Hepatocellular carcinoma recurrence and death following living and deceased donor liver transplantation

Liver transplantation for hepatocellular carcinoma: five steps to prevent recurrence

Liver transplantation is the best treatment of patients with unresectable early hepatocellular carcinoma, allowing disease-free survival rates of 60-80% at 5 years. Despite these good results, some 10% of recipients experience a posttransplant HCC recurrence, which leads to death in almost all patients. Recurrence is either due to the growth of occult metastases or to the engraftment of circulating tumor cells. It can be hypothesized that strategies to decrease the engraftment of circulating tumor cells could decrease the risk of recurrence and, in addition, extend access to transplantation to patients with more advanced HCC. These potential strategies can be schematized into five steps, including (1) selecting recipients with low baseline levels of circulating HCC cells, by adding biological markers (such as alpha fetoprotein or molecular signatures) to the accepted combination of morphological criteria; (2) decreasing the perioperative release of HCC cells, with careful perioperative handling of the tumors; (3) preventing the engraftment of circulating HCC cells by decreasing liver graft ischemia-reperfusion injury, which has been shown to promote cancer cell engraftment and growth; (4) using anticancer drugs, including mammalian target of rapamycin inhibitors and (5) tuning immunity toward HCC clearance.

Liver transplant recipient survival benefit with living donation in the model for endstage liver disease allocation era

Receipt of a living donor liver transplant (LDLT) has been associated with improved survival compared with waiting for a deceased donor liver transplant (DDLT). However, the survival benefit of liver transplant has been questioned for candidates with Model for Endstage Liver Disease (MELD) scores <15, and the survival advantage of LDLT has not been demonstrated during the MELD allocation era, especially for low MELD patients. Transplant candidates enrolled in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study after February 28, 2002 were followed for a median of 4.6 years. Starting at the time of presentation of the first potential living donor, mortality for LDLT recipients was compared to mortality for patients who remained on the waiting list or received DDLT (no LDLT group) according to categories of MELD score (<15 or ≥ 15) and diagnosis of hepatocellular carcinoma (HCC). Of 868 potential LDLT recipients (453 with MELD <15; 415 with MELD ≥ 15 at entry), 712 underwent transplantation (406 LDLT; 306 DDLT), 83 died without transplant, and 73 were alive without transplant at last follow-up. Overall, LDLT recipients had 56% lower mortality (hazard ratio [HR] = 0.44, 95% confidence interval [CI] 0.32-0.60; P < 0.0001). Among candidates without HCC, mortality benefit was seen both with MELD <15 (HR = 0.39; P = 0.0003) and MELD ≥ 15 (HR = 0.42; P = 0.0006). Among candidates with HCC, a benefit of LDLT was not seen for MELD <15 (HR = 0.82, P = 0.65) but was seen for MELD ≥ 15 (HR = 0.29, P = 0.043).

CONCLUSION

Across the range of MELD scores, patients without HCC derived a significant survival benefit when undergoing LDLT rather than waiting for DDLT in the MELD liver allocation era. Low MELD candidates with HCC may not benefit from LDLT.

Recurrence of hepatocellular carcinoma after living donor liver transplantation: what is the current optimal approach to prevent recurrence?

BACKGROUND

Liver transplantation plays an important role in the multimodal treatment options for patients with hepatocellular carcinoma (HCC). However, there has been little information about the prognosis for HCC recurrence after living donor liver transplantation (LDLT).

METHODS

We retrospectively analyzed 164 HCC patients who underwent LDLT at our institution between February 1999 and March 2009.

RESULTS

In all, 23 of 164 liver recipients developed HCC recurrence 1 to 44 months (median 8 months) after LDLT. The 5-year survival was significantly lower for patients with recurrence than for patients without recurrence (14 vs. 82%; p<0.0001). The 3-year survival was significantly lower for patients with early recurrence (≤1 year) than for patients with late recurrence (>1 year) (8 vs. 40%; p=0.0082). Concerning sites of first tumor recurrence, the 3-year survival rate in patients with recurrence in the graft liver was significantly higher than that of patients with recurrence to other organs (50 vs. 17%, respectively; p=0.0421).

CONCLUSIONS

As the prognosis of patients with HCC recurrence is quite poor, currently the optimal method of preventing HCC recurrence would be the use of appropriate criteria to select candidates for LDLT.

Liver transplantation in the 21st century: expanding the donor options

Over the past decade, use of ECD organs for OLT has allowed many transplant programs to afford patients access to an otherwise scarce resource and to maintain center volume. Although overall posttransplant outcomes are inferior to results with optimal, whole-liver grafts, aggressive utilization of ECD and DCD organs significantly lowers median wait-times for OLT, MELD score at OLT, and death while awaiting transplantation. It is incumbent on the transplant community to provide continued scrutiny of the many factors involved in ECD organ utilization, evaluate the degree of risk and benefit such allografts may impart on particular recipients, and thereby provide suitable “matching” to maximize favorable outcomes. Transplant caregivers need to provide patients with evidence-based care decisions, be good stewards of a scarce resource, and maintain threshold survival results for their programs. This requires balancing the urgency with which a transplant is needed and the utility of such a transplant. There is a clear necessity to pursue additional donor research to improve use of these marginal grafts and assess interventions that enhance the safety of ECD livers.

Characterization of hepatocellular carcinoma recurrence after liver transplantation: perioperative prognostic factors, patterns, and outcome

OBJECTIVE

Liver transplantation (LT) is known to be a promising treatment for patients with liver cirrhosis associated with hepatocellular carcinoma (HCC). This study, however, found that HCC recurrence remains to be a concern.

METHODS

A total of 126 HCC patients who had undergone LT between January 2000 and December 2009 were retrospectively reviewed. The clinicopathological features of the patients were analyzed by univariate and multivariate analyses to determine prognostic factors. Patients who had HCC recurrence were further analyzed in terms of recurrent pattern, management, and outcome.

RESULTS

Seventeen patients (13.5%) exhibited HCC recurrence following LT. Univariate and multivariate analyses identified two prognostic factors: tumor number > three [hazard ratio (HR) = 3.249] and presence of microvascular invasion (HR = 4.336). Among patients with HCC recurrence, 15 out of 17 (88%) patients developed extrahepatic metastasis shortly after recurrence. The survival of patients after HCC recurrence was dismal with 18.3 months of median survival.

CONCLUSIONS

Multiple tumors (>three) are an important prognostic factor for HCC recurrence following LT, but an accurate assessment of tumor status by pretransplantation radiological examination is required. The outcome of patients with HCC recurrence after LT remains very poor because of a tendency of HCC to recur as extrahepatic metastasis.

Intention-to-treat analysis of liver transplantation for hepatocellular carcinoma: living versus deceased donor transplantation

For patients who have cirrhosis with hepatocellular carcinoma (HCC), living donor liver transplantation (LDLT) reduces waiting time and dropout rates. We performed a comparative intention-to-treat analysis of recurrence rates and survival outcomes after LDLT and deceased donor liver transplantation (DDLT) in HCC patients. Our study included 183 consecutive patients with HCC who were listed for liver transplantation over a 9-year period at our institution. Tumor recurrence was the primary endpoint. At listing, patient and tumor characteristics were comparable in the two groups (LDLT, n = 36; DDLT, n = 147). Twenty-seven (18.4%) patients dropped out, all from the DDLT waiting list, mainly due to tumor progression (19/27 [70%] patients). The mean waiting time was shorter in the LDLT group (2.6 months versus 7.9 months; P = 0.001). The recurrence rates in the two groups were similar (12.9% and 12.7%, P = 0.78), and there was a trend toward a longer time to recurrence after LDLT (38 ± 27 months versus 16 ± 13 months, P = 0.06). Tumors exceeding the University of California, San Francisco (UCSF) criteria, tumor grade, and microvascular invasion were independent predictive factors for recurrence. On an intention-to-treat basis, the overall survival (OS) in the two groups was comparable. Patients beyond the Milan and UCSF criteria showed a trend toward worse outcomes with LDLT compared with DDLT (P = 0.06).

CONCLUSION

The recurrence and survival outcomes after LDLT and DDLT were comparable on an intent-to-treat analysis. Shorter waiting time preventing dropouts is an additional advantage with LDLT. LDLT for HCC patients beyond validated criteria should be proposed with caution.

Living Donor Liver Transplantation

A perception that living donor liver transplantation can be accomplished with an acceptable donor complication rate and recipient survival rate has led to the acceptance of living donor liver transplantation as a viable alternative to decreased deceased donor transplantation. Careful candidate evaluation and selection has been crucial to the success of this procedure. Advancements in the understanding of the lobar nature of the liver and of liver regeneration have advanced the surgical technique. Initial attempts at adult-to-adult donation utilized the left hepatic lobe, but now have evolved into use of the right hepatic lobe. Size matching is very important to successful graft function in the recipient. There is great concern regarding morbidity and mortality in donors. Biliary complications and infections continue to be among the most highly reported complications, although rates vary among centers and countries. Reports of single center complications have ranged from 9% to 67%. A survey of centers in the United States in 2003 reported complications of 10%. A series from our institution reported complications arising in 13 (33%) of 39 patients. A review focused on documenting donor deaths found 33 living liver donor deaths worldwide. The much publicized immediate postoperative mishap of 2002 that resulted in a donor’s death resulted in a drop in the utilization of living donor liver transplantation in the United States, from which this procedure has never fully recovered. The future development and expansion of living donor liver transplantation depends on open communication regarding donor complications and deaths. Close immediate postoperative monitoring and meticulous management will remain an essential aspect in limiting donor complications and deaths.

Liver transplantation for alcohol-related cirrhosis: a single centre long-term clinical and histological follow-up

BACKGROUND

Alcohol-induced liver cirrhosis is one of the leading indications for liver transplantation today. Due to the general organ shortage and continuous deaths on the waiting list there has been some debate on the issue of indication and ethical problems. It was the aim of this study to critically analyse the outcome of patients with alcoholic cirrhosis transplanted at our centre with special emphasis on alcohol-recurrence frequency and long-term histological follow-up.

METHODS

Three hundred five patients who received LT for alcoholic cirrhosis at our institution were followed over a period of 3-10 years after transplantation. Biopsies were taken 1, 3, 5, and 10 years after LT. Specimens were analysed and staged concerning inflammation, rejection, fatty involution, and fibrosis/cirrhosis. Clinical characteristics as well as serological parameters, immunosuppressive protocols, rejection episodes, and patient and graft survival were recorded.

RESULTS

Recurrence of alcohol abuse occurred in 27% of all patients analysed. Regardless of alcohol consumption, 5-year graft and patient survival were excellent; after 10 years abstinent patients showed significantly better survival (82% vs. 68%; P=0.017). Histological changes were slightly more pronounced among recurrent drinkers, no significant difference regarding inflammation or fibrosis was detected.

CONCLUSION

Patients undergoing LT for alcohol-induced cirrhosis show excellent long-term survival rates with stable graft function. Alcohol recurrence impairs long-term prognosis; however, compared to other patient sub-populations (HCC, HCV) results are clearly above average.

Does living donation have advantages over deceased donation in liver transplantation?

Liver transplantation (LT) is the best treatment option for patients with end-stage liver disease. Living donor LT (LDLT) has developed as an alternative to deceased donor LT (DDLT) in order to overcome the critical shortage of deceased organ donations, particularly in Asia. LDLT offers several advantages over DDLT. The major advantage of LDLT is the reduction in waiting time mortality. Especially among patients with hepatocellular carcinoma (HCC), LDLT can shorten the waiting time and lower the dropout rate. The Hong Kong group reported that median waiting time was significantly shorter for LDLT than for DDLT. Intention-to-treat survival rates of HCC patients with voluntary live donors were significantly higher than those of patients without voluntary live donors. In contrast, a multicenter adult-to-adult LDLT retrospective cohort study reported that LDLT recipients displayed a significantly higher rate of HCC recurrence than DDLT recipients, although LDLT recipients had shorter waiting times than DDLT recipients. The advantage of LDLT involves the more liberal criteria for HCC compared with those for DDLT. Various preoperative interventions including nutritional treatment can also be planned for both the donor and recipient in LDLT. Conversely, LDLT has marked unfavorable characteristics in terms of donor risks. Donor morbidity is not infrequent and the donor mortality rate is estimated at around 0.1-0.3%. In conclusion, living donation is not necessarily advantageous over deceased donation in LT. Taking the advantages and disadvantages of each option into consideration, LDLT and DDLT should both be used to facilitate effective LT for patients requiring transplant.

Liver transplantation for hepatocellular carcinoma: the Hong Kong experience

Orthotopic liver transplantation (OLT) is the best treatment option for selected patients with hepatocellular carcinoma (HCC) with the background of cirrhosis since this treatment modality can cure both diseases at once. Over the years, the applicability of OLT for HCC has evolved. In Asia, including Hong Kong, a shortage of deceased donor liver grafts is a universal problem having to be faced in all transplant centers. Living-donor liver transplant (LDLT) has therefore been developed to counteract organ shortage and the high prevalence of HCC. The application of LDLT for HCC is a complex process involving donor voluntarism, selection criteria for the recipient and justification with respect to long-term survival in comparison to the result of deceased donor liver transplant. This article reviews the authors' experience with OLT for HCC patients in Hong Kong, with emphasis on the applicability and outcome of LDLT for HCC. Donor voluntarism has a significant impact on the application of LDLT. "Fast-track" LDLT in the setting of recurrence following curative treatment carries a high risk of recurrence even though the tumor stage fulfills the standard criteria. Although the survival outcome may be worse following LDLT than DDLT for HCC, LDLT is still the main treatment option for patients with transplantable HCC in Hong Kong, and a reasonable survival outcome can be achieved in selected patients with extended indications. It is particularly true that LDLT provides the only hope for patients with advanced HCC under the constricting problem of organ shortage.

Response to therapy as a criterion for awarding priority to patients with hepatocellular carcinoma awaiting liver transplantation

BACKGROUND

How to prioritize patients with hepatocellular carcinoma (HCC) for liver transplantation (LT) remains controversial. This study was designed to assess the effectiveness of a policy for prioritizing HCC patients according to their response to pre-LT therapy.

METHODS

The study period was from 2000 to 2008. Dropout criteria included macroscopic vascular invasion, metastases, and poorly differentiated grade at pre-LT biopsy. A specific treatment algorithm was adopted to treat HCC before LT, and the effect of treatment was evaluated 3 months after listing or after the diagnosis of HCC for patients diagnosed while already on the waiting list. Patients were divided into two groups: group 1, patients with disease that completely or partially responded to therapy; and group 2, patients with stable, progressive, or untreatable disease. Group 2 patients were prioritized for LT unless full restaging and repeat biopsy identified dropout criteria.

RESULTS

At the 3-month visit, 62 HCC patients (42%) were assigned to group 2 and 85 (58%) to group 1. Eleven of 12 dropouts due to tumor progression came from group 2 (P < 0.01). Response to therapy was the sole predictor of dropout probability, independent of tumor stage (competing risk analysis). The 42 patients in group 2 who were transplanted had much the same 3-year post-LT survival rate as the 57 transplanted patients in group 1 (with survival rates of 82% and 83%, respectively; P > 0.05), but a slightly higher risk of post-LT HCC recurrence (13% and 2%, respectively; P = 0.04).

CONCLUSIONS

Response to therapy is a potentially effective tool for prioritizing HCC patients for LT.

Prognostic factors affecting survival after recurrence in adult living donor liver transplantation for hepatocellular carcinoma

Liver transplantation is regarded as an effective treatment for early hepatocellular carcinoma (HCC). However, some patients experience recurrence and subsequently rapid progression of the disease. We investigated prognostic factors affecting survival after recurrence in patients who underwent adult living donor liver transplantation (LDLT) for HCC. From October 1992 to December 2005, 138 adult patients underwent LDLT for HCC. Among these, 28 patients (20.3%) who suffered recurrence were retrospectively reviewed. Univariate and multivariate analyses were performed to analyze factors affecting survival after recurrence. The median time to recurrence was 7.9 months. The median survival time after recurrence was 11.7 months, and the 1- and 3-year survival rates after recurrence were 52.8% and 15.8%, respectively. Initially, 7 patients (25%) showed multiorgan involvement; however, in the follow-up, 21 patients (75%) had multiorgan involvement. On univariate analysis, a pretransplant alpha-fetoprotein level >1000 ng/mL, major vascular invasion, a poorly differentiated tumor, a time to recurrence < or =6 months, unresectable disease, and bony metastases were related to shorter survival after recurrence. The independent prognostic factors by multivariate analysis were major vascular invasion [hazard ratio (HR) = 7.6], a poorly differentiated tumor (HR = 4.3), unresectable disease (HR = 10.4), and bony metastases (HR = 3.2). Two patients survived more than 36 months. One of them underwent retransplantation and survived for 45 months without additional recurrences. In conclusion, after transplantation, recurrent HCC has a tendency to involve multiple organs, and the prognosis is very poor. However, some patients have a good prognosis, and the appropriate treatment can prolong their survival. If the recurrent lesion is locally controllable, surgical resection should be considered.

Management of small hepatocellular carcinoma: a review of transplantation, resection, and ablation

PURPOSE AND DESIGN

The management of patients with early hepatocellular carcinoma has become increasingly complex. The most appropriate therapy largely depends on the functional status of the underlying liver. Here we review the modalities of transplantation, resection, and ablation in this patient population.

RESULTS AND CONCLUSION

In patients with cirrhosis and/or portal hypertension, and disease extent within the Milan criteria, liver transplantation is clearly the best option. This modality not only provides therapy for the cancer but also treats the underlying hepatic parenchymal disease. In patients with well-preserved hepatic function, on the other hand, liver resection remains the most appropriate and effective treatment. Hepatic resection is not constrained by the same variables of tumor extent and location that limit the applicability of transplantation and ablative therapies. In addition, patients whose disease recurs after resection are often still eligible for transplantation. Ablative therapies, particularly percutaneous radiofrequency ablation and transarterial embolization/chemoembolization, have been used primarily to treat patients with low-volume unresectable tumors. The question has increasingly been raised regarding whether ablation of small tumors (<3 cm) provides long-term disease control that is comparable to resection. Ablative therapies has also been used as a means of controlling disease in patients who are on transplantation waiting lists, although improved posttransplantation outcome using these techniques has yet to be proven prospectively. The major problem with assessing the efficacy of various treatment modalities in these patients is the heterogeneity of disease presentation, which often precludes the use of certain therapies and therefore makes the conduct of randomized control trial difficult.

Management of small hepatocellular carcinoma: a review of transplantation, resection, and ablation

PURPOSE AND DESIGN

The management of patients with early hepatocellular carcinoma has become increasingly complex. The most appropriate therapy largely depends on the functional status of the underlying liver. Here we review the modalities of transplantation, resection, and ablation in this patient population.

RESULTS AND CONCLUSION

In patients with cirrhosis and/or portal hypertension, and disease extent within the Milan criteria, liver transplantation is clearly the best option. This modality not only provides therapy for the cancer but also treats the underlying hepatic parenchymal disease. In patients with well-preserved hepatic function, on the other hand, liver resection remains the most appropriate and effective treatment. Hepatic resection is not constrained by the same variables of tumor extent and location that limit the applicability of transplantation and ablative therapies. In addition, patients whose disease recurs after resection are often still eligible for transplantation. Ablative therapies, particularly percutaneous radiofrequency ablation and transarterial embolization/chemoembolization, have been used primarily to treat patients with low-volume unresectable tumors. The question has increasingly been raised regarding whether ablation of small tumors (<3 cm) provides long-term disease control that is comparable to resection. Ablative therapies has also been used as a means of controlling disease in patients who are on transplantation waiting lists, although improved posttransplantation outcome using these techniques has yet to be proven prospectively. The major problem with assessing the efficacy of various treatment modalities in these patients is the heterogeneity of disease presentation, which often precludes the use of certain therapies and therefore makes the conduct of randomized control trial difficult.

Gender-specific differences associated with living donor liver transplantation: a review study

Living donor liver transplantation (LDLT) has developed into an important therapeutic option for liver diseases. For living donor kidney transplantation (LDKT), gender-specific differences have been observed among both donors (two-thirds being women and one-third being men) and recipients (two-thirds being men and one-third being women). The aim of this study was to determine whether there is a gender disparity for LDLT. We contacted 89 national and international transplantation registries, single transplant centers, and coordinators. In addition, a sample of 274 articles dealing with LDLT and its outcomes was reviewed and compared with the registry data. The data included the gender of the donors and recipients, the country of transplantation, and the donor-recipient relationship. The investigation showed that overall there were slightly more men among the donors (53% male and 47% female). As for the recipients, 59% of the organs were distributed to males, and 41% were distributed to females. Differences in the gender distribution were observed with respect to individual countries. Worldwide, 80% of the donors were blood-related, 11% were not blood-related, and 9% were spouses. The data acquired from the publications were similar to the registry data. Our research has shown that there are hardly any registry data published, a lot of countries do not have national registries, or the access to these data is difficult. Even widely ranging published studies often do not give information on the gender distribution or the donor-recipient relationship. Further investigations are needed to understand the possible medical, psychosocial, or cultural reasons for gender distribution in LDLT and the differences in comparison with LDKT.

Hepatocellular carcinoma: review of current treatment with a focus on targeted molecular therapies

The treatment of hepatocellular carcinoma (HCC) remains a challenge, with 1- and 3-year survival rates of 20% and 5%, respectively, and a median survival of 8 months. However, a better understanding of the pathogenesis of HCC, and advances in targeted molecular therapies provide physicians treating this disease with new hope. The treatment of HCC is multidisciplinary, requiring surgeons, hepatologists, interventional radiologists and oncologists. Thus, there is enormous potential to combine various treatment modalities to improve survival for patients. This review will describe what is currently known about the molecular pathogenesis of HCC, explore current and future treatments based on these pathways, and describe how these new therapies fit into existing approaches to HCC treatment.

Medical treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common neoplasm and the third leading cause of cancer-related deaths worldwide. Cirrhosis, most often due to viral hepatitis, is the predominant risk factors for HCC and geographical differences in both risk factors and incidence are largely due to epidemiological variations in hepatitis B and C infection. Hepatic function is a relevant parameter in selecting therapy in HCC. The current clinical classification of HCC split patients into 5 stages, with a specific treatment schedule for any stage. As patients with early stages can receive curative treatments, such as surgical resection, liver transplantation or local ablation, surveillance program in high-risk populations has become mandatory. Sorafenib, a multikinase inhibitor, has recently shown survival benefits in patients at advanced stage of disease. Hopefully, new molecular targeted therapies and their combination with sorafenib or interventional and surgical procedures, should expand the therapeutic armamentarium against HCC.

Living donor liver transplantation for hepatocellular carcinoma: Increased recurrence but improved survival

In regions with a limited deceased donor pool, living donor adult liver transplantation (LDALT) has become an important treatment modality for patients with hepatocellular carcinoma (HCC) and cirrhosis. Studies have shown higher recurrence rates of HCC after LDALT in comparison with deceased donor liver transplantation (DDLT). The aim of our study was to examine the outcome results and recurrence rates for patients with HCC who underwent LDALT at our center. During an 8-year period, 139 patients underwent LDALT, of whom 28 (20.1%) had HCC in their explanted livers. The median follow-up was 40.8 months. The mean explant tumor size was 3.3 +/- 1.2, and the mean number of tumors was 1.5 +/- 0.8. Twenty-one patients (75%) had tumors within the Milan criteria, 5 patients had tumors outside the Milan criteria but within the University of California San Francisco (UCSF) criteria, and 2 patients were beyond the UCSF criteria. The overall 1- and 5-year patient and graft survival rates were 96% and 81%, respectively. Survival following LDALT was significantly better than survival following DDLT for HCC during the same time period (P = 0.02). Eight patients (28.6%) developed tumor recurrence. Poor differentiation of tumor cells was the most significant determinant of recurrence. Despite high recurrence rates of HCC following LDALT, overall 5-year survival appears to be excellent.

Liver transplantation for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the commonest primary malignancy of the liver. It usually occurs in the setting of chronic liver disease and has a poor prognosis if untreated. Orthotopic liver transplantation (OLT) is a suitable therapeutic option for early, unresectable HCC particularly in the setting of chronic liver disease. Following on from disappointing initial results, the seminal study by Mazzaferro et al in 1996 established OLT as a viable treatment for HCC. In this study, the “Milan criteria” were applied achieving a 4-year survival rate similar to OLT for benign disease. Since then various groups have attempted to expand these criteria whilst maintaining long term survival rates. The technique of living donor liver transplantation has evolved over the past decade, particularly in Asia, and published outcome data is comparable to that of OLT. This article will review the evidence, indications, and the future direction of liver transplantation for liver cancer.

Small-for-size liver graft injury--impact on tumor behavior

The success of liver transplantation has led to an ever-increasing demand for liver grafts. Since the first successful living donor liver transplantation, this surgical innovation has been well established in children and has significantly relieved the crisis of donor organ shortage for children. However, the extension of living donor liver transplantation to adult recipients is limited by the graft volume. The major concern of adult-to-adult living donor liver transplantation is the adequate graft that can be harvested from a living donor. Small-for-size graft injury is frequently observed. To develop novel effective treatments attenuating small-for-size liver graft injury during living donor liver transplantation, it is important to explore the precise mechanism of acute phase small-for-size graft damage. Recently, a number of clinical studies and animal experiments have been conducted to investigate the possible key issues on acute phase small-for-size liver graft injury, such as mechanical injury from shear stress, subsequent inflammatory responses, and imbalance of vasoregulatory factors. This review focuses on the mechanism of small-for-size liver graft injury based on the number of clinical and experimental studies. The latest research findings of the significance of acute phase liver graft injury on late phase tumor recurrence and metastasis are also addressed.

Liver transplantation for hepatocellular carcinoma: Korean experience

Hepatocellular carcinoma (HCC) is the second most common cause of male cancer death in Korea, where the major etiology, chronic hepatitis B virus infection, is endemic. With a high incidence of unresectable HCCs and a low cadaveric organ donation rate, the number of adult living-donor liver transplantations (LDLTs) has increased rapidly, by tenfold, over the past 10 years, as an alternative to deceased-donor liver transplantation (DDLT) in Asia, including Korea. Currently, HCC accounts for more than 40% of the indications for adult LDLT as the associated decompensation cirrhosis or unresectable HCC with 2.8% perioperative mortality at our institute. In determining eligibility for LDLT, the Milan criteria, which have a major aim of reducing the wastage of cadaveric liver grafts, still remain the gold standard. Our published results with 168 adult LDLTs show no difference from the results with DDLT for HCC that meets the Milan criteria. However, since a substantial proportion of adult LDLT patients not fulfilling the Milan criteria have been found to survive for longer than expected, and because a live donor organ is a private gift, most LDLT programs in Korea accept HCC patients beyond the Milan criteria, and the reported 3-year survival rates for such patients are approximately 63%. Our new proposal for expanded criteria (Asan criteria; tumor diameter <or=5 cm, number of lesions <or=6, no gross vascular invasion) in LDLT has focused on extending the number limits but keeping the maximum tumor size at 5 cm, because even modest expansion of tumor size limits beyond the Milan criteria adversely affected survival. The overall 5-year patient survival rates were 76.3 and only 18.9% within and beyond the Asan criteria, respectively; these criteria broaden the indications for patient selection and can more accurately identify patients who will benefit from LDLT than the conventional Milan criteria and the University of California at San Francisco criteria. In Asia, where the option for DDLT is minimal or negligible, LDLT with the modest expanded selection criteria will continue to provide a chance of long-term survival for some patients with advanced HCC.

[Adult living-donor liver transplantation]

Living donor liver transplantation in adults continues to be controversial. Viewed as an alternative to prevent deaths on the waiting list, this type of transplant is the only possibility in Asian countries (Japan, Korea, China, etc) but is not widely applied in the west. This intervention is associated with significant donor morbidity (depending on the scale of the intervention) and mortality which, although sporadic, reduces its acceptance, especially in a context with high cadaveric donation. Outcomes in recipients are similar to those in cadaveric transplant recipients, although the high incidence of biliary complications could compromise long-term results. We describe the experience of Hospital Clínic in a total of 67 transplant recipients. Graft and patient survival at 1 and 5 years was 90.7%, 70.3%, 90.7% and 77.6%, respectively. Although the frequency of biliary complications was high (37.3%), death from sepsis and retransplantation only occurred in two patients.

Current management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC), one of the most common cancers worldwide, continues to increase in incidence in several regions around the world and is associated with poor overall survival. Patients with cirrhosis are at the highest risk and are candidates for surveillance. Wide implementation of surveillance programs and improvement in noninvasive radiologic techniques has led to tumor diagnosis at earlier stages. Surgical options that include resection and liver transplantation offer the best chance of successful outcomes. Locoregional therapies, such as radiofrequency ablation and chemoembolization, provide effective local control in those with acceptable hepatic function. A multikinase inhibitor, sorafenib, is the first molecular targeted oral therapy that has recently been shown to provide a survival benefit in HCC in select patients.

Management of early hepatocellular carcinoma in patients with well-compensated cirrhosis

Hepatocellular carcinoma (HCC) usually affects patients with chronic liver disease. While resection is the primary treatment of HCC in patients without cirrhosis, in the setting of moderate to severe cirrhosis, liver transplantation is the preferred therapy, as it simultaneously treats the tumor and the underlying liver condition. The optimal management of patients with HCC and early cirrhosis remains controversial. Although liver transplantation for HCC within the Milan criteria has been shown to have excellent long-term survival rates and low recurrence rates, its application is limited by organ availability. Due to the shortage of donors, a portion of patients drop out from the waiting list due to tumor progression. One alternative to transplantation is hepatic resection. In addition to the reported 50% 5-year survival rates, resection allows a better understanding of tumor biology through pathologic examination of the specimen, which may guide decision-making regarding salvage liver transplantation. Other nonsurgical locoregional therapies, such as transarterial chemoembolization and radiofrequency ablation, also serve as primary therapies and as a bridge to transplantation. The management of patients with early HCC is complex and multidimensional. The care of these patients is best served by a multidisciplinary approach, with consideration of the feasibility of transplantation weighed against the aggressiveness of the tumor biology and underlying hepatic dysfunction. All modalities of therapy should be viewed as complementary, not exclusive, therapeutic strategies.

Liver transplantation: from Child to MELD

The widespread availability of transplantation in most major medical centers in the United States, together with a growing number of transplant candidates, has made it necessary for primary care providers, especially internal medicine and family practice physicians to be active in the clinical care of these patients before and after transplantation. This review provides an overview of the liver transplantation process, including indications, contraindications, time of referral to a transplant center, the current organ allocation system, and briefly touches on the expanding field of living donor liver transplantation.

Recent advances in liver transplantation for the practicing gastroenterologist

Liver transplantation is the definitive therapy for end-stage liver disease of various etiologies as well as acute liver failure and early-stage hepatocellular carcinoma. The Model for End-Stage Liver Disease (MELD) score is essential for organ allocation in the United States. Addition of the serum sodium level to the MELD score is a recent development that helps prognosticate cirrhotic patients with hyponatremia, a commonly seen manifestation of end-stage liver disease. The currently used Milan criteria for hepatocellular carcinoma have been expanded with some success at certain transplant centers, and tumor downstaging prior to transplant is being used more frequently. The tremendous shortage of donor organs continues to be the major limitation of this life-saving therapy. This has led to the use of extended-criteria donors, donation after cardiac death, split liver grafts, and live donor liver transplants. Renal dysfunction following liver transplant requires close monitoring and dose adjustments of immunosuppressive medications. Although most liver transplants in the United States are for chronic hepatitis C infection and its sequelae, hepatitis C virus recurrence is a common problem that is challenging to treat in the post-transplant population.

Liver transplantation: an update 2009

PURPOSE OF REVIEW

In this review we focus on three challenging aspects of liver transplantation: living donor liver transplant, transplantation in HIV-positive recipients and down-staging of hepatocellular carcinoma for liver transplantation.

RECENT FINDINGS

The adult-to-adult living donor liver transplantation cohort study is providing valuable information on recipient and donor outcomes associated with living donor liver transplantation. The recipient outcomes with living donor liver transplantation are comparable to those with deceased donor liver transplantation for most diseases, but increased hepatocellular carcinoma recurrence has been reported with living donor liver transplantation. Donor morbidity is not infrequent and donor mortality remains a concern. Liver transplantation for HIV-positive recipients is associated with equivalent outcomes as HIV-negative recipients for selected recipients. Transplantation in coinfected recipients (HIV and HCV+) is associated with less favorable outcomes. Drug interaction between immunosuppression and highly active antiretroviral therapy is increasingly recognized and requires major modifications in dosing. Down-staging hepatocellular carcinoma to within transplant criteria is being used in some centers using loco-regional therapy. Waiting time after loco-regional therapy is currently the best predictor of recurrence. The role of newer chemotherapeutics is being tested as part of neoadjuvant therapy after resection or loco-regional therapy.

SUMMARY

Living donor liver transplantation is a viable strategy to increase transplantation and reduce death on the waiting list. Donor morbidity should be the subject of further efforts to minimize these risks. The increased recurrence risk with living donor liver transplantation for hepatocellular carcinoma warrants further study. Careful coordination between transplant professionals and HIV experts is necessary to monitor issues of posttransplant care of the HIV-infected recipient. The role of loco-regional therapies in down-staging patients with hepatocellular carcinoma is expanding.

Living donor liver transplantation for hepatocellular carcinoma: long-term results compared with deceased donor liver transplantation

OBJECTIVE

Living donor liver transplantation (LDLT) may represent a valid therapeutic option allowing several advantages for patients affected by hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT). However, some reports in the literature have demonstrated worse long-term and disease-free survivals among patients treated by LDLT than deceased donor liver transplantation (DDLT) for HCC. Herein we have reported our long-term results comparing LDLT with DDLT for HCC.

PATIENTS AND METHODS

Among 179 patients who underwent OLT from January 2000 to December 2007, 25 (13.9%) received LDLT with HCC 154 (86.1%) received DDLT. Patients were selected based on the Milan criteria. Transarterial chemoembolization, radiofrequency ablation, percutaneous alcoholization, or liver resection was applied as a downstaging procedure while on the waiting list. Patients with stage II HCC were proposed for LDLT.

RESULTS

The overall 3- and 5-year survival rates were 77.3% and 68.7% versus 82.8% and 76.7% for LDLT and DDLT recipients, respectively, with no significant difference by the log-rank test. Moreover, the 3- and 5-year recurrence-free survival rates were 95.5% and 95.5% (LDLT) versus 90.5% and 89.4% (DDLT; P = NS).

CONCLUSIONS

LDLT guarantees the same long-term results as DDLT where there are analogous selection criteria for candidates. The Milan criteria remain a valid tool to select candidates for LDLT to achieve optimal long-term results.

Impact of model for end-stage liver disease on patient survival and disease-free survival in patients receiving liver transplantation for hepatocellular carcinoma

We combined data from two transplant centers to determine the impact of the model for end-stage liver disease (MELD) allocation system on outcomes in patients undergoing liver transplantation for hepatocellular carcinoma (HCC). We compared 55 patients listed before MELD to 117 patients in the MELD era. Patients before MELD were less likely to receive a transplant (67% vs 91%) and waited a median of 127 days vs 20 days (P < .001). On an intention to treat (ITT) basis, the 1-, 3-, and 5-year survivals for patients before MELD were 79%, 60%, and 48%, and in the MELD era were 84%, 73%, and 73% (P = .055). On an ITT basis, the 1-, 3-, and 5-year tumor-free survivals before MELD were 58%, 58%, and 55% vs 83%, 74%, and 70% in the MELD era (P = .018). In patients who received a transplant, however, there were no differences in overall or tumor-free survival. In these patients, the 1-, 3-, and 5-year patient survivals were 92%, 84%, and 67% before MELD, and 90%, 81%, and 81% in the MELD era (P = .57). In transplanted patients, the 1-, 3-, and 5-year tumor-free survivals before MELD were 88%, 88%, and 83% vs 92%, 83%, and 78% in the MELD era (P = .403). On explant, patients listed before MELD had lower grade tumors (P = .046). We concluded that patients with HCC listed in the MELD era had higher and more rapid rates of transplantation with improvements in survival. However, the more efficacious rates of transplantation did not result in lower rates of tumor recurrence.

Liver Transplantation in Asia: Past, Present and Future

With the technical advances and improvements in perioperative management and immunosuppressants, liver transplantation is the standard treatment for patients with end-stage liver diseases. In Asia, a shortage of deceased donor liver grafts is the universal problem to be faced with in all transplant centres. Many surgical innovations are then driven to counteract this problem. This review focuses on 3 issues that denote the development of liver transplantation in Asian countries. These include living donor liver transplantation (LDLT), split liver transplantation (SLT) and liver transplantation for hepatocellular carcinoma (HCC). Minimal graft weight, types of liver graft to donate and the inclusion of the middle hepatic vein with the graft are the main issues to be established in LDLT. The rapid growth and wide dissemination of LDLT has certainly alleviated the supply-and-demand problem of liver grafts in Asia. SLT is another attractive approach. Technical expertise, donor selection and graft allocation are the main determinants for its success. Liver transplantation plays a key role in the management of HCC in Asia. LDLT would be the main strategy in this aspect. The issue of extending the selection criteria for HCC patients for LDLT is still controversial. On the whole, future developments to increase the donor pool for the expanding recipient need in Asia would involve transplantation from non-heart beating donor and ABO incompatible transplantation.

Longterm outcomes for whole and segmental liver grafts in adult and pediatric liver transplant recipients: a 10-year comparative analysis of 2,988 cases

BACKGROUND

Data on longterm outcomes after liver transplantation with partial grafts are limited. We compared 10-year outcomes for liver transplant patients who received whole grafts (WLT), split grafts from deceased donors (SLT), and partial grafts from living donors (LDLT).

STUDY DESIGN

We conducted a single-center analysis of 2,988 liver transplantations performed between August 1993 and May 2006 with median followup of 5 years. Graft types included 2,717 whole-liver, 181 split-liver, and 90 living-donor partial livers. Split-liver grafts included 109 left lateral and 72 extended right partial livers. Living-donor grafts included 49 left lateral and 41 right partial livers.

RESULTS

The 10-year patient survivals for WLT, SLT, and LDLT were 72%, 69%, and 83%, respectively (p=0.11), and those for graft survival were 62%, 55%, and 65%, respectively (p=0.088). There were differences in outcomes between adults and children when compared separately by graft types. In adults, 10-year patient survival was significantly lower for split extended right liver graft compared with adult whole liver and living-donor right liver graft (57% versus 72% versus 75%, respectively, p=0.03). Graft survival for adults was similar for all graft types. Retransplantation, recipient age older than 60 years, donor age older than 45 years, split extended right liver graft, and cold ischemia time>10 hours were predictors of diminished patient survival outcomes. In children, the 10-year patient and graft survivals were similar for all graft types.

CONCLUSIONS

Longterm graft survival rates in both adults and children for segmental grafts from deceased and living donors are comparable with those in whole organ liver transplantation. In adults, patient survival was lower for split compared with whole grafts when used in retransplantations and in critically ill recipients. Split graft-to-recipient matching is crucial for optimal organ allocation and best use of a scarce and precious resource.

Live donor adult liver transplantation

PURPOSE OF REVIEW

Because the gap between liver organ supply and demand continues to increase, adult living-donor liver transplantation continues to represent a significant pool of organs.

RECENT FINDINGS

With this in mind, we discuss recent issues in adult living-donor liver transplantation, including issues with donor evaluation and selection, donor liver biopsy, orphan organ allocation, donor morbidity and mortality, outcomes compared with deceased donor liver transplant from time of evaluation, death on the waiting list, and evolving recipient indications for living-donor liver transplantation.

SUMMARY

Increasing the number of living-donor liver transplants would allow us to expedite transplant, avoid death on the waitlist, and possibly save more lives by expanding the criteria for transplant. These benefits must always be weighed against the potential risks and complications to the donor, which can be significant.

Liver transplantation for hepatocellular carcinoma: beyond the Milan criteria

Liver transplantation represents a cornerstone in the management of early-stage hepatocellular carcinoma (HCC). Expansion beyond the Milan criteria for liver transplantation (1 lesion <or= 5 cm, or 2 to 3 lesions each <or= 3 cm) remains controversial. This review covers several key areas: (1) Recent developments and published data on expanded criteria for deceased donor and live-donor liver transplantation, with emphasis on criteria that have been applied to preoperative imaging. (2) Independent testing of expanded criteria, where published data are largely limited to the proposed University of California, San Francisco criteria (1 lesion <or= 6.5 cm, 2-3 lesions each <or= 4.5 cm with total tumor diameter <or= 8 cm). (3) Response to loco-regional therapy and tumor downstaging. (4) The fundamental questions and answers in resolving the controversy over expanded criteria. The key issue pertains to whether acceptable outcome can be achieved on a broader scale beyond single center experience, which appears to support modest expansion beyond the Milan criteria. The foundation of the debate over expanded criteria may rest upon what the transplant community would consider to be the acceptable threshold for patient survival using expanded criteria, without causing significant harm to other transplant candidates without HCC.

Diagnosis and treatment of hepatocellular carcinoma

The diagnosis and treatment of hepatocellular carcinoma (HCC) have witnessed major changes over the past decade. Until the early 1990s, HCC was a relatively rare malignancy, typically diagnosed at an advanced stage in a symptomatic patient, and there were no known effective palliative or therapeutic options. However, the rising incidence of HCC in several regions around the world coupled with emerging evidence for efficacy of screening in high-risk patients, liver transplantation as a curative option in select patients, ability to make definitive diagnosis using high-resolution imaging of the liver, less dependency on obtaining tissue diagnosis, and proven efficacy of transarterial chemoembolization and sorafenib as palliative therapy have improved the outlook for HCC patients. In this article, we present a summary of the most recent information on screening, diagnosis, staging, and different treatment modalities of HCC, as well as our recommended management approach.

Hepatocellular carcinoma: latest developments

PURPOSE OF REVIEW

This review primarily focuses on new developments in the field of hepatocellular carcinoma.

RECENT FINDINGS

Potential preventive strategies in the development of hepatocellular carcinoma are being recognized. Novel molecular markers identified may aid in the diagnosis of early hepatocellular carcinoma in patients with chronic hepatitis C virus. Prognostic information gained by preoperative tumor biopsy is being investigated. Treatment of early hepatocellular carcinoma with resection versus primary or salvage transplantation continues to be debated. Expansion of selection criteria beyond the Milan criteria appears feasible. The role of living donor liver transplantation in hepatocellular carcinoma will require further study to determine the risk of recurrence. Improvements in chemoembolization with drug eluting beads appear promising.

SUMMARY

Further insight into the pathogenesis of hepatocellular carcinoma will result in the continued evolution of our approach and management of the disease. Tailored therapies based on tumor biology are needed to improve treatment response and ultimately patient survival.

Live donors in liver transplantation

Living donor liver transplantation (LDLT) has been controversial since its inception. Begun in response to deceased donor organ shortage and waiting list mortality, LDLT was initiated in 1989 in children, grew rapidly after its first general application in adults in the United States in 1998, and has declined since 2001. There are significant risks to the living donor, including the risk of death and substantial morbidity, and 2 highly publicized donor deaths are thought to have contributed to decreased enthusiasm for LDLT. Significant improvements in outcomes have been seen over recent years, and data, including from the National Institutes of Health-funded Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL), have established a survival benefit from pursuing LDLT. Despite this, LDLT still composes less than 5% of adult liver transplants, significantly less than in kidney transplantation where living donors compose approximately 40% of all transplantations performed. The ethics, optimal utility, and application of LDLT remain to be defined. In addition, most studies to date have focused on posttransplantation outcomes and have not included the effect of the learning curve on outcome or the potential impact of LDLT on waiting list mortality. Further growth of LDLT will depend on defining the optimal recipient and donor characteristics for this procedure as well as broader acceptance and experience in the public and in transplant centers.