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

Liver transplantation for hepatocellular carcinoma in Asia

Hepatocellular carcinoma (HCC) is a leading cause of cancer death, particularly in Asia where the major etiology, chronic hepatitis B virus infection, is endemic. The tumor frequently develops in a background of cirrhosis, and liver transplantation offers a chance to cure both the tumor and the underlying cirrhosis. The Milan criteria based on tumor size and number as an estimate of tumor burden are conventionally the gold standard in determining eligibility for transplantation, and the outcome is excellent. The shortage of organs from deceased donors has curtailed the adoption of extended criteria and led to the problems of long waiting times and dropouts. Several measures have been taken to tackle these issues, including prioritization of patients with HCC, use of pretransplant adjuvant treatment to prevent tumor progression, and living donor liver transplantation (LDLT). With a high incidence of HCC and a low organ donation rate, Asia has developed a distinctive pattern of indication and strategy in the application of liver transplantation. Over the last decade, the number of liver transplants in Asia has increased rapidly, by 10-fold, largely as a result of the development of LDLT. The proportion of patients who undergo liver transplantation for HCC is increasing and HCC comprises one third of the indication for liver transplantation in Asia. LDLT is the dominant strategy, accounting for 96% of the liver transplants for HCC. Many transplant programs accept patients beyond the Milan criteria, and the reported 3-year survival rate is about 60%. With the promotion of organ donation, better quantification of the benefit of LDLT for extended indications, and identification of predictors for survival, the practice of liver transplantation for HCC in Asia will continue to evolve.

Live donor liver transplantation: current status

The inequality between supply of grafts and demand for transplants has forced the transplant community to devise ways to increase the number of available livers for transplant (ie, through use of extended criteria donor grafts and living donation). Since 2002, the number of live donor liver transplantations (LDLT) performed has declined due to concerns of donor safety and lack of clear outcome data establishing success equivalent to that of deceased donor liver transplantation (DDLT). Recent data suggest that LDLT outcomes are comparable with those of DDLT, provided a center has performed more than 20 procedures, both in patients with and without hepatitis C. Further studies are needed to define the optimal donor and the ideal recipient for LDLT. Results from a National Institutes of Health-funded consortium of nine transplant centers are highly anticipated. These data are expected to underscore the viability of LDLT as a life-saving therapy for certain patients with end-stage liver disease.

Early detection of liver cancer: diagnosis and management

Hepatocellular carcinoma (HCC) is the fifth most common cause of cancer deaths worldwide, and the incidence is rising. Despite a wide array of treatment options, fewer than half of candidates for potentially curative treatments receive them. The diagnosis and management of HCC require a multidisciplinary approach involving various clinical specialties. The foundation of diagnosis is high-quality imaging, with MRI being the test of choice. Some patients also require guided biopsy when MRI is equivocal. Treatment options depend upon the tumor stage and the degree of underlying synthetic dysfunction. Potentially curative treatments include surgical resection and transplantation. Other treatments that prolong survival include percutaneous ablation and transarterial chemoembolization. A new oral agent, sorafenib, was recently shown to prolong survival in patients with advanced HCC. By increasing surveillance and treatment of HCC, outcomes for these patients may be improved.

Liver transplantation for hepatocellular carcinoma: validation of the UCSF-expanded criteria based on preoperative imaging

We previously suggested that in patients with heptocellular carcinoma (HCC), the conventional Milan criteria (T1/T2) for orthotopic liver transplantation (OLT) could be modestly expanded based on pathology (UCSF criteria). The present study was undertaken to prospectively validate the UCSF criteria based on pretransplant imaging. Over a 5-year period, the UCSF criteria were used as selection guidelines for OLT in 168 patients, including 38 patients exceeding Milan but meeting UCSF criteria (T3A). The 1- and 5-year recurrence-free probabilities were 95.9% and 90.9%, and the respective survivals without recurrence were 92.1% and 80.7%. Patients with preoperative T1/T2 HCC had 1- and 5-year recurrence-free probabilities of 95.7% and 90.1%, respectively, versus 96.9% and 93.6%, respectively, for preoperative T3A stage (p = 0.58). Under-staging was observed in 20% of T2 and 29% of T3A HCC (p = 0.26). When explant tumor exceeded UCSF criteria (15%), the 1- and 5-year recurrence-free probabilities were 80.4% and 59.5%, versus 98.6% and 96.7%, respectively, for those within UCSF criteria (p < 0.0001). In conclusion, our results validated the ability of the UCSF criteria to discriminate prognosis after OLT and to serve as selection criteria for OLT, with a similar risk of tumor recurrence and under-staging when compared to the Milan criteria.

Extending indication: role of living donor liver transplantation for hepatocellular carcinoma

Living donor liver transplantation. Indication of hepatocellular carcinoma. Milan criteria. United Network for Organ Sharing (UNOS) tumor staging. Alfa-fetoprotein (AFP). Protein induced by vitamin K absence or antagonism factor II (PIVKA II).

Living donor liver transplantation for hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is increasing at an alarming rate in the United States, such that HCC has become an important indication for liver transplantation. The role of liver transplantation in patients with HCC has evolved over the past 2 decades, and transplantation has become one of the few curative treatment modalities for patients with HCC, especially in selected patients with favorable tumors. The advent of living donor liver transplantation for adult recipients provides another therapeutic venue, in particular for patients with HCC who are disadvantaged by current allocation algorithms for grafts from deceased donors. Living donor transplantation may limit the waiting time and, as a result, may decrease the progression of disease so that intuitively the recurrence rate should be lower than for recipients who wait for an organ from a deceased donor. There are limited data on the efficacy of living donor liver transplantation in the setting of HCC. Based on a limited cohort of patients undergoing transplantation for HCC at Northwestern University Medical Center, a higher recurrence rate, stage for stage, was found in recipients whose transplants were accelerated ("fast-tracked") by performing a living donor transplant, especially in the era in which patients with HCC were disadvantaged by the allocation algorithm. Clearly, the role of living donor liver transplantation in management of patients with HCC requires prospective direct analysis of both recurrence and dropout rates in comparable patient cohorts with HCC undergoing either deceased or living donor liver transplantation.