Isik
- Departmant of Surgery, Liver Transplantation Institute, Inonu University, 44315, Malatya, Turkey
| | - Sezai Yilmaz
- Departmant of Surgery, Liver Transplantation Institute, Inonu University, 44315, Malatya, Turkey
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An FDG PET/CT metabolic parameter-based nomogram for predicting the early recurrence of hepatocellular carcinoma after liver transplantation. Eur J Nucl Med Mol Imaging 2021; 48:3656-3665. [PMID: 33813592 DOI: 10.1007/s00259-021-05328-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/21/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE To construct an FDG PET/CT metabolic parameter-based model to predict early recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT). METHODS A total of 62 patients with HCC after LT were enrolled with a follow-up period of 1 year. Basic clinical, pathology, and laboratory data, CT features (CPLC), and PET metabolic parameters (CPLCP) were collected for model construction. A CPLC nomogram without metabolic parameters and a CPLCP nomogram with metabolic parameters were established. The net reclassification index (NRI) and integrated discrimination improvement (IDI) of the two models were calculated. The constructed model was compared with Milan criteria and University of California San Francisco (UCSF) criteria. The time-dependent area under the receiver operating characteristic curve (time-AUC) was used to compare the efficiency of the models, and the bootstrap method was used to for verification. Harrell's concordance index (C-index) was used to evaluate the performance of these models. Decision curve analysis (DCA) was used to evaluate the clinical practicability of each model. RESULTS Thirty out of 62 patients experienced a recurrence during the 1-year follow-up. BCLC stage (P = 0.009), MVI (P = 0.032), AFP (P = 0.004), CTdmax (P = 0.033), and MTV (P = 0.039) were the independent predictors. The CPLC nomogram and the CPLCP nomogram were established. Compared with the CPLC nomogram, the NRI of the CPLCP nomogram increased by 38.98% (95% CI = -18.77-60.43%) and the IDI increased by 4.40% (95% CI = -1.00-16.62%). The AUC value of the CPLCP nomogram was higher than those of Milan criteria and UCSF criteria in the time-AUC curve. Moreover, the CPLCP nomogram had a higher C-index (0.774) than other models. Finally, the DCA curve showed that clinical practicability of the CPLCP nomogram outperformed the Milan criteria and UCSF criteria. CONCLUSIONS The CPLCP nomogram combining basic clinical data, pathology data, laboratory data, CT features, and PET metabolic parameters showed good efficacy and high clinical practicability in predicting the early recurrence of HCC after LT.
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68
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Systemic treatment of HCC in special populations. J Hepatol 2021; 74:931-943. [PMID: 33248171 DOI: 10.1016/j.jhep.2020.11.026] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/05/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
Recent years have seen significant progress in the systemic treatment of hepatocellular carcinoma (HCC), including the advent of immunotherapy. While several large phase III trials have provided the evidence for a multi-line treatment paradigm, they have focused on a highly selected group of patients by excluding potentially confounding comorbidities. As a result, high quality evidence for the systemic treatment of HCC in patients with various comorbidities is missing. This review summarises current knowledge on the use of approved medicines in patients with HIV, autoimmune disease, cardiovascular disease, diabetes, fibrolamellar HCC, mixed HCC-cholangiocarcinoma, decompensated cirrhosis (Child-Pugh B and C), a significant bleeding history, vascular invasion or portal vein thrombosis, as well as the elderly, those on haemodialysis, and those after solid organ transplantation. The article highlights relevant knowledge gaps and current clinical challenges. To improve the safety and efficacy of HCC treatment in these subgroups, future trials should be designed to specifically include patients with comorbidities.
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69
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Maccali C, Chagas AL, Boin I, Quiñonez E, Marciano S, Vilatobá M, Varón A, Anders M, Hoyos Duque S, Lima AS, Menendez J, Padilla-Machaca M, Poniachik J, Zapata R, Maraschio M, Chong Menéndez R, Muñoz L, Arufe D, Figueroa R, Soza A, Fauda M, Perales SR, Vergara Sandoval R, Bermudez C, Beltran O, Arenas Hoyos I, McCormack L, Mattera FJ, Gadano A, Parente García JH, Tani CM, Augusto Carneiro D'Albuquerque L, Carrilho FJ, Silva M, Piñero F. Recurrence of hepatocellular carcinoma after liver transplantation: Prognostic and predictive factors of survival in a Latin American cohort. Liver Int 2021; 41:851-862. [PMID: 33217193 DOI: 10.1111/liv.14736] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/20/2020] [Accepted: 11/16/2020] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIM Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) has a poor prognosis, and the adjusted effect of different treatments on post-recurrence survival (PRS) has not been well defined. This study aims to evaluate prognostic and predictive variables associated with PRS. METHODS This Latin American multicenter retrospective cohort study included HCC patients who underwent LT between the years 2005-2018. We evaluated the effect of baseline characteristics at time of HCC recurrence diagnosis and PRS (Cox regression analysis). Early recurrences were those occurring within 12 months of LT. To evaluate the adjusted treatment effect for HCC recurrence, a propensity score matching analysis was performed to assess the probability of having received any specific treatment for recurrence. RESULTS From a total of 1085 transplanted HCC patients, the cumulative incidence of recurrence was 16.6% (CI 13.5-20.3), with median time to recurrence of 13.0 months (IQR 6.0-26.0). Factors independently associated with PRS were early recurrence (47.6%), treatment with sorafenib and surgery/trans-arterial chemoembolization (TACE). Patients who underwent any treatment presented "early recurrences" less frequently, and more extrahepatic metastasis. This unbalanced distribution was included in the propensity score matching, with correct calibration and discrimination (receiving operator curve of 0.81 [CI 0.72;0.88]). After matching, the adjusted effect on PRS for any treatment was HR of 0.2 (0.10;0.33); P < .0001, for sorafenib therapy HR of 0.4 (0.27;0.77); P = .003, and for surgery/TACE HR of 0.4 (0.18;0.78); P = .009. CONCLUSION Although early recurrence was associated with worse outcome, even in this population, systemic or locoregional treatments were associated with better PRS.
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Affiliation(s)
- Claudia Maccali
- São Paulo Clinics Liver Cancer Group - Hospital das Clínicas Complex, Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Aline L Chagas
- São Paulo Clinics Liver Cancer Group - Hospital das Clínicas Complex, Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Ilka Boin
- Unit of Liver Transplantation, State University of Campinas, Campinas, Brazil
| | | | | | - Mario Vilatobá
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", México
| | | | | | - Sergio Hoyos Duque
- Hospital Pablo Tobón Uribe and Gastrohepatology Group, Universidad de Antioquia, Medellín, Colombia
| | - Agnaldo S Lima
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | | | - Rodrigo Zapata
- Clinica Alemana, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | | | | | | | - Diego Arufe
- Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | | | - Alejandro Soza
- Department of Gastroenterology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Martín Fauda
- Hospital Universitario Austral, Buenos Aires, Argentina
| | - Simone R Perales
- Unit of Liver Transplantation, State University of Campinas, Campinas, Brazil
| | | | - Carla Bermudez
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Isabel Arenas Hoyos
- Hospital Pablo Tobón Uribe and Gastrohepatology Group, Universidad de Antioquia, Medellín, Colombia
| | | | | | - Adrián Gadano
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Claudia Megumi Tani
- São Paulo Clinics Liver Cancer Group - Hospital das Clínicas Complex, Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- São Paulo Clinics Liver Cancer Group - Hospital das Clínicas Complex, Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Flair J Carrilho
- São Paulo Clinics Liver Cancer Group - Hospital das Clínicas Complex, Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Marcelo Silva
- Hospital Universitario Austral, Buenos Aires, Argentina.,Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires, Argentina
| | - Federico Piñero
- Hospital Universitario Austral, Buenos Aires, Argentina.,Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires, Argentina
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Minimization of Immunosuppressive Therapy Is Associated with Improved Survival of Liver Transplant Patients with Recurrent Hepatocellular Carcinoma. Cancers (Basel) 2021; 13:cancers13071617. [PMID: 33807392 PMCID: PMC8037838 DOI: 10.3390/cancers13071617] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Liver transplantation is a curative treatment option for a subset of patients with hepatocellular carcinoma (HCC). However, about twenty percent of patients develop recurrence in the graft or at extrahepatic sites, which is associated with limited therapeutic options and poor survival. To date, management of the immunosuppressive regimen after recurrence and its impact on survival are unknown. In this retrospective study, we analyzed a cohort of liver recipients with HCC recurrence. Our findings indicate that reduction of immunosuppressive therapy after diagnosis of recurrence has a beneficial impact on patient survival. Therefore, we propose further investigation into the management of immunosuppressive therapy following recurrence. Abstract Introduction: Recurrence of hepatocellular carcinoma (rHCC) after liver transplantation (LT) is associated with limited survival. Therefore, identification of factors that prolong survival in these patients is of great interest. Surgical resection, radiotherapy, and transarterial chemoembolization (TACE) are established interventions to improve outcomes in these patients; however, the impact of immunosuppression is unknown. Methods: All patients diagnosed with rHCC in the follow-up after LT were identified from a database of liver recipients transplanted between 1988 and 2019 at our institution (Charité Universitätsmedizin Berlin, Germany). Based on the immunosuppressive regimen following diagnosis of rHCC and the oncological treatment approach, survival analysis was performed. Results: Among 484 patients transplanted for HCC, 112 (23.1%) developed rHCC in the follow-up. Recurrent HCC was diagnosed at a median interval of 16.0 months (range 1.0–203.0), with the majority presenting early after transplantation (63.0%, <2 years). Median survival after rHCC diagnosis was 10.6 months (0.3–228.7). Reduction of immunosuppression was associated with improved survival, particularly in patients with palliative treatment (8.4 versus 3.0 months). In addition, greater reduction of immunosuppression seemed to be associated with greater prolongation of survival. Graft rejection after reduction was uncommon (n = 7, 6.8%) and did not result in any graft loss. Patients that underwent surgical resection showed improved survival rates (median 19.5 vs. 8.7 months). Conclusion: Reduction of immunosuppressive therapy after rHCC diagnosis is associated with prolonged survival in LT patients. Therefore, reduction of immunosuppression should be an early intervention following diagnosis. In addition, surgical resection should be attempted, if technically feasible and oncologically meaningful.
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Akhan O, Sarıkaya Y, Köksal A, Ünal E, Çiftçi T, Akıncı D. Irreversible Electroporation of Recurrent Hepatocellular Carcinoma After Liver Transplantation: Report of Two Cases. Cardiovasc Intervent Radiol 2021; 44:807-811. [PMID: 33655357 DOI: 10.1007/s00270-021-02784-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
The treatment strategies of post-transplant hepatocellular carcinoma (HCC) recurrence have not been completely clarified. Thermal ablative techniques have been increasingly performed for the treatment of post-transplant HCC recurrences. However, thermal ablation can create abnormal communication with the biliary tract and the ablation site by causing biliary injury. This abnormal communication may cause bacterial contamination and abscess formation. Irreversible electroporation (IRE) is a nonthermal ablative technique which may reduce the risk of abscess development at the ablation site due to its low risk of thermal injury to the biliary system. IRE may also preserve the perilesional blood vessels. This report describes two cases of post-transplant intrahepatic HCC recurrence which were successfully treated with IRE.
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Affiliation(s)
- Okan Akhan
- Departmant of Radiology, Faculty of Medicine, Hacettepe University, Sıhhiye, 06100, Ankara, Turkey.
| | - Yasin Sarıkaya
- Department of Radiology, Faculty of Medicine, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Ali Köksal
- Departmant of Radiology, Bayindir Hospital, Sogutozu, Ankara, Turkey
| | - Emre Ünal
- Departmant of Radiology, Faculty of Medicine, Hacettepe University, Sıhhiye, 06100, Ankara, Turkey
| | - Türkmen Çiftçi
- Departmant of Radiology, Faculty of Medicine, Hacettepe University, Sıhhiye, 06100, Ankara, Turkey
| | - Devrim Akıncı
- Departmant of Radiology, Faculty of Medicine, Hacettepe University, Sıhhiye, 06100, Ankara, Turkey
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Surveillance for HCC After Liver Transplantation: Increased Monitoring May Yield Aggressive Treatment Options and Improved Postrecurrence Survival. Transplantation 2021; 104:2105-2112. [PMID: 31972705 DOI: 10.1097/tp.0000000000003117] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Currently, no surveillance guidelines for hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) exist. In this retrospective, multicenter study, we have investigated the role of surveillance imaging on postrecurrence outcomes. METHODS Patients with recurrent HCC after LT from 2002 to 2016 were reviewed from 3 transplant centers (University of California San Francisco, Mayo Clinic Florida, and University of Toronto). For this study, we proposed the term cumulative exposure to surveillance (CETS) as a way to define the cumulative sum of all the protected intervals that each surveillance test provides. In our analysis, CETS has been treated as a continuous variable in months. RESULTS Two hundred twenty-three patients from 3 centers had recurrent HCC post-LT. The median follow-up was 31.3 months, and median time to recurrence was 13.3 months. Increasing CETS was associated with improved postrecurrence survival (hazard ratio, 0.94; P < 0.01) as was treatment of recurrence with resection or ablation (hazard ratio, 0.31; P < 0.001). An receiver operating characteristic curve (area under the curve, 0.64) for CETS covariate showed that 252 days of coverage (or 3 surveillance scans) within the first 24 months provided the highest probability for aggressive postrecurrence treatment. CONCLUSIONS In this review of 223 patients with post-LT HCC recurrence, we found that increasing CETS does lead to improved postrecurrence survival as well as a higher probability for aggressive recurrence treatment. We found that 252 days of monitoring (ie, 3 surveillance scans) in the first 24 months was associated with the ability to offer potentially curative treatment.
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A Meta-Analysis on the Rate of Hepatocellular Carcinoma Recurrence after Liver Transplant and Associations to Etiology, Alpha-Fetoprotein, Income and Ethnicity. J Clin Med 2021; 10:jcm10020238. [PMID: 33440759 PMCID: PMC7828059 DOI: 10.3390/jcm10020238] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/16/2020] [Accepted: 01/06/2021] [Indexed: 02/08/2023] Open
Abstract
Hepatocellular carcinoma (HCC) recurrence after liver transplant is associated with a poor prognosis and significantly increases morbidity and mortality among liver transplant patients. Therefore, this meta-analysis aims to evaluate the overall prevalence of HCC recurrence following liver transplant. Medline and Embase databases were searched, and a meta-analysis of proportions was conducted. Observational studies reporting the prevalence of recurrent hepatocellular carcinoma (HCC) after liver transplant were included, with the analysis being stratified by adherence to Milan criteria, ethnicity, socio-economic status, alpha fetoprotein (AFP) levels, living donor vs. deceased donor, and the underlying aetiology of the liver disease. A meta-regression on the date of the study completion was also performed. Of a total 40,495 patients, 3888 developed an HCC recurrence. The overall prevalence of recurrent HCC was 13% (CI: 0.12-0.15). Patients beyond the Milan criteria (MC) were more likely to recur than patients within MC. Asian populations had the greatest prevalence of HCC recurrence (19%; CI: 0.15-0.24) when compared to Western (12%; CI: 0.11-0.13) and Latin American populations (11%; CI: 0.09-0.14). The prevalence of recurrent HCC was the highest in patients infected with hepatitis B virus (HBV) (18%; CI: 0.11-0.27) compared to other aetiologies. A higher AFP also resulted in an increased recurrence. This highlights interesting differences based on ethnicity, income, and aetiology, and further studies are needed to determine the reasons for the disparity.
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Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is an increasingly common disease with liver transplant (LT) the best long-term therapy for early stage disease. We will review the data for assessing risk and managing recurrence for patients undergoing LT for HCC. AREAS COVERED In this review, we will provide an overview of methods of patient risk stratification in the post-transplant period, the data around surveillance for HCC recurrence, and the evidence for and against post-LT adjuvant treatment strategies. Finally, we will provide data regarding treatment options for patients with HCC recurrence after LT. Using an extensive search of original papers and society guidelines, this paper provides a comprehensive review of the data for assessing risk and managing recurrence for patients undergoing LT for HCC. EXPERT OPINION The development of multiple post-transplant prognostic scoring systems have allowed for improved assessment of recurrence risk and stratification of patients. However, the ability to translate this information into surveillance and therapeutic strategies that improve patient outcomes still have to be fully demonstrated. Post-LT immunosuppression strategies have been implemented in order to attempt to reduce this risk. Evidence-based strategies for managing recurrent HCC are evolving. We expect that with further understanding of individual patient characteristics will allow for optimal therapeutic selection.
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Affiliation(s)
- Daniel Hoffman
- Department of Surgery, University of California , San Francisco, CA, USA
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California , San Francisco, CA, USA
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75
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A National Survey of Hepatocellular Carcinoma Surveillance Practices Following Liver Transplantation. Transplant Direct 2020; 7:e638. [PMID: 33324743 PMCID: PMC7725259 DOI: 10.1097/txd.0000000000001086] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 12/13/2022] Open
Abstract
Recurrence of hepatocellular carcinoma (HCC) is an important predictor of survival after liver transplantation (LT). Recent studies show that early diagnosis, aggressive treatment, and surveillance may improve outcomes after HCC recurrence. We sought to determine the current practices and policies regarding surveillance for HCC recurrence after LT. Methods We conducted a web-based national survey of adult liver transplant centers in the United States to capture center-specific details of HCC surveillance post-LT. Responses were analyzed to generate numerical and graphical summaries. Results Of 101 eligible adult liver transplant centers, 48 (48%) centers across the United States responded to the survey. Among the participating centers, 79% stratified transplant recipients for HCC recurrence risk, while 19% did not have any risk stratification protocol. Explant microvascular invasion (mVI) was the most common factor used in risk stratification. Use of pretransplant serum biomarkers such as alpha-fetoprotein (AFP) was variable, with only 48% of the participating centers reporting specific "cutoff" values. While a majority of centers (88%) reported having a routine imaging protocol for HCC recurrence surveillance, there was considerable heterogeneity in terms of frequency and duration of such surveillance. Of the centers that did risk stratify patients to identify those at higher risk of HCC recurrence, about 50% did not change their surveillance protocol. Conclusions Our study affirms significant variability in center practices, and our results reflect the need for high-quality studies to guide risk stratification and surveillance for HCC recurrence.
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Piñero F, Thompson M, Marín JI, Silva M. Lenvatinib as first-line therapy for recurrent hepatocellular carcinoma after liver transplantation: Is the current evidence applicable to these patients? World J Transplant 2020; 10:297-306. [PMID: 33312891 PMCID: PMC7708877 DOI: 10.5500/wjt.v10.i11.297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/09/2020] [Accepted: 09/22/2020] [Indexed: 02/05/2023] Open
Abstract
Liver transplantation (LT) is one of the leading curative therapies for hepatocellular carcinoma (HCC). Despite recent optimization of transplant selection criteria, including alpha-feto protein, HCC recurrence after LT is still the leading cause of death in these patients. During the last decades, effective systemic treatments for HCC, including tyrosine kinase inhibitors and immunotherapy, have been approved. We describe the clinical scenario of a patient with recurrence of HCC five years after LT, who received lenvatinib as first-line systemic therapy to introduce systemic treatment options in this clinical setting. In this opinion review, we detail first and second-line systemic treatment options, focusing on those feasible for patients with recurrent HCC after LT. Several trials have evaluated new drugs to treat HCC patients in first and second-line therapy, but patients with recurrent HCC after LT have been excluded from these trials. Consequently, most of the evidence comes from observational retrospective studies. Whether tyrosine kinase inhibitors will remain the primary therapeutic approach in these patients, due to a relative contraindication for immunotherapy, may be clarified in the near future.
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Affiliation(s)
- Federico Piñero
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires B1629HJ, Argentina
- Hospital Universitario Austral, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires B1629HJ, Argentina
- Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires B1629HJ, Argentina
| | - Marcos Thompson
- Hospital Universitario Austral, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires B1629HJ, Argentina
| | - Juan Ignacio Marín
- Hepatology and Liver Transplantation Unit, Hospital Pablo Tobón Uribe, Medellín 240, Colombia
| | - Marcelo Silva
- Hospital Universitario Austral, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires B1629HJ, Argentina
- Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires B1629HJ, Argentina
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Liu B, Huang G, Xie X, Zhao Q, Su L, Liu M, Li X, Long J, Kuang M, Xie X. Feasibility and outcomes of percutaneous radiofrequency ablation for intrahepatic recurrent hepatocellular carcinoma after liver transplantation: a single-center experience. Int J Hyperthermia 2020; 37:1202-1209. [PMID: 33100042 DOI: 10.1080/02656736.2020.1834154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Baoxian Liu
- Division of Interventional Ultrasound, Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guangliang Huang
- Division of Interventional Ultrasound, Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaohua Xie
- Division of Interventional Ultrasound, Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qiang Zhao
- Department of Organ Transplantation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liya Su
- Division of Interventional Ultrasound, Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ming Liu
- Division of Interventional Ultrasound, Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoju Li
- Division of Interventional Ultrasound, Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianting Long
- Department of Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ming Kuang
- Division of Interventional Ultrasound, Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoyan Xie
- Division of Interventional Ultrasound, Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Moeckli B, Ivanics T, Claasen M, Toso C, Sapisochin G. Recent developments and ongoing trials in transplant oncology. Liver Int 2020; 40:2326-2344. [PMID: 33021344 DOI: 10.1111/liv.14621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022]
Abstract
Over the past two decades since the introduction of the Milan criteria, the field of transplant oncology has undergone a rapid development with a rising proportion of liver transplantations being performed for oncological indications. For many patients with liver tumours, transplantation represents the only chance for cure. However, many challenges remain, such as the adequate patient selection, management of post-transplant recurrence and refinement of neoadjuvant treatment protocols. This review provides an overview of the current state of the art of liver transplantation for oncological indications such as hepatocellular carcinoma, cholangiocarcinoma, colorectal liver metastasis and metastatic neuroendocrine tumours. We also summarize the ongoing research and explore future trends. Clinical trials are currently studying new diagnostic modalities, innovative pharmacological treatments, novel surgical techniques, downstaging regimens and new indications for liver transplantation. These emerging results will continue to shape the field of transplant oncology and provide us with the necessary tools to better select, treat and follow patients with liver tumours qualifying for liver transplantation.
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Affiliation(s)
- Beat Moeckli
- Department of Visceral and Transplantation Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Tommy Ivanics
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Marco Claasen
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Christian Toso
- Department of Visceral and Transplantation Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Division of General Surgery, University Health Network, Toronto, ON, Canada
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Ferrante ND, Pillai A, Singal AG. Update on the Diagnosis and Treatment of Hepatocellular Carcinoma. Gastroenterol Hepatol (N Y) 2020; 16:506-516. [PMID: 34017223 PMCID: PMC8132669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Hepatocellular carcinoma (HCC) is the fourth-leading cause of cancer-related mortality worldwide and the fastest-rising cause of cancer-related death in the United States. Given the strong association between tumor stage and prognosis, HCC surveillance is recommended in high-risk patients, including patients with cirrhosis from any etiology. The diagnosis can be made based on characteristic imaging findings, with histologic confirmation primarily reserved for patients with atypical imaging findings. Over the last 2 decades, the treatment landscape for HCC has experienced significant advances. Curative therapies, including liver transplantation and surgical resection, are available to patients with early-stage HCC; however, recent data have expanded the potentially eligible patient population. Locoregional therapies, including transarterial chemoembolization and transarterial radio-embolization, continue to be standard therapies for patients with intermediate-stage disease. The greatest advances have been observed for patients with advanced HCC, where there are now multiple first- and second-line options that can prolong survival by up to 2 years when used sequentially. The increasing complexity of HCC treatment options underlies the necessity for multidisciplinary care, which has been associated with increased survival. This article reviews data on best practices for early detection and diagnosis of HCC and the current status of treatment options.
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Affiliation(s)
- Nicole D. Ferrante
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics; Center for Clinical Epidemiology and Biostatistics; Center for Pharmacoepidemiology Research and Training; Perelman School of Medicine; University of Pennsylvania; Philadelphia; Pennsylvania
| | - Anjana Pillai
- Division of Gastroenterology and Hepatology, University of Chicago Medicine, Chicago, Illinois
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
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Walton M, Wade R, Claxton L, Sharif-Hurst S, Harden M, Patel J, Rowe I, Hodgson R, Eastwood A. Selective internal radiation therapies for unresectable early-, intermediate- or advanced-stage hepatocellular carcinoma: systematic review, network meta-analysis and economic evaluation. Health Technol Assess 2020; 24:1-264. [PMID: 33001024 PMCID: PMC7569721 DOI: 10.3310/hta24480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hepatocellular carcinoma is the most common type of primary liver cancer. Treatment choice is dependent on underlying liver dysfunction and cancer stage. Treatment options include conventional transarterial therapies for patients with intermediate-stage disease and systemic therapy [e.g. sorafenib (Nexavar®; Bayer plc, Leverkusen, Germany)] for patients with advanced-stage disease. Selective internal radiation therapies deliver radiation to liver tumours via microspheres that are injected into the hepatic artery. There are three selective internal radiation therapies: TheraSphere™ [BTG Ltd, London, UK (now Boston Scientific, Marlborough, MA, USA)], SIR-Spheres® (Sirtex Medical Ltd, Woburn, MA, USA) and QuiremSpheres® (Quirem Medical BV, Deventer, the Netherlands). OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of selective internal radiation therapies for treating patients with unresectable early-, intermediate- or advanced-stage hepatocellular carcinoma. METHODS A search was undertaken to identify clinical effectiveness literature relating to selective internal radiation therapies and relevant comparators for the treatment of hepatocellular carcinoma. Studies were critically appraised and summarised. The network of evidence was mapped to estimate the relative effectiveness of the different selective internal radiation therapies and comparator treatments. An economic analysis evaluated the cost-effectiveness. RESULTS Twenty studies were included in the clinical effectiveness review. Two large randomised controlled trials rated as having a low risk of bias [SARAH: Vilgrain V, Pereira H, Assenat E, Guiu B, Ilonca AD, Pageaux GP, et al. Efficacy and safety of selective internal radiotherapy with yttrium-90 resin microspheres compared with sorafenib in locally advanced and inoperable hepatocellular carcinoma (SARAH): an open-label randomised controlled Phase 3 trial. Lancet Oncol 2017;18:1624-36; and SIRveNIB: Chow PKH, Gandhi M, Tan SB, Khin MW, Khasbazar A, Ong J, et al. SIRveNIB: selective internal radiation therapy versus sorafenib in Asia-Pacific patients with hepatocellular carcinoma. J Clin Oncol 2018;36:1913-21] found no significant difference in overall survival or progression-free survival between SIR-Spheres and sorafenib (systemic therapy) in an advanced population, despite greater tumour response in the SIR-Spheres arm of both trials. There were some concerns regarding generalisability of the SARAH and SIRveNIB trials to UK practice. All other studies of SIR-Spheres, TheraSphere or QuiremSpheres were either rated as being at a high risk of bias or caused some concerns regarding bias. A network meta-analysis was conducted in adults with unresectable hepatocellular carcinoma who had Child-Pugh class A liver cirrhosis and were ineligible for conventional transarterial therapies. The analysis included the SARAH and SIRveNIB trials as well as a trial comparing lenvatinib (Kisplyx®; Eisai Ltd, Tokyo, Japan) (systemic therapy) with sorafenib. There were no meaningful differences in overall survival between any of the treatments. The base-case economic analysis suggested that TheraSphere may be cost-saving relative to both SIR-Spheres and QuiremSpheres. However, incremental cost differences between TheraSphere and SIR-Spheres were small. In a fully incremental analysis, which included confidential Patient Access Scheme discounts, lenvatinib was the most cost-effective treatment and dominated all selective internal radiation therapies. In pairwise comparisons of sorafenib with each selective internal radiation therapy, sorafenib also dominated all selective internal radiation therapies. LIMITATIONS The existing evidence cannot provide decision-makers with clear guidance on the comparative effectiveness of treatments in early- and intermediate-stage hepatocellular carcinoma or on the efficacy of TheraSphere or QuiremSpheres. CONCLUSIONS In the advanced-stage hepatocellular carcinoma population, two large randomised trials have shown that SIR-Spheres have similar clinical effectiveness to sorafenib. None of the selective internal radiation therapies was cost-effective, being more costly and less effective than lenvatinib, both at list price and with Patient Access Scheme discounts. FUTURE WORK Future studies may wish to include early- and intermediate-stage hepatocellular carcinoma patients and the low tumour burden/albumin-bilirubin 1 subgroup of advanced-stage patients. Future high-quality studies evaluating alternative selective internal radiation therapies would be beneficial. STUDY REGISTRATION This study is registered as PROSPERO CRD42019128383. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 48. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew Walton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Ros Wade
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lindsay Claxton
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Melissa Harden
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Jai Patel
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ian Rowe
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Alison Eastwood
- Centre for Reviews and Dissemination, University of York, York, UK
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Boteon Y, Flores Carvalho MA, Panconesi R, Muiesan P, Schlegel A. Preventing Tumour Recurrence after Liver Transplantation: The Role of Machine Perfusion. Int J Mol Sci 2020; 21:E5791. [PMID: 32806712 PMCID: PMC7460879 DOI: 10.3390/ijms21165791] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 07/31/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023] Open
Abstract
Tumour recurrence is currently a hot topic in liver transplantation. The basic mechanisms are increasingly discussed, and, for example, recurrence of hepatocellular carcinoma is often described in pre-injured donor livers, which frequently suffer from significant ischemia/reperfusion injury. This review article highlights the underlying mechanisms and describes the specific tissue milieu required to promote tumour recurrence after liver transplantation. We summarise the current literature in this field and show risk factors that contribute to a pro-tumour-recurrent environment. Finally, the potential role of new machine perfusion technology is discussed, including the most recent data, which demonstrate a protective effect of hypothermic oxygenated perfusion before liver transplantation.
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Affiliation(s)
- Yuri Boteon
- Liver Unit, Albert Einstein Hospital, 05652–900 São Paulo, Brazil;
- Albert Einstein Jewish Institute for Education and Research, 05652–900 São Paulo, Brazil
| | - Mauricio Alfredo Flores Carvalho
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy; (M.A.F.C.); (R.P.); (P.M.)
| | - Rebecca Panconesi
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy; (M.A.F.C.); (R.P.); (P.M.)
| | - Paolo Muiesan
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy; (M.A.F.C.); (R.P.); (P.M.)
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham B15 2TT, UK
| | - Andrea Schlegel
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy; (M.A.F.C.); (R.P.); (P.M.)
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Yang Z, Wang S, Tian XY, Xie QF, Zhuang L, Li QY, Chen CZ, Zheng SS. Impact of treatment modalities on patients with recurrent hepatocellular carcinoma after liver transplantation: Preliminary experience. Hepatobiliary Pancreat Dis Int 2020; 19:365-370. [PMID: 32553774 DOI: 10.1016/j.hbpd.2020.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 06/01/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Post-liver transplantation (LT) hepatocellular carcinoma (HCC) recurrence still occurs in approximately 20% of patients and drastically affects their survival. This study aimed to evaluate the efficacy of various treatments for recurrent HCC after LT in a Chinese population. METHODS A total of 64 HCC patients with tumor recurrence after LT were enrolled in this study. Univariate and multivariate analyses were performed to identify factors affecting post-recurrence survival. RESULTS Of the 64 patients with recurrent HCC after LT, those who received radical resection followed by nonsurgical therapy had a median overall survival (OS) of 20.9 months after HCC recurrence, significantly superior to patients who received only nonsurgical therapy (9.4 months) or best supportive care (2.4 months). The one- and two-year OS following recurrence was favorable for patients receiving radical resection followed by nonsurgical therapy (93.8%, 52.6%), poor for patients receiving only nonsurgical therapy (30.8%, 10.8%), and dismal for patients receiving best supportive care (0%, 0%; overall P < 0.001). Median OS in sorafenib-tolerant patients treated with lenvatinib was 19.5 months, far surpassing the patients that discontinued sorafenib or were treated with regorafenib after sorafenib failure (12 months, P < 0.001). Compared with tacrolimus-based immunosuppressive therapy, OS was significantly increased with sirolimus-based therapy at one and two years after HCC recurrence (P = 0.035). Multivariate analysis showed radical resection combined with nonsurgical therapy for recurrent HCC and sorafenib-lenvatinib sequential therapy were independent favorable factors for post-recurrence survival. CONCLUSIONS Aggressive surgical intervention in well-selected patients significantly improves OS after recurrence. A multidisciplinary treatment approach is required to slow down disease progression for patients with unresectable recurrent HCC.
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Affiliation(s)
- Zhe Yang
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, 848 Dongxin Road, Hangzhou 310022, China
| | - Shuo Wang
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, 848 Dongxin Road, Hangzhou 310022, China
| | - Xin-Yao Tian
- Division of Hepatobiliary Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China
| | - Qin-Fen Xie
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, 848 Dongxin Road, Hangzhou 310022, China
| | - Li Zhuang
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, 848 Dongxin Road, Hangzhou 310022, China
| | - Qi-Yong Li
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, 848 Dongxin Road, Hangzhou 310022, China
| | - Cheng-Ze Chen
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, 848 Dongxin Road, Hangzhou 310022, China
| | - Shu-Sen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, 848 Dongxin Road, Hangzhou 310022, China; Division of Hepatobiliary Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China; National Clinical Research Center of Infectious Diseases, 79 Qingchun Road, Hangzhou 310003, China.
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83
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Au KP, Chiang CL, Chan ACY, Cheung TT, Lo CM, Chok KSH. Initial experience with stereotactic body radiotherapy for intrahepatic hepatocellular carcinoma recurrence after liver transplantation. World J Clin Cases 2020; 8:2758-2768. [PMID: 32742986 PMCID: PMC7360706 DOI: 10.12998/wjcc.v8.i13.2758] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Graft hepatocellular carcinoma (HCC) recurrence after liver transplant is more frequently encountered. Graft hepatectomy is technically challenging and is associated with high morbidity. Stereotactic body radiation therapy (SBRT) has been shown to be safe and effective for the treatment of primary HCC. However, its role in HCC recurrence in a liver graft remains unclear.
AIM To evaluate the safety and efficacy of SBRT for the treatment of graft HCC recurrence after liver transplantation.
METHODS A retrospective study was conducted. From 2012 to 2018, 6 patients with intrahepatic HCC recurrence after liver transplant were treated with SBRT at Queen Mary Hospital, the University of Hong Kong. The primary outcome was time to overall disease progression and secondary outcomes were time to local progression and best local response, as assessed with the Modified response Evaluation Criteria for Solid Tumours criteria. Patients were monitored for treatment related toxicities and graft dysfunction.
RESULTS A total of 9 treatment courses were given for 13 tumours. The median tumour size was 2.3 cm (range 0.7-3.6 cm). Two (22%) patients had inferior vena cava tumour thrombus. The best local treatment response was: 5 (55%) complete response, 1 (11%) partial response and 3 (33%) stable disease. After a median follow up duration of 15.5 mo, no local progression or mortality was yet observed. The median time to overall disease progression was 6.5 mo. There were 6 regional progression in the liver graft (67%) and 2 distant progression in the lung (22%). There was no grade 3 or above toxicity and there was no graft dysfunction after SBRT.
CONCLUSION SBRT appears to be safe in this context. Regional progression is the mode of failure.
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Affiliation(s)
- Kin Pan Au
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong 999077, China
| | - Chi Leung Chiang
- Department of Clinical Oncology, Queen Mary Hospital, the University of Hong Kong, Hong Kong 999077, China
| | - Albert Chi Yan Chan
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong 999077, China
| | - Tan To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong 999077, China
| | - Chung Mau Lo
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong 999077, China
| | - Kenneth Siu Ho Chok
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong 999077, China
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84
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Simsek C, Kim A, Ma M, Danis N, Gurakar M, Cameron AM, Philosophe B, Garonzik-Wang J, Ottmann S, Gurakar A, Saberi B. Recurrence of hepatocellular carcinoma following deceased donor liver transplantation: case series. ACTA ACUST UNITED AC 2020; 6. [PMID: 32582866 PMCID: PMC7313412 DOI: 10.20517/2394-5079.2019.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aim We aimed to study the clinical and pathological characteristics of liver transplant recipients with hepatocellular carcinoma recurrence. Methods We reviewed the data for 26 patients who had tumor recurrence after deceased donor liver transplant for hepatocellular carcinoma at the Johns Hopkins Hospital from January 2005 to December 2015. Results In total, 88% of recipients were males. The mean age was 59 years. On explant, poor differentiation was detected in 43%, while 73% had microvascular invasion. Overall, 62% were diagnosed to be outside of Milan criteria. Out of these, 15% met the criteria for downstaging. Twenty (77%) patients had pre-transplant alpha fetoprotein levels ≥ 20 ng/mL. In 54% of patients, the location of hepatocellular carcinoma (HCC) recurrence was extrahepatic, followed by intrahepatic in 31% and both intra- and extrahepatic in 15%. The post-transplant tumor recurrence was diagnosed at a mean of 427 days (range 34-1502). Fifty percent of HCC recurrences were diagnosed within one year following liver transplant. Twenty (77%) patients received treatment for their recurrent HCC: external radiation (n = 10), surgical resections (n = 8; brain 4, spine 2, bone 1, and Whipple surgery 1), sorafenib (n = 7), locoregional therapy (n = 5). Overall, 24 out of 26 (92%) recipients died within four years after the transplant. Conclusion HCC recurrence after liver transplant is infrequent. More than fifty percent of HCC recurrences following liver transplant are extrahepatic. Despite better recipient selection for liver transplant, the curative options are limited in recurrent cases and associated with extremely poor outcomes.
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Affiliation(s)
- Cem Simsek
- Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology-Transplant Hepatology, Baltimore, MD 21205, USA
| | - Amy Kim
- Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology-Transplant Hepatology, Baltimore, MD 21205, USA
| | - Michelle Ma
- Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology-Transplant Hepatology, Baltimore, MD 21205, USA
| | - Nilay Danis
- Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology-Transplant Hepatology, Baltimore, MD 21205, USA
| | - Merve Gurakar
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Andrew M Cameron
- Johns Hopkins University School of Medicine, Division of Transplant Surgery, Baltimore, MD 21205, USA
| | - Benjamin Philosophe
- Johns Hopkins University School of Medicine, Division of Transplant Surgery, Baltimore, MD 21205, USA
| | - Jacqueline Garonzik-Wang
- Johns Hopkins University School of Medicine, Division of Transplant Surgery, Baltimore, MD 21205, USA
| | - Shane Ottmann
- Johns Hopkins University School of Medicine, Division of Transplant Surgery, Baltimore, MD 21205, USA
| | - Ahmet Gurakar
- Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology-Transplant Hepatology, Baltimore, MD 21205, USA
| | - Behnam Saberi
- Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology-Transplant Hepatology, Baltimore, MD 21205, USA
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85
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Tohyama T, Sakamoto K, Tamura K, Nakamura T, Watanabe J, Wakisaka H, Takada Y. Pharyngeal metastasis following living-donor liver transplantation for hepatocellular carcinoma: a case report and literature review. World J Surg Oncol 2020; 18:109. [PMID: 32466780 PMCID: PMC7257203 DOI: 10.1186/s12957-020-01873-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/06/2020] [Indexed: 12/12/2022] Open
Abstract
Background The most common sites of recurrence after liver transplantation for hepatocellular carcinoma (HCC) have been reported to be the liver, lung, bone, and adrenal glands, but there have also been many reports of cases of multiple recurrence. The prognosis after recurrence is poor, with reported median survival after recurrence of HCC ranging from 9 to 19 months. Here, we report a case of long-term survival after recurrence of pharyngeal metastasis following living-donor liver transplantation (LDLT) for HCC within the Milan criteria, by resection of the metastatic region and cervical lymph node dissection. Case presentation A 47-year-old man with a Model End-stage Liver Disease (MELD) score of 11 underwent LDLT for HCC within the Milan criteria for liver cirrhosis associated with hepatitis B virus infection, with his 48-year-old elder brother as the living donor. One year and 10 months after liver transplantation, he visited a nearby hospital with a chief complaint of discomfort on swallowing. A pedunculated polyp was found in the hypopharynx, and biopsy revealed HCC metastasis. We performed pharyngeal polypectomy. Two years later, cervical lymph node metastasis appeared, and neck lymph node dissection was performed. Although recurrence subsequently occurred three times in the grafted liver, the patient is still alive 12 years and 10 months after recurrence of pharyngeal metastasis. He is now a tumor-free outpatient taking sorafenib. Conclusion It is necessary to recognize that the nasopharyngeal region is a potential site of HCC metastasis. Prognostic improvement can be expected with close follow-up, early detection, and multidisciplinary treatment, including radical resection.
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Affiliation(s)
- Taiji Tohyama
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan. .,Department of Surgery, Kurashiki Medical Center, Bakuro-cho, Kurashiki, Okayama, 710-8522, Japan.
| | - Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kei Tamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Taro Nakamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Jota Watanabe
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Hiroyuki Wakisaka
- Laboratory of Head and Neck Surgery, Ehime Prefectural University of Health Sciences, 543, Takoda, Tobe-cho, Iyo-gun, Ehime, 791-2101, Japan
| | - Yasutsugu Takada
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
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86
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Ju MR, Yopp AC. Evolving thresholds for liver transplantation in hepatocellular carcinoma: A Western experience. Ann Gastroenterol Surg 2020; 4:208-215. [PMID: 32490334 PMCID: PMC7240148 DOI: 10.1002/ags3.12316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/09/2020] [Accepted: 01/16/2020] [Indexed: 12/13/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related deaths worldwide. Once considered an experimental treatment with dismal survival rates, liver transplantation for HCC entered a new era with the establishment of the Milan criteria over 20 years ago. In the modern post-Milan-criteria era, 5-year survival outcomes are now upwards of 70% in select patients. Liver transplantation (LT) is now considered the optimal treatment for patients with moderate to severe cirrhosis and HCC, and the rates of transplantation in the United States are continuing to rise. Several expanded selection criteria have been proposed for determining which patients with HCC should be candidates for undergoing LT with similar overall and recurrence-free survival rates to patients within the Milan criteria. There is also a growing experience with downstaging of patients who fall outside conventional LT criteria at the time of HCC diagnosis with the goal of tumor shrinkage via locoregional therapies to become a candidate for transplantation. The aim of this review article is to characterize the various patient selection criteria for LT, discuss balancing organ stewardship with outcome measures in HCC patients, present evidence on the role of downstaging for large tumors, and explore future directions of LT for HCC.
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Affiliation(s)
- Michelle R. Ju
- Division of Surgical OncologyDepartment of SurgeryUniversity of Texas Southwestern Medical CenterDallasTexas
| | - Adam C. Yopp
- Division of Surgical OncologyDepartment of SurgeryUniversity of Texas Southwestern Medical CenterDallasTexas
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87
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Pandey A, Cohen DJ. Ipilumumab for hepatocellular cancer in a liver transplant recipient, with durable response, tolerance and without allograft rejection. Immunotherapy 2020; 12:287-292. [PMID: 32248723 DOI: 10.2217/imt-2020-0014] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Organ transplant recipients are not routinely included in clinical trials, and as a result there is a paucity of data to guide clinicians in the treatment of malignancies in this unique patient population. This is a case report and focused review of the treatment of hepatocellular carcinoma in patients with orthotopic liver transplants. We describe a single patient's treatment over a period of 4 years from the time of diagnosis to submission of this case report. We submit evidence that the anti-CTLA-4 antibody ipilimumab can produce a durable response, with a tolerable adverse event profile and without associated allograft rejection.
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Affiliation(s)
- Abhishek Pandey
- Department of Internal Medicine, New York University School of Medicine, NYU Langone Health, 550 1st Avenue, New York, NY 10016, USA
| | - Deirdre J Cohen
- Department of Medicine, NYU Langone Health, Perlmutter Cancer Center, New York, NY 10016, USA
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88
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Experience With Early Sorafenib Treatment With mTOR Inhibitors in Hepatocellular Carcinoma Recurring After Liver Transplantation. Transplantation 2020; 104:568-574. [DOI: 10.1097/tp.0000000000002955] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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89
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Li H, Yang Z, Li R, Lu S, Lu W. Regorafenib Combined With Sirolimus Achieves Successful Treatment of Diffuse Double Lung Metastasis After Liver Transplantation in Giant Liver Cancer Beyond Transplantation Criteria: A Case Report. Transplant Proc 2020; 52:634-637. [PMID: 32035675 DOI: 10.1016/j.transproceed.2019.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/25/2019] [Accepted: 12/15/2019] [Indexed: 02/06/2023]
Abstract
The treatment of hepatocellular carcinoma after liver transplantation (LT) is controversial because of its high recurrence rate and low survival rate. Here, we report a case of early diffuse bilateral lung metastasis after LT beyond the Milan transplantation criteria (d = 18 cm, α-fetoprotein >24,000 ng/mL) that successfully achieved 1-year tumor-free remission survival with sirolimus combined with regorafenib. The donor source of the liver is legal, and this study followed the guidelines of the Helsinki Congress in this LT. To the best of our knowledge, this is the first report of the use of regorafenib as a first-line agent combined with sirolimus to treat recurrent hepatocellular carcinoma after LT, and this case expands the indications for LT.
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Affiliation(s)
- Huixin Li
- Department of Hepatobiliary Surgery, First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhanyu Yang
- Department of Hepatobiliary Surgery, First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Ruofan Li
- Department of Hepatobiliary Surgery, First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Shichun Lu
- Department of Hepatobiliary Surgery, First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Wenping Lu
- Department of Hepatobiliary Surgery, First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China.
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90
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Verna EC, Patel YA, Aggarwal A, Desai AP, Frenette C, Pillai AA, Salgia R, Seetharam A, Sharma P, Sherman C, Tsoulfas G, Yao FY. Liver transplantation for hepatocellular carcinoma: Management after the transplant. Am J Transplant 2020; 20:333-347. [PMID: 31710773 DOI: 10.1111/ajt.15697] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/03/2019] [Accepted: 10/21/2019] [Indexed: 02/05/2023]
Abstract
Hepatocellular carcinoma (HCC) is an increasingly common indication for liver transplantation (LT) in the United States and in many parts of the world. In the last decade, significant work has been done to better understand how to risk stratify LT candidates for recurrence of HCC following transplant using a combination of biomarker and imaging findings. However, despite the high frequency of HCC in the LT population, guidance regarding posttransplant management is lacking. In particular, there is no current evidence to support specific post-LT surveillance strategies, leading to significant heterogeneity in practices. In addition, there are no current recommendations regarding recurrence prevention, including immunosuppression regimen or secondary prevention with adjuvant chemotherapy. Finally, guidance on treatment of disease recurrence is also lacking and there is significant controversy about the use of immunotherapy in transplant recipients due to the risk of rejection. Thus, outcomes for patients with recurrence are poor. This paper therefore provides a comprehensive review of the current literature on post-LT management of patients with HCC and identifies gaps in our current knowledge that are in urgent need of further investigation.
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Affiliation(s)
- Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University, New York, New York, USA
| | - Yuval A Patel
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Avin Aggarwal
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Arizona College of Medicine, Tuscon, Arizona, USA
| | - Archita P Desai
- Division of Gastroenterology, Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Catherine Frenette
- Scripps Center for Organ Transplantation, Scripps Green Hospital, La Jolla, California, USA
| | - Anjana A Pillai
- Center for Liver Diseases, University of Chicago Medicine, Chicago, Illinois, USA
| | - Reena Salgia
- Department of Gastroenterology/Hepatology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Anil Seetharam
- Transplant Hepatology, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Pratima Sharma
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Courtney Sherman
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Georgios Tsoulfas
- Department of Surgery, Aristotle University School of Medicine, Thessaloniki, Greece
| | - Francis Y Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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91
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Kim B, Kahn J, Terrault NA. Liver transplantation as therapy for hepatocellular carcinoma. Liver Int 2020; 40 Suppl 1:116-121. [PMID: 32077598 DOI: 10.1111/liv.14346] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 12/26/2019] [Indexed: 12/20/2022]
Abstract
Liver transplantation can provide curative therapy in selected patients with hepatocellular carcinoma. Well-established criteria include tumours that are within the Milan criteria and without evidence of vascular or extrahepatic involvement. Modest expansion of the original Milan criteria has been shown to achieve similar recurrence-free survival rates. Overall, HCC recurrence occurs in about 10%-15% of LT recipients, most within the first 2 years. Predictors of post-transplant recurrence include high alpha-foetoprotein, macrovascular invasion, as well as tumour size and number. Once HCC recurs after transplantation, prognosis is poor, though better if detected early. There is no established role for systemic prophylactic post-transplant chemotherapy.
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Affiliation(s)
- Brian Kim
- Department of Medicine and Division of GI and Liver Diseases, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey Kahn
- Department of Medicine and Division of GI and Liver Diseases, University of Southern California, Los Angeles, CA, USA
| | - Norah A Terrault
- Department of Medicine and Division of GI and Liver Diseases, University of Southern California, Los Angeles, CA, USA
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92
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Posttransplantation HCC Surveillance: Impact on Outcome or Byproduct of Biology? Transplantation 2020; 104:1997-1998. [PMID: 31996664 DOI: 10.1097/tp.0000000000003140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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93
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Liu J, Chen D, Yao B, Guan G, Liu C, Jin X, Wang X, Liu P, Sun Y, Zang Y. Effects of donor-recipient combinational CYP3A5 genotypes on tacrolimus dosing in Chinese DDLT adult recipients. Int Immunopharmacol 2020; 80:106188. [PMID: 31931373 DOI: 10.1016/j.intimp.2020.106188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND For liver transplant (LT) recipients, the liver CYP3A5 metabolic enzymes are determined by the donor's genes, whereas the intestinal enzymes are encoded by the recipient's genes. This combinational form confuses the metabolism of tacrolimus (Tac) in vivo. This retrospective study was conducted to investigate the combined effects of donor-recipient CYP3A5 genotype on tacrolimus pharmacokinetics in Chinese LT adult patients. METHODS Three hundred seventy-three LT patients from two Chinese organ transplant centers were enrolled, and both recipients and donors were genotyped for CYP3A5. Patients were divided into four groups (RNDN, REDN, RNDE, REDE) according to CYP3A5*3 allele expressers (E) and non-expressers (N) in recipients (R) and donors (D). The dose-adjusted trough levels (C/D ratio) of tacrolimus were assessed for six months among the four groups. Multiple linear regression analysis was performed to assess the effects of the CYP3A5 genotype and several clinical variables on the C/D ratio. RESULTS The RNDN group consistently had the largest C/D ratio throughout the entire study period, whereas the REDE group had the smallest C/D ratio, and the REDN/RNDE group had an intermediate (RNDN > REDN/RNDE > REDE) ratio. The C/D ratio in the RNDN and RNDE groups was higher than that in the REDN and REDE groups within three months, respectively; the ratio in the RNDN group was higher than that in the RNDE group, and the ratio in the REDN group was higher than that in the REDE group at six months. The effect of the donor CYP3A5 genotype on C/D values was observed throughout the timeline, and the recipient's genetics correlated only in the first three months. Among non-genetic factors, hemoglobin (HGB) and albumin (ALB) were correlated with Tac C/D values at a few time points. CONCLUSIONS To predict the initial dose of tacrolimus in LT patients, both donor and recipient CYP3A5 genotypes must be taken into account; during the maintenance phase of targeted blood concentration, the donor's CYP3A5 genotype may be of prime importance, especially at three months after transplantation.
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Affiliation(s)
- Jianyu Liu
- Institute of Transplantation Science, Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Dexi Chen
- Institute of Hepatology, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Bo Yao
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Ge Guan
- Institute of Transplantation Science, Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Chao Liu
- Institute of Transplantation Science, Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xinmin Jin
- Institute of Transplantation Science, Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xin Wang
- Institute of Transplantation Science, Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Peng Liu
- Institute of Transplantation Science, Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yandong Sun
- Institute of Transplantation Science, Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yunjin Zang
- Institute of Transplantation Science, Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China.
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94
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Kumar A, Acharya SK, Singh SP, Arora A, Dhiman RK, Aggarwal R, Anand AC, Bhangui P, Chawla YK, Datta Gupta S, Dixit VK, Duseja A, Kalra N, Kar P, Kulkarni SS, Kumar R, Kumar M, Madhavan R, Mohan Prasad V, Mukund A, Nagral A, Panda D, Paul SB, Rao PN, Rela M, Sahu MK, Saraswat VA, Shah SR, Shalimar, Sharma P, Taneja S, Wadhawan M. 2019 Update of Indian National Association for Study of the Liver Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri II Recommendations. J Clin Exp Hepatol 2020; 10:43-80. [PMID: 32025166 PMCID: PMC6995891 DOI: 10.1016/j.jceh.2019.09.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/15/2019] [Indexed: 01/27/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality, and healthcare expenditure in patients with chronic liver disease in India. The Indian National Association for Study of the Liver (INASL) had published its first guidelines on diagnosis and management of HCC (The Puri Recommendations) in 2014, and these guidelines were very well received by the healthcare community involved in diagnosis and management of HCC in India and neighboring countries. However, since 2014, many new developments have taken place in the field of HCC diagnosis and management, hence INASL endeavored to update its 2014 consensus guidelines. A new Task Force on HCC was constituted that reviewed the previous guidelines as well as the recent developments in various aspects of HCC that needed to be incorporated in the new guidelines. A 2-day round table discussion was held on 5th and 6th May 2018 at Puri, Odisha, to discuss, debate, and finalize the revised consensus statements. Each statement of the guideline was graded according to the Grading of Recommendations Assessment Development and Evaluation system with minor modifications. We present here the 2019 Update of INASL Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri-2 Recommendations.
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Key Words
- AFP, alpha-fetoprotein
- AIH, autoimmune hepatitis
- ALT, alanine aminotransferase
- DAA, direct-acting antiviral
- DALY, disability-adjusted life-year
- DNA, deoxyribonucleic acid
- GRADE, Grading of Recommendations Assessment Development and Evaluation
- Gd-BOPTA, gadolinium benzyloxypropionictetraacetate
- Gd-EOB-DTPA, gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid
- HBV, hepatitis B virus
- HBeAg, hepatitis B envelope antigen
- HCC, hepatocellular carcinoma
- HIV, human immunodeficiency virus
- IARC, International Agency for Research on Cancer
- IFN, interferon
- INASL, Indian National Association for Study of the Liver
- MiRNA, micro-RNA
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- PIVKA, protein induced by vitamin K absence
- RFA
- RNA, ribonucleic acid
- SVR, sustained virological response
- TACE
- TACE, trans-arterial chemoembolization
- TARE, transarterial radioembolization
- TNF, tumor necrosis factor
- WHO, World Health Organization
- liver cancer
- targeted therapy
- transplant
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Affiliation(s)
- Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226 014, India
| | - Anil C. Anand
- Department of Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110 076, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Siddhartha Datta Gupta
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Vinod K. Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, 221 005, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Naveen Kalra
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Premashish Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Suyash S. Kulkarni
- Division of Interventional Radiology, Tata Memorial Hospital, Dr. E Borges Road, Parel, Mumbai, Maharashtra, 400 012, India
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver & Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Ram Madhavan
- Department of Radiation Oncology, Amrita Institute of Medical Sciences, Amrita University, Peeliyadu Road, Ponekkara, Edappally, Kochi, Kerala, 682 041, India
| | - V.G. Mohan Prasad
- Department of Gastroenterology, VGM Gastro Centre, 2100, Trichy Road, Rajalakshmi Mills Stop, Singanallur, Coimbatore, Tamil Nadu, 641 005, India
| | - Amar Mukund
- Department of Radiology, Institute of Liver & Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
| | - Dipanjan Panda
- Department of Oncology, Institutes of Cancer, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110 076, India
| | - Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Padaki N. Rao
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, No. 6-3-661, Punjagutta Road, Somajiguda, Hyderabad, Telangana, 500 082, India
| | - Mohamed Rela
- The Institute of Liver Disease & Transplantation, Gleneagles Global Health City, 439, Cheran Nagar, Perumbakkam, Chennai, Tamil Nadu, 600 100, India
| | - Manoj K. Sahu
- Department of Medical Gastroenterology, IMS & SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, Odisha 751 003, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226 014, India
| | - Samir R. Shah
- Department of Gastroenterology, Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Praveen Sharma
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Manav Wadhawan
- Liver & Digestive Diseases Institute, Institute of Liver & Digestive Diseases, BLK Super Specialty Hospital, Delhi, 110 005, India
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Qin JM. Postoperative recurrent factors and therapeutic and preventive strategies for hepatocellular carcinoma. Shijie Huaren Xiaohua Zazhi 2019; 27:1407-1418. [DOI: 10.11569/wcjd.v27.i23.1407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in China. The recurrence rate is about 50% at 3 years and over 70% at 5 years after hepatectomy for HCC. The high recurrence rate seriously affects the curative effect and long-term survival of patients with HCC, and is the primary cause of death after operation. Postoperative recurrence of HCC is a complex multi-step, multi-factorial process involving three factors: the body, microenvironment, and tumor tissue, which include body immunity, local pH value, interstitial pressure, vascular osmotic pressure, inflammatory reaction, tumor cell adhesion, extracellular matrix degradation, cell migration, cell proliferation, and tumor angiogenesis. HCC recurrence is closely related to abnormal gene expression and related molecular function changes, but the molecular mechanism has not been fully elucidated. How to treat the recurrence of HCC after operation directly affects the prognosis of patients with HCC, and treatments include reoperation, liver transplantation, local minimally invasive treatment, radiotherapy, molecular targeted drugs, immunotherapy, and traditional Chinese medicine treatment. It is difficult to cure or control tumor progression by a single therapy. Two or more therapeutic methods need to be combined organically to achieve a synergistic therapeutic effect. According to the specific situation of patients with HCC, it is key to analyze the individual characteristics of patients, to combine the clinical experience of clinicians and the best evidence, to adopt the individualized treatment plan, and to choose the appropriate treatment methods. For HCC patients with high-risk factors for recurrence, selecting the appropriate treatment is important to reduce the recurrence of HCC after operation and prolong the survival of patients.
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Affiliation(s)
- Jian-Min Qin
- Department of General Surgery, the Third Hospital Affiliated to Naval Military Medical University, Shanghai 201805, China
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96
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Chao JS, Zhao SL, Ou-yang SW, Qian YB, Liu AQ, Tang HM, Zhong L, Peng ZH, Xu JM, Sun HC. Post-transplant infection improves outcome of hepatocellular carcinoma patients after orthotopic liver transplantation. World J Gastroenterol 2019; 25:5630-5640. [PMID: 31602163 PMCID: PMC6785522 DOI: 10.3748/wjg.v25.i37.5630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/22/2019] [Accepted: 09/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tumor recurrence after orthotopic liver transplantation (OLT) remains a serious threat for long-term survival of the recipients with hepatocellular carcinoma (HCC), since very few factors or measures have shown impact on overcoming HCC recurrence after OLT. Postoperative infection suppresses tumor recurrence and improves patient survival in lung cancer and malignant glioma probably via stimulating the immune system. Post-transplant infection (PTI), a common complication, is deemed to be harmful for the liver transplant recipients from a short-term perspective. Nevertheless, whether PTI inhibits HCC recurrence after OLT and prolongs the long-term survival of HCC patients needs to be clarified.
AIM To investigate the potential influence of PTI on the survival and tumor recurrence of patients with HCC after OLT.
METHODS A total of 238 patients with HCC who underwent OLT between August 2002 and July 2016 at our center were retrospectively included and accordingly subdivided into a PTI group (53 patients) and a non-PTI group (185 patients). Univariate analyses, including the differences of overall survival (OS), recurrence-free survival (RFS), and post-recurrence survival (PRS), between the PTI and non-PTI subgroups as well as survival curve analysis were performed by the Kaplan-Meier method, and the differences were compared using the log rank test. The variables with a P-value < 0.1 in univariate analyses were included in the multivariate survival analysis by using a Cox proportional-hazards model.
RESULTS The 1-, 3-, and 5-year OS and RFS rates of the whole cohort were 86.6%, 69.0%, and 63.6%, and 75.7%, 60.0%, and 57.3%, respectively. The 1-, 3-, and 5-year OS rates for the PTI patient group (96.0%, 89.3%, and 74.0%) were significantly higher than those for the non-PTI group (84.0%, 63.4%, and 60.2%) (P = 0.033). The absence of PTI was an independent risk factor for dismal OS (relative risk [RR] = 2.584, 95%CI: 1.226-5.449) and unfavorable RFS (RR = 2.683, 95%CI: 1.335-5.390). Subgroup analyses revealed that PTI remarkably improved OS (P = 0.003) and RFS (P = 0.003) rates of HCC patients with vascular invasion (IV), but did not impact on OS (P = 0.404) and RFS (P = 0.304) of patients without VI. Among the patients who suffered post-transplant tumor recurrence, patients with PTI showed significantly better OS (P = 0.026) and PRS (P = 0.042) rates than those without PTI.
CONCLUSION PTI improves OS and RFS of the transplant HCC patients at a high risk for post-transplant death and tumor recurrence, which is attributed to suppressive effect of PTI on HCC recurrence.
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Affiliation(s)
- Jia-Shuo Chao
- Department of General Surgery, Shanghai Organ Transplantat Medical Center, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200080, China
| | - Sen-Lin Zhao
- Department of Colorectal Surgery, Fudan University, Shanghai Cancer Center, Shanghai 200032, China
| | - Si-Wen Ou-yang
- Department of General Surgery, Shanghai Organ Transplantat Medical Center, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200080, China
| | - Yong-Bing Qian
- Division of Critical Care, Department of Liver Surgery, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200127, China
| | - Ai-Qun Liu
- Department of Radiology, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200080, China
| | - Hua-Mei Tang
- Department of Pathology, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200080, China
| | - Lin Zhong
- Department of General Surgery, Shanghai Organ Transplantat Medical Center, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200080, China
| | - Zhi-Hai Peng
- Department of General Surgery, Shanghai Organ Transplantat Medical Center, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200080, China
| | - Jun-Ming Xu
- Department of General Surgery, Shanghai Organ Transplantat Medical Center, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200080, China
| | - Hong-Cheng Sun
- Department of General Surgery, Shanghai Organ Transplantat Medical Center, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200080, China
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97
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Very Late Recurrence of Hepatocellular Carcinoma After Orthotopic Liver Transplantation: Presentation and Management. Transplant Direct 2019; 5:e483. [PMID: 31579811 PMCID: PMC6739045 DOI: 10.1097/txd.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/01/2019] [Accepted: 06/03/2019] [Indexed: 11/27/2022] Open
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98
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Hong SK, Lee K, Yoon KC, Kim H, Ahn S, Kim H, Lee J, Cho J, Yi N, Suh K. Different prognostic factors and strategies for early and late recurrence after adult living donor liver transplantation for hepatocellular carcinoma. Clin Transplant 2019; 33:e13703. [DOI: 10.1111/ctr.13703] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/23/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Suk Kyun Hong
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Kwang‐Woong Lee
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Kyung Chul Yoon
- Department of Surgery Division of HBP Surgery & Liver Transplantation Anam Hospital Korea University College of Medicine Seoul Korea
| | - Hyo‐Sin Kim
- Department of Surgery Chonnam National University Medical School and Hospital Gwangju Korea
| | - Sung‐Woo Ahn
- Department of Surgery Chonbuk National University College of Medicine Jeonju Korea
| | - Hyeyoung Kim
- Department of Surgery Eulji University Hospital Eulji University College of Medicine Daejeon Korea
| | - Jeong‐Moo Lee
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Jae‐Hyung Cho
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Nam‐Joon Yi
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Kyung‐Suk Suh
- Department of Surgery Seoul National University College of Medicine Seoul Korea
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99
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Hepatocellular carcinoma recurrence after liver transplantation in a Brazilian multicenter study: clinical profile and prognostic factors of survival. Eur J Gastroenterol Hepatol 2019; 31:1148-1156. [PMID: 31247632 PMCID: PMC6687037 DOI: 10.1097/meg.0000000000001448] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplantation (LT) is the treatment of choice for patients with unresectable early hepatocellular carcinoma (HCC). Post-LT HCC recurrence rates range from 8 to 20% and still impact on overall survival (OS). The aim of our study was to evaluate the impact of HCC recurrence on post-LT survival and analyze prognostic factors among those patients with recurrence. PATIENTS AND METHODS We carried out a national, multicenter, retrospective cohort study in Brazil. Medical records of 1119 LT recipients with HCC were collected. Data from patients with post-LT HCC recurrence were analyzed and correlated with post-relapse survival. RESULTS OS of the 1119 patients included in the study was 63% over 5 years. Post-LT HCC recurrence occurred in 86 (8%) patients. The mean time to recurrence was 12 months. Sites of recurrence were extrahepatic in 55%, hepatic in 27%, and both hepatic and extrahepatic in 18%. Recurrence treatment was performed in 50 (64%) cases, mostly with sorafenib. Post-relapse survival rates were 34% at 1 year and 13% at 5 years. Univariable analysis identified α-fetoprotein more than 1000 ng/ml at relapse, recurrence treatment, extrahepatic location, and time to recurrence more than 2 years as prognostic factors. In multivariable analysis, recurrence treatment, extrahepatic location, and time to recurrence more than 2 years were independent predictors of better survival. CONCLUSION In a large Brazilian cohort of LT recipients with HCC, post-LT HCC recurrence occurred in 8% and impacted significantly on the OS. Patients with early recurrence presented a worse prognosis. However, treatment of recurrence improved outcomes, highlighting the importance of early diagnosis.
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100
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Hepatocellular metastasis recurrence in liver transplant after treatment with direct antiviral agents. Clin J Gastroenterol 2019; 13:260-266. [PMID: 31410743 DOI: 10.1007/s12328-019-01031-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022]
Abstract
Chronic HCV liver infection is considered one of the main causes of liver cirrhosis and hepatocellular carcinoma (HCC). For a selected group of patients, orthotopic liver transplantation (OLTx) is the most effective option to cure both liver diseases. After liver transplantation, patients may be at risk of viral infection reactivation and HCC recurrence. HCV recurrence on the transplanted organ can lead to graft cirrhosis and therefore the clearance of virus with antiviral therapies has a pivotal role on the prevention of graft damage. Nowadays, direct antiviral agents (DAAs) represent the choice treatment for HCV recurrence in liver transplanted patients, ensuring high eradication rates. We present the case of a liver transplant recipient who developed, 7 years after OLTx and immediately after a DAAs treatment, a subcutaneous abdominal mass with histological characteristics of HCC.
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