1
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Mazur RD, Cron DC, Chang DC, Yeh H, Dageforde LAD. Impact of Median MELD at Transplant Minus 3 National Policy on Quality of Transplanted Livers for Patients With and Without Hepatocellular Carcinoma. Transplantation 2024; 108:204-214. [PMID: 37189232 PMCID: PMC10651798 DOI: 10.1097/tp.0000000000004621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Patients with hepatocellular carcinoma (HCC) have been overprioritized in the deceased donor liver allocation system. The United Network for Organ Sharing adopted a policy in May 2019 that limited HCC exception points to the median Model for End-Stage Liver Disease at transplant in the listing region minus 3. We hypothesized this policy change would increase the likelihood to transplant marginal quality livers into HCC patients. METHODS This was a retrospective cohort study of a national transplant registry, including adult deceased donor liver transplant recipients with and without HCC from May 18, 2017, to May 18, 2019 (prepolicy) to May 19, 2019, to March 1, 2021 (postpolicy). Transplanted livers were considered of marginal quality if they met ≥1 of the following: (1) donation after circulatory death, (2) donor age ≥70, (3) macrosteatosis ≥30% and (4) donor risk index ≥95th percentile. We compared characteristics across policy periods and by HCC status. RESULTS A total of 23 164 patients were included (11 339 prepolicy and 11 825 postpolicy), 22.7% of whom received HCC exception points (prepolicy versus postpolicy: 26.1% versus 19.4%; P = 0.03). The percentage of transplanted donor livers meeting marginal quality criteria decreased for non-HCC (17.3% versus 16.0%; P < 0.001) but increased for HCC (17.7% versus 19.4%; P < 0.001) prepolicy versus postpolicy. After adjusting for recipient characteristics, HCC recipients had 28% higher odds of being transplanted with marginal quality liver independent of policy period (odds ratio: 1.28; confidence interval, 1.09-1.50; P < 0.01). CONCLUSIONS The median Model for End-Stage Liver Disease at transplant in the listing region minus 3 policy limited exception points and decreased the quality of livers received by HCC patients.
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Affiliation(s)
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Heidi Yeh
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Leigh Anne D Dageforde
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, MA
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2
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de Freitas ACT, Espinoza FDS, Mattar CA, Coelho JCU. INDICATION FOR LIVER TRANSPLANTATION DUE TO HEPATOCELLULAR CARCINOMA: ANALYSIS OF 1,706 PROCEDURES OVER THE PAST DECADE IN THE STATE OF PARANÁ. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2022; 35:e1701. [PMID: 36542003 PMCID: PMC9767419 DOI: 10.1590/0102-672020220002e1701] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/30/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients listed for liver transplantation and hepatocellular carcinoma are considered priority on the waiting list, and this could overly favor them. AIM This study aimed to evaluate the impact of this prioritization. METHODS We analyzed the liver transplants performed in adults from 2011 to 2020 and divided into three groups: adjusted Model of End-Stage Liver Disease (MELD) score for hepatocellular carcinoma, other adjusted Model of End-Stage Liver Disease situations, and no adjusted Model of End-Stage Liver Disease. RESULTS A total of 1,706 patients were included in the study, of which 70.2% were male. Alcoholism was the main etiology of cirrhosis (29.6%). Of the total, 305 patients were with hepatocellular carcinoma, 86 with other adjusted Model of End-Stage Liver Disease situations, and 1,315 with no adjusted Model of End-Stage Liver Disease. Patients with hepatocellular carcinoma were older (58.9 vs. 53.5 years). The predominant etiology of cirrhosis was viral hepatitis (60%). The findings showed that group with adjusted Model of End-Stage Liver Disease had lower physiological Model of End-Stage Liver Disease (10.9), higher adjusted Model of End-Stage Liver Disease (22.6), and longer waiting list time (131 vs. 110 days), as compared to the group with no adjusted Model of End-Stage Liver Disease. The total number of transplants and the proportion of patients transplanted for hepatocellular carcinoma increased from 2011 to 2020. There was a reduction in the proportion of patients with hepatocellular carcinoma and adjusted Model of End-Stage Liver Disease of 20 and there was an increase on waiting list time in this group. There was an increase in the proportion of those with adjusted Model of End-Stage Liver Disease of 24 and 29, but the waiting list time remained stable. CONCLUSION Over the past decade, prioritization of hepatocellular carcinoma resulted in an increased proportion of transplanted patients in relation to those with no priority. It also increased waiting list time, requiring higher adjusted Model of End-Stage Liver Disease to transplant an organ.
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Affiliation(s)
| | | | - Cristina Alvarez Mattar
- Universidade Federal do Paraná, Department of Surgery and Liver Transplant Unit – Curitiba (PR), Brazil
| | - Júlio Cezar Uili Coelho
- Universidade Federal do Paraná, Department of Surgery and Liver Transplant Unit – Curitiba (PR), Brazil
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3
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Yoon YI, Song GW, Lee S, Moon D, Hwang S, Kang WH, Cho HD, Ha SM, Kim MJ, Kim SH, Na BG, Yang G, Min Kim S, Hyun Shim J, Park JI. Salvage living donor liver transplantation versus repeat liver resection for patients with recurrent hepatocellular carcinoma and Child-Pugh class A liver cirrhosis: A propensity score-matched comparison. Am J Transplant 2022; 22:165-176. [PMID: 34383368 DOI: 10.1111/ajt.16790] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 01/27/2023]
Abstract
Following curative liver resection (LR), resectable tumor recurrence in patients with preserved liver function leads to deciding between a repeat LR and a salvage liver transplantation (LT), if a donor's liver is available. This retrospective study compared survival outcomes and recurrence pattern following salvage living donor LT (LDLT) and repeat LR in patients with recurrent hepatocellular carcinoma (HCC). We reviewed the medical records of patients who underwent repeat LR (n = 163) or LDLT (n = 84) for recurrent HCC following curative resections, between January 2005 and December 2017 at a single institution. A 1:1 propensity score matching led to 42 patients per group. Disease-specific and recurrence-free survival were significantly better in the salvage LDLT group than in the repeat LR group (p = .042; HR = 2.40; 95% CI, 0.69-6.00 and p < .001; HR = 4.23; 95% CI, 2.05-8.71, respectively). Despite significant differences in recurrence patterns between the two groups (p = .019), the patient death rates, after recurrence, were similar for both groups (p = .760). This study indicates that salvage LDLT is superior to repeat LR for treating patients with transplantable, intrahepatic HCC recurrence, even in patients with Child-Pugh class A liver cirrhosis.
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Affiliation(s)
- Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - SungGyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - DeokBog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwui-Dong Cho
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su-Min Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Jae Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Hoon Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byeong-Gon Na
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Geunhyeok Yang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Min Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hyun Shim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Ik Park
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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4
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Li H, Yu X, Shi B, Zhang K, Yuan L, Liu X, Wang P, Lv J, Meng G, Xuan Q, Wu W, Li B, Peng X, Qin X, Liu W, Zhong L, Peng Z. Reduced pannexin 1-IL-33 axis function in donor livers increases risk of MRSA infection in liver transplant recipients. Sci Transl Med 2021; 13:13/606/eaaz6169. [PMID: 34380770 DOI: 10.1126/scitranslmed.aaz6169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/28/2020] [Accepted: 07/12/2021] [Indexed: 12/28/2022]
Abstract
Liver transplantation patients are at increased risk for methicillin-resistant Staphylococcus aureus (MRSA) infection, but the molecular mechanism remains unclear. We found that genetic predisposition to low pannexin 1 (PANX1) expression in donor livers was associated with MRSA infection in human liver transplantation recipients. Using Panx1 and Il-33-knockout mice for liver transplantation models with MRSA tail vein injection, we demonstrated that Panx1 deficiency increased MRSA-induced liver injury and animal death. We found that decreased PANX1 expression in the liver led to reduced release of adenosine triphosphate (ATP) from hepatocytes, which further reduced the activation of P2X2, an ATP-activating P2X receptor. Reduced P2X2 function further decreased the NLRP3-mediated release of interleukin-33 (IL-33), reducing hepatic recruitment of macrophages and neutrophils. Administration of mouse IL-33 to Panx1-/- mice significantly (P = 0.011) ameliorated MRSA infection and animal death. Reduced human hepatic IL-33 protein abundance also associated with increased predisposition to MRSA infection. Our findings reveal that genetic predisposition to reduced PANX1 function increases risk for MRSA infection after liver transplantation by decreasing hepatic host innate immune defense, which can be attenuated by IL-33 treatment.
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Affiliation(s)
- Hao Li
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Xiaoyu Yu
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200085, China
| | - Baojie Shi
- Department of General Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, China.,Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen 361000, China
| | - Kun Zhang
- Department of General Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, China.,Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen 361000, China
| | - Liyun Yuan
- Bio-Med Big Data Center, CAS-MPG Partner Institute for Computational Biology, Shanghai Institutes of Biological Sciences, Chinese Academy of Sciences, Shanghai 200031, China
| | - Xueni Liu
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Pusen Wang
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Junwei Lv
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Guangxun Meng
- Institut Pasteur of Shanghai, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai 200031, China
| | - Qiankun Xuan
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200085, China
| | - Wenjuan Wu
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200085, China
| | - Bin Li
- Shanghai Institute of Immunology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xiao Peng
- Department of Neuroscience, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 10140, USA
| | - Xuebin Qin
- Department of Neuroscience, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 10140, USA.,Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA 70112, USA.,Department of Pathology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Wanqing Liu
- Department of Pharmaceutical Sciences and Department of Pharmacy, Wayne State University, Detroit, MI 48201, USA.
| | - Lin Zhong
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China.
| | - Zhihai Peng
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China. .,Department of General Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, China.,Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen 361000, China
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5
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Mehta N, Bhavsar R, Das SP. Transplantation in hepatocellular carcinoma - controversies and recommendations: A review of current literature. INTERNATIONAL JOURNAL OF ADVANCED MEDICAL AND HEALTH RESEARCH 2021. [DOI: 10.4103/ijamr.ijamr_220_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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6
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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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7
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Vasconcellos M, Zamith LM. Impact of the MELD score on the survival of hepatocellular carcinoma transplantation patients in Brazil: a systematic review. Rev Col Bras Cir 2020; 46:e20192392. [PMID: 32022116 DOI: 10.1590/0100-6991e-20192392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/12/2019] [Indexed: 12/29/2022] Open
Abstract
This study aimed to analyse the predictive value of Model For End-Stage Liver Disease (MELD) score on medium- and long-term survival in transplanted hepatocellular carcinoma (HCC) patients in Brazil. The study was registered with International Prospective Register of Systematic Reviews (PROSPERO) under N# 152,363. Inclusion criteria were based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. The search was performed on the indexed databases of Lilacs, SciELO, PubMed, and Cochrane Library, and used as search strategy the following Medical Subject Headings (MeSH) terms: ((("MELD Score") OR "Model For End-Stage Liver Disease") AND "Hepatocellular Carcinoma") AND ("Brazil"). We included full-text articles published from January 2006 to October 2019. The initial search found 162 articles. After reading the available abstracts and full texts, 156 articles were excluded, totaling six articles for qualitative analysis. Although the small number of eligible articles was a limiting factor of the study, our results partially corroborated those found in the United States, United Kingdom, and Ireland. In these countries, unlike Brazil, MELD prognostic model has shown a strong association with post-liver transplant (LT) survival. However, the low predictive capacity of the model in medium- and long-term has been similar to the one of our study. The urgency of the development and validation of a post-transplant survival model for patients with HCC is set, improving the organ allocation system in Brazil.
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Affiliation(s)
- Marcel Vasconcellos
- Centro Universitário Serra dos Órgãos (UNIFESO), Faculdade de Medicina, Teresópolis, RJ, Brasil
| | - Luíza Magalhães Zamith
- Centro Universitário Serra dos Órgãos (UNIFESO), Faculdade de Medicina, Teresópolis, RJ, Brasil
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8
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Abstract
Identifying the optimal allocation policy with regard to hepatocellular carcinoma has been a persistent and evolving challenge. The current criteria for LT for HCC endorsed by the United Network of Organ Sharing (UNOS) are based on the Milan Criteria: a solitary tumor < 5 cm, or maximum of three tumors ≤ 3 cm each, without vascular invasion or evidence of extrahepatic spread. Contraindications to HCC exception points include: stage 1 HCC, ruptured HCC, extrahepatic HCC, and main portal or hepatic vein HCC invasion. Based upon projected waitlist dropout rates due to tumor growth, patients with HCC are assigned MELD standardized exception points. In addition to tumor size and number, AFP levels are an important predictor of recurrence of HCC following liver transplantation. Standardized exception points for HCC patients are not awarded to patients with AFP levels > 1000 ng/mL that do not decrease to < 500 ng/mL with treatment. Appeals for MELD exception points for patients with HCC vary widely between UNOS regions, with success of nonstandardized exception point appeals varying from 3.1 to 21% between regions. In an effort to make prioritization for HCC more consistent, a national liver review board (NLRB)is being convened that will focus on developing a national guidance for assessing common requests and addressing exception points, including for HCC.
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9
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Abstract
Multidisciplinary tumor boards have evolved to address the increasing complexity of cancer care management. Given that hepatocellular carcinoma (HCC) often arises in the setting of underlying cirrhosis, expert input from hepatologists alongside hepatobiliary and transplant surgeons, radiation oncologists, interventional and body radiologists, and medical oncologists has become increasingly important in order to offer patients appropriate cancer treatments. The MDLTB structure has evolved since the early 2000s to bring these specialists together at regularly scheduled meetings to develop a therapeutic treatment plan for HCC management. MDLTBs have reduced the time to treatment and improved patient satisfaction. Standardized documentation with common data elements has been recommended to ensure adequate communication from MDLTB to referring healthcare providers. Retrospective studies consistently highlight the frequency of changes in treatment plans after MDLTB review to better adhere to guideline recommended care. Despite several decades of MDLTBs implementation, few studies describe clinical outcomes associated with MDLTBs such as patient survival and cost benefits. More research is needed in this area to further justify the heavy use of resources that are needed to maintain MDLTBs. Development and use of a centralized database to store such information may assist with future studies of clinical outcomes and inform quality improvement projects.
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Affiliation(s)
- Melissa M Gadsden
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 7th Floor, 3400 Civic Center Drive, Philadelphia, PA, 19104, USA.,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 7th Floor, 3400 Civic Center Drive, Philadelphia, PA, 19104, USA. .,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
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10
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Jain A, Miller D, Schreibman I, Riley TR, Krok KL, Dohi T, Sharma R, Kadry Z. Is there increased risk of hepatocellular carcinoma recurrence in liver transplant patients with direct-acting antiviral therapy? Hepatol Int 2019; 13:190-198. [PMID: 30680672 DOI: 10.1007/s12072-019-09930-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 01/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recently, a controversy has emerged: is the rate of recurrence of hepatocellular carcinoma (HCC) higher following treatment of hepatitis C virus (HCV) with direct-acting antiviral (DAA) therapy? However, the risk of HCC recurrence has not been studied in liver transplant (LTx) recipients who received DAA therapy. The aim of the present study is to compare the rate of HCC recurrence in LTx recipients who did or did not receive DAA therapy. PATIENTS AND METHODS Sixty-three patients received LTx with HCC. Twenty-seven (42.9%) with HCV received DAA therapy (Group A), 20 (31.7%) with HCV did not receive DAA therapy (Group B), and 16 (25.4%) did not have HCV (Group C). RESULTS In group A, three (11%), in group B, one (5%), and in group C, none had recurrence of HCC. Actuarial 4-year recurrence-free survival was 88.9, 95, and 100% in group A, B, and C, respectively (p = 0.37). Group A was subdivided into two groups for comparison with Group B: A1 included five patients who had end of treatment response (ETR) without sustained virological response (SVR), and A2 included 20 patients who achieved SVR. Three patients from A1 had HCC recurrence and no patients from A2 had HCC recurrence. (p = 0.0038; group A1, A2, and B). CONCLUSIONS The rate of HCC recurrence in LTx patients with DAA therapy was significantly higher with ETR, without SVR, after DAA therapy compared to patients with SVR or patients who did not receive DAA therapy. LTx recipients with HCC receiving DAA therapy requires further studies.
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Affiliation(s)
- Ashokkumar Jain
- Division of Transplantation, Department of Surgery, College of Medicine, Pennsylvania State University, Mail Code H062, 500 University Drive, PO Box 850, Hershey, PA, 17033-0850, USA.
| | - Danielle Miller
- Division of Transplantation, Department of Surgery, College of Medicine, Pennsylvania State University, Mail Code H062, 500 University Drive, PO Box 850, Hershey, PA, 17033-0850, USA
| | - Ian Schreibman
- Division of Gastroenterology, Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Thomas R Riley
- Division of Gastroenterology, Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Karen L Krok
- Division of Gastroenterology, Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Takehiko Dohi
- Division of Transplantation, Department of Surgery, College of Medicine, Pennsylvania State University, Mail Code H062, 500 University Drive, PO Box 850, Hershey, PA, 17033-0850, USA
| | - Rajeev Sharma
- CSL Behring, 1020 First Ave, King of Prussia, PA, USA
| | - Zakiyah Kadry
- Division of Transplantation, Department of Surgery, College of Medicine, Pennsylvania State University, Mail Code H062, 500 University Drive, PO Box 850, Hershey, PA, 17033-0850, USA
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11
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D'Souza AM, Shah R, Gupta A, Towbin AJ, Alonso M, Nathan JD, Bondoc A, Tiao G, Geller JI. Surgical management of children and adolescents with upfront completely resected hepatocellular carcinoma. Pediatr Blood Cancer 2018; 65:e27293. [PMID: 29968976 DOI: 10.1002/pbc.27293] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/13/2018] [Accepted: 05/30/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is an aggressive malignant neoplasm that is often chemoresistant. Complete surgical resection remains the mainstay of therapy. The role of liver transplantation (LT) in pediatric HCC is in evolution, as is the role of adjuvant chemotherapy for stage I disease. METHODS A retrospective review of patients < 18 years of age with completely resected HCC treated with surgical intervention alone at our institution from 2004 to 2015 was conducted. RESULTS Twelve patients with a median age of 12 years (range = 1-17; number of females = 7) with upfront resected HCC (Evans stage I) were identified. Four patients had HCC without identifiable risk factors (fibrolamellar-HCC = 2; early HCC arising in focal nodular hyperplasia = 1, well-differentiated [wd] HCC = 1). Four patients had early or wd-HCC in the context of portosystemic shunts (Abernethy = 2; mesocaval shunt and portal vein thrombosis = 2). Four patients had moderate to wd-HCC in the context of pre-existing liver disease with cirrhosis (progressive familial intrahepatic cholestasis type-2 = 2, alpha-1 antitrypsin deficiency = 1, Alagille syndrome = 1). Seven patients underwent LT (multifocal = 5; solitary = 2); five exceeded Milan criteria (MC) by imaging. Five patients underwent complete resection (segmentectomy = 2; hemihepatectomy = 3). Ten patients received no adjuvant chemotherapy. All patients are alive without evidence of disease with a median follow-up of 54.1 months (range = 28.1-157.7 months). CONCLUSIONS Pediatric and adolescent patients with upfront, completely resected HCC can be effectively treated without chemotherapy. LT should be considered for nonmetastatic HCC, especially in the context of pre-existing chronic liver disease, even when the tumor exceeds MC. Distinct pediatric selection criteria are needed to identify patients most suitable for LT.
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Affiliation(s)
- Amber M D'Souza
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rachana Shah
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anita Gupta
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maria Alonso
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alex Bondoc
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Greg Tiao
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James I Geller
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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12
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Cascales-Campos PA, Ramírez P, González-Sánchez MR, Alconchel F, Martínez-Insfran LA, Sánchez-Bueno F, Robles R, Pons JA, Vargas Á, Sanmartín J, Royo-Villanova M, Parrilla P. Orthotopic Liver Transplantation With Elderly Donors (Over 80 Years of Age): A Prospective Evaluation. Transplant Proc 2018; 50:3594-3600. [PMID: 30577243 DOI: 10.1016/j.transproceed.2018.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/19/2018] [Accepted: 08/03/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Our main objective was to assess the clinical outcomes obtained in a single orthotopic liver transplant (OLT) hospital with donors ≥80 years of age compared to a control group of patients subjected to OLT during the same period of time with donors who were under 65 years of age. METHODS A prospective analysis was carried out on all the OLTs performed using liver grafts from donors in a state of brain death and with an age of ≥80 years (study group) between April 2007 and January 2015. The results of the study group (n = 36) were compared with those of a control group of patients less than 65 years of age receiving transplants with grafts. RESULTS A total of 51 potential donors ≥80 years were assessed, with a total of 36 liver transplants being carried out and their results were compared with a control group of 283 patients receiving transplants. The median follow-up time of the patients in the series was 36 months (range: 24-120 months). Graft survival at 1, 2, and 3 years was 77%, 72%, and 62%, respectively, among the patients in the study group and 79%, 73%, and 65% among the patients in the control group, and there were no statistically significant differences. Patient survival at 1, 2, and 3 years was 86%, 82%, and 75%, respectively, among the patients in the study group and 82%, 76%, and 72% among the patients in the control group, also without there being any statistically significant differences. CONCLUSIONS There is no age limit for liver transplant donors. The use of octogenarian donors makes it possible to increase the pool of donors while providing enough safety for the recipient.
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Affiliation(s)
- P A Cascales-Campos
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - P Ramírez
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - M R González-Sánchez
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - F Alconchel
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain.
| | - L A Martínez-Insfran
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - F Sánchez-Bueno
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - R Robles
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - J A Pons
- Department of Hepatology, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - Á Vargas
- Department of Hepatology, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - J Sanmartín
- Intensive Care Department, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - M Royo-Villanova
- Intensive Care Department, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - P Parrilla
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
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13
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Dorcaratto D, Udupa V, Hogan NM, Brophy DP, McCann JW, Maguire D, Geoghegan J, Cantwell CP, Hoti E. Does neoadjuvant doxorubicin drug-eluting bead transarterial chemoembolization improve survival in patients undergoing liver transplant for hepatocellular carcinoma? Diagn Interv Radiol 2018; 23:441-447. [PMID: 29063856 DOI: 10.5152/dir.2017.17106] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE We aimed to compare the overall (OS) and disease-free survival (DFS) of patients undergoing orthotopic liver transplant (OLT) for hepatocellular carcinoma who did and did not have neoadjuvant doxorubicin drug-eluting bead transarterial chemoembolization (DEB-TACE). METHODS This is a retrospective study of 94 patients with HCC transplanted between 2000 and 2014 in a single tertiary center. Pre- and postoperative features, DFS and OS were compared between patients who received pre-OLT DEB-TACE (n=34, DEB-TACE group) and those who did not (n=60, non-TACE group). Radiologic and histologic response to neoadjuvant treatment as well as its complications were also studied. RESULTS There were no significant differences in post-transplantation DFS and OS rates between groups (5-year DFS: 70% in DEB-TACE group vs. 63% in non-TACE group, P = 0.454; 5-year OS: 70% in DEB-TACE group vs. 65% in non-TACE group, P = 0.532). The DEB-TACE group had longer OLT waiting time compared with the non-TACE group (110 vs. 72 days; P = 0.01). On univariate and multivariate analyses, alpha-fetoprotein (AFP) levels >500 ng/mL prior to OLT were associated with decreased OS and DFS regardless of neoadjuvant approach (hazard ratio of 6, P = 0.001 and 5.5, P = 0.002, respectively). CONCLUSION Patients who underwent neoadjuvant DEB-TACE and OLT for hepatocellular carcinoma had no statistically different OS or DFS at 3 and 5 years from patients undergoing OLT alone.
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Affiliation(s)
- Dimitri Dorcaratto
- Hepatobiliary and Liver Transplant Surgical Unit, St. Vincent's University Hospital, Elm Park, Dublin, Ireland.
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15
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Thayer D, Noda C, Charalel R, Mills A, Chang R, Tao Y, Akinwande O. Survival comparison of hepatocellular carcinoma patients treated with radioembolization versus nonoperative/interventional treatment. J Comp Eff Res 2018; 7:343-356. [PMID: 29553286 DOI: 10.2217/cer-2017-0064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM To compare the overall survival (OS) and liver cancer-specific survival of advanced-stage hepatocellular carcinoma (HCC) patients who received transarterial radioembolization (TARE) with those who received nonoperative/interventional treatment (NOT). MATERIALS & METHODS A total of 12,520 HCC patients from the Surveillance, Epidemiology and End Results database were categorized by treatment with either radioembolization or NOT. Kaplan-Meier and multivariate Cox regression were conducted. RESULTS The TARE group had both a significantly longer median overall survival than the NOT group (TARE = 9 months; NOT = 2 months; p < 0.0001) and a significantly higher probability of liver cancer-specific survival (hazard ratio = 0.474). CONCLUSION TARE appears to provide a significant survival advantage over the NOT population in advanced HCC patients.
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Affiliation(s)
- David Thayer
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St Louis, St Louis, MO 63110, USA
| | - Christopher Noda
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St Louis, St Louis, MO 63110, USA
| | - Resmi Charalel
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St Louis, St Louis, MO 63110, USA
| | - Abigail Mills
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St Louis, St Louis, MO 63110, USA
| | - Randy Chang
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St Louis, St Louis, MO 63110, USA
| | - Yu Tao
- Siteman Biostatistics, Washington University School of Medicine in St Louis, St Louis, MO 63110, USA
| | - Olaguoke Akinwande
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St Louis, St Louis, MO 63110, USA.,Siteman Cancer Center, Washington University School of Medicine in St Louis, St Louis, MO 63110, USA
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Abstract
Over the last several years, liver transplantation has evolved to become a widely used treatment for hepatocellular carcinoma (HCC). The criteria used were developed in order to have acceptable outcomes for transplant with survival similar to other indications for transplant. These criteria are discussed in detail along with alternate options, including surgical resection and downstaging of HCC in cirrhotics. Technical considerations of liver transplantation must be considered, and living donor liver transplant is a possibility for treatment.
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Affiliation(s)
- Jennifer Berumen
- Department of Surgery, University of California, San Diego, 9300 Campus Point Dr, MC 7745, La Jolla, CA, 92037, USA.
| | - Alan Hemming
- Department of Surgery, University of California, San Diego, 9300 Campus Point Dr, MC 7745, La Jolla, CA, 92037, USA
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Kornberg A, Schernhammer M, Friess H. 18F-FDG-PET for Assessing Biological Viability and Prognosis in Liver Transplant Patients with Hepatocellular Carcinoma. J Clin Transl Hepatol 2017; 5:224-234. [PMID: 28936404 PMCID: PMC5606969 DOI: 10.14218/jcth.2017.00014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/18/2017] [Accepted: 06/05/2017] [Indexed: 12/12/2022] Open
Abstract
Liver transplantation (LT) has become standard of care in patients with non-resectable early stage hepatocellular carcinoma (HCC) in liver cirrhosis. Currently, patient selection for LT is strictly based on tumor size and number, provided by the Milan criteria. This may, however, exclude patients with advanced tumor load but favourable biology from a possibly curative treatment option. It became clear in recent years that biological tumor viability rather than tumor macromorphology determines posttransplant outcome. In particular, microvascular invasion and poor grading reflect tumor aggressiveness and promote the risk of tumor relapse. Pretransplant biopsy is not applicable due to tumor heterogeneity and risk of tumor cell seeding. 18F-fludeoxyglucose (18F-FDG) positron emission tomography (PET), an established nuclear imaging device in oncology, was demonstrated to non-invasively correlate with unfavorable histopathologic features. Currently, there is an increasing amount of evidence that 18F-FDG-PET is very useful for identifying eligible liver transplant patients with HCC beyond standard criteria but less aggressive tumor properties. In order to safely expand the HCC selection criteria and the pool of eligible liver recipients, tumor evaluation with 18F-FDG-PET should be implemented in pretransplant decision process.
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Affiliation(s)
- Arno Kornberg
- *Correspondence to: Arno Kornberg, Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, D-81675 Munich, Germany. Tel: +89-41405087, Fax: +89-41404884, E-mail:
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Gabr A, Abouchaleh N, Ali R, Vouche M, Atassi R, Memon K, Asadi AA, Baker T, Caicedo JC, Desai K, Fryer J, Hickey R, Abeccassis M, Habib A, Hohlastos E, Ganger D, Kulik L, Lewandowski RJ, Riaz A, Salem R. Comparative study of post-transplant outcomes in hepatocellular carcinoma patients treated with chemoembolization or radioembolization. Eur J Radiol 2017; 93:100-106. [DOI: 10.1016/j.ejrad.2017.05.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/18/2017] [Accepted: 05/19/2017] [Indexed: 02/08/2023]
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19
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Increased Risk of Death for Patients on the Waitlist for Liver Transplant Residing at Greater Distance From Specialized Liver Transplant Centers in the United States. Transplantation 2017; 100:2146-52. [PMID: 27490419 DOI: 10.1097/tp.0000000000001387] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND We have previously shown that patients listed for orthotopic liver transplantation (OLT) in United Network for Organ Sharing Region 4 (Texas and Oklahoma) have higher waitlist mortality rates when residing more than 30 miles from specialized liver transplant centers (LTC). Considering that findings might only be exclusive for this region with its peculiarities in terms of having the highest land surface extensions, lowest population densities, and largest rural populations. We investigated the entire OLT patient population in the United States to assess if our previous regional findings are nationally validated and if a rural, micropolitan, or metropolitan residence location affects outcome of waitlisted OLT patients in the nation. METHODS Patients waiting for OLT in the United States from 2002 to 2012 were stratified by distance from the patients' residence to LTC and by Rural Urban Commuting Area (RUCA) codes classification. Statistical analyses were performed to evaluate risk of mortality on the waitlist and the likelihood to receive an OLT using a Cox proportional hazards model and a generalized additive model with a logistic link. RESULTS Survival time and probability of death while on the waitlist for OLT using distance to LTC showed significant increased risk with the distance (P = 0.001 and P < 0.0001, respectively). At the same time, using RUCA classification as the variable did not show significance (P = 0.14 and P = 0.73, respectively). CONCLUSIONS Distance from an LTC is a risk factor of mortality on the waitlist for OLT, whereas RUCA classification is not a significant factor.
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21
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Inappropriate inferences from registry data: Pitfalls of inaccurate data handling? Indian J Gastroenterol 2017; 36:77-80. [PMID: 28357774 DOI: 10.1007/s12664-017-0749-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 03/12/2017] [Indexed: 02/04/2023]
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22
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23
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Sharma P, Parikh ND, Yu J, Barman P, Derstine BA, Sonnenday CJ, Wang SC, Su GL. Bone mineral density predicts posttransplant survival among hepatocellular carcinoma liver transplant recipients. Liver Transpl 2016; 22:1092-8. [PMID: 27064263 PMCID: PMC4961525 DOI: 10.1002/lt.24458] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 01/07/2023]
Abstract
Hepatocellular carcinoma (HCC) is a common indication for liver transplantation (LT). Recent data suggest that body composition features strongly affect post-LT mortality. We examined the impact of body composition on post-LT mortality in patients with HCC. Data on adult LT recipients who received Model for End-Stage Liver Disease exception for HCC between February 29, 2002, and December 31, 2013, and who had a computed tomography (CT) scan any time 6 months prior to LT were reviewed (n = 118). All available CT scan Digital Imaging and Communication in Medicine files were analyzed using a semiautomated high throughput methodology with algorithms programmed in MATLAB. Analytic morphomics measurements including dorsal muscle group (DMG) area, visceral and subcutaneous fat, and bone mineral density (BMD) were taken at the bottom of the eleventh thoracic vertebral level. Thirty-two (27%) patients died during the median follow-up of 4.4 years. The number of HCC lesions (hazard ratio [HR], 2.81; P < 0.001), BMD (HR = 0.90/Hounsfield units [HU]; P = 0.03), pre-LT locoregional therapy (HR = 0.14; P < 0.001), and donor age (HR = 1.05; P < 0.001) were the independent predictors of post-LT mortality. DMG area did not affect post-LT survival. In conclusion, in addition to number of HCC lesions and pre-LT locoregional therapy, low BMD, a surrogate for bone loss rather than DMG area, was independently associated with post-LT mortality in HCC patients. Bone loss may be an early marker of deconditioning that precedes sarcopenia and may affect transplant outcomes. Liver Transplantation 22 1092-1098 2016 AASLD.
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Affiliation(s)
- Pratima Sharma
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Neehar D Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI,Gastroenterology, Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | | | | | - Brian A Derstine
- Morphomics Analysis Group, University of Michigan, Ann Arbor, MI
| | | | - Stewart C Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI,Morphomics Analysis Group, University of Michigan, Ann Arbor, MI
| | - Grace L Su
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI,Morphomics Analysis Group, University of Michigan, Ann Arbor, MI,Gastroenterology, Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, MI
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24
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Current Treatment Approaches to HCC with a Special Consideration to Transplantation. J Transplant 2016; 2016:7926264. [PMID: 27413539 PMCID: PMC4931061 DOI: 10.1155/2016/7926264] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/19/2016] [Indexed: 12/13/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths worldwide. The mainstay of treatment of HCC has been both resectional and transplantation surgery. It is well known that, in selected, optimized patients, hepatectomy for HCC may be an option, even in patients with underlying cirrhosis. Resectable patients with early HCC and underlying liver disease are however increasingly being considered for transplantation because of potential for better disease-free survival and resolution of underlying liver disease, although this approach is limited by the availability of donor livers, especially in resectable patients. Outcomes following liver transplantation improved dramatically for patients with HCC following the implementation of the Milan criteria in the late 1990s. Ever since, the rather restrictive nature of the Milan criteria has been challenged with good outcomes. There has also been an increase in the donor pool with marginal donors including organs retrieved following cardiac death being used. Even so, patients still continue to die while waiting for a liver transplant. In order to reduce this attrition, bridging techniques and methods for downstaging disease have evolved. Additionally new techniques for organ preservation have increased the prospect of this potentially curative procedure being available for a greater number of patients.
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25
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Xu X, Lu D, Ling Q, Wei X, Wu J, Zhou L, Yan S, Wu L, Geng L, Ke Q, Gao F, Tu Z, Wang W, Zhang M, Shen Y, Xie H, Jiang W, Wang H, Zheng S. Liver transplantation for hepatocellular carcinoma beyond the Milan criteria. Gut 2016; 65:1035-41. [PMID: 25804634 PMCID: PMC4893115 DOI: 10.1136/gutjnl-2014-308513] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 03/04/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Liver transplantation is an optimal radical therapy for selected patients with hepatocellular carcinoma. The stringent organ allocation system driven by the Milan criteria has been challenged by alternative sets of expanded criteria. Careful analysis is needed to prove that the Milan criteria can be expanded safely and effectively. DESIGN This study collectively reviewed 6012 patients of hepatocellular carcinoma from the China Liver Transplant Registry. Expanded criteria were evaluated to characterise an optimised expansion with acceptable outcomes beyond the Milan criteria. RESULTS Compared with the Milan criteria, Valencia, University of California, San Francisco, University Clinic of Navarra and Hangzhou criteria provided an expansion of 12.4%, 16.3%, 19.6%, and 51.5%, respectively. The post-transplant survivals of patients fulfilling the expanded criteria were comparable to that of the Milan criteria. The analysis of net reclassification improvement and area under the receiver operating characteristic curves showed an excellent efficiency in recurrence prediction for the expanded criteria compared with the Milan criteria. In patients exceeding Milan but fulfilling the Hangzhou criteria (N=1352), α-fetoprotein (AFP) >100 ng/mL and tumour burden>8 cm were the only two independent prognostic factors (p<0.001). Accordingly, the Hangzhou criteria were stratified as type A (tumour burden ≤8 cm, or tumour burden >8 cm but AFP≤100 ng/mL) and type B (tumour burden >8 cm but AFP between 100 and 400 ng/mL). Type A showed significantly higher 5-year tumour-free survival rates compared with type B (p<0.001). CONCLUSIONS The Milan criteria can be expanded safely and effectively. The prognostic stratification system based on the Hangzhou criteria serves as a hierarchy of transplant candidates for hepatocellular carcinoma.
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Affiliation(s)
- Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Di Lu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qi Ling
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuyong Wei
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lin Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liming Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lei Geng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qinghong Ke
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Feng Gao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhenhua Tu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weilin Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yan Shen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haiyang Xie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenshi Jiang
- China Liver Transplant Registry, Shenzhen, China
| | - Haibo Wang
- China Liver Transplant Registry, Shenzhen, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
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Rate of observation and inter-observer agreement for LI-RADS major features at CT and MRI in 184 pathology proven hepatocellular carcinomas. Abdom Radiol (NY) 2016; 41:963-9. [PMID: 27193793 DOI: 10.1007/s00261-015-0623-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To compare frequency and inter-reader agreement for LI-RADS v2014 major features at CT vs. MRI in pathology-proven cases of hepatocellular carcinoma. METHODS Pathology reports and imaging studies from patients having undergone liver transplant or hepatectomy for hepatocellular carcinoma were reviewed. Size, location, washout, and capsule appearance for each lesion were recorded by two radiologists. Cohen's kappa and intraclass correlation coefficients (ICC) were calculated. RESULTS One hundred and thirty-four patients with 184 tumors were reviewed. Seventy-seven percentage of lesions were imaged by CT and 23% by MRI. No lesions were evaluated with both modalities. Mean lesion diameter was 2.6 ± 1.3 cm (ICC = 0.92). Arterial phase hyperenhancement was seen in 86% of lesions (κ = 0.75). Washout was seen in 82% of studies (κ = 0.61). Arterial phase hyperenhancement and washout were seen equally at CT and MRI (p = 1.00 and 0.46, respectively). Capsule was infrequently observed (27%) but was seen more commonly at MRI (44%) than at CT (17%) with p = 0.002 and (κ = 0.56). Forty-seven percent of lesions with at least one prior study met LI-RADS criteria for threshold growth. The rates of LI-RADS categories 3, 4, and 5 were 9%, 37%, and 54%, respectively. More 1-2 cm LI-RADS 5 lesions were seen at MRI (43%) than at CT (8%), p = 0.01. CONCLUSION A combined LI-RADS 4/5 group was 91% sensitive for hepatocellular carcinoma. Arterial enhancement and washout were seen more frequently than capsule, the sole finding seen more frequently at MRI than at CT. Inter-reader reliability was substantial for arterial hyperenhancement and washout but moderate for capsule. Capsule remains an important finding in small arterially enhancing lesions (1-2 cm) which require a second major criterion to upgrade to a LI-RADS 5 lesion.
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Sarpel U, Suprun M, Sofianou A, Berger Y, Tedjasukmana A, Sekendiz Z, Bagiella E, Schwartz ME. Disentangling the effects of race and socioeconomic factors on liver transplantation rates for hepatocellular carcinoma. Clin Transplant 2016; 30:714-21. [PMID: 27027869 DOI: 10.1111/ctr.12739] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Liver transplantation is the most effective treatment for hepatocellular carcinoma (HCC) in eligible patients, but is not accessed equally by all. We explored the effects of race and socioeconomic factors on transplantation for HCC while controlling for stage, resection status, and transplant candidacy. PATIENTS AND METHODS All HCC patients, 2003-2013, were retrospectively analyzed using multivariate analysis to explore differences in transplantation rates among cohorts. RESULTS Of 3078 HCC patients, 754 (24%) were considered transplant eligible. Odds of transplantation were significantly higher for those with commercial insurance (OR = 1.99, 95% CI [1.42, 2.79]) and lower for black patients (OR = 0.55, 95% CI [0.33, 0.91]). Asians were more likely to be resected than white patients with similarly staged tumors and transplant criteria (p < 0.001). Patients not listed for transplantation for non-medical reasons were more likely to be government-insured (p = 0.02) and not white (p = 0.05). No step along the transplantation pathway was identified as the dominant hurdle. DISCUSSION Patients who are black or government-insured are significantly less likely to undergo transplantation for HCC despite controlling for tumor stage, resection status, and transplant eligibility. Asian patients have higher rates of hepatic resection, but also appear to have lower transplantation rates beyond this effect.
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Affiliation(s)
- Umut Sarpel
- Division of Surgical Oncology, Department of Surgery, New York, NY, USA
| | - Maria Suprun
- Department of Population, Health Science and Policy, New York, NY, USA
| | | | - Yaniv Berger
- Division of Surgical Oncology, Department of Surgery, New York, NY, USA
| | | | | | - Emilia Bagiella
- Department of Population, Health Science and Policy, New York, NY, USA
| | - Myron E Schwartz
- The Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Zhong L, Li H, Li Z, Shi B, Wang P, Wang C, Fan J, Sun H, Wang P, Qin X, Peng Z. C7 genotype of the donor may predict early bacterial infection after liver transplantation. Sci Rep 2016; 6:24121. [PMID: 27063552 PMCID: PMC4827091 DOI: 10.1038/srep24121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/14/2016] [Indexed: 01/27/2023] Open
Abstract
Post-transplantation infection causes high mortality and remains a significant challenge. High clinical risk factors for bacterial infection in recipients are often found in critically ill patients. However, for some recipients, bacterial infections are inevitable. It is conceivable that this susceptibility may be related to the genetics of the donor and recipient. Using expression quantitative trait loci (eQTL) analysis, we found that the C7 rs6876739 CC genotypes and mannan-binding lectin (MBL2) gene polymorphisms of liver donors were significantly associated with bacterial infection in recipients. In an extended validation group of 113 patients, donor C7 rs6876739 genetic variation was an independent risk factor for bacterial infection. The donor C7 rs6876739 CC genotype was associated with lower levels of recipient C7 protein, soluble membrane attack complex (MAC), and IL-1β expression compared with the donor C7 rs6876739 TT genotype. In vitro, the MAC significantly triggered NLRP3 inflammasome activation and IL-1β release, suggesting that the mechanism by which C7 defends against bacteria may involve MAC formation, leading to NLRP3 inflammasome activation and IL-1β release. Our findings may be helpful in identifying transplantation recipients at risk of bacterial infection prior to surgery and may contribute to novel infection prevention strategies and the improvement of postoperative outcomes.
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Affiliation(s)
- Lin Zhong
- Department of General Surgery, Shanghai Jiao Tong University Affiliated First People's Hospital, 85 Wu Jing Road, 200080, China
| | - Hao Li
- Department of General Surgery, Shanghai Jiao Tong University Affiliated First People's Hospital, 85 Wu Jing Road, 200080, China
| | - Zhiqiang Li
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders, Shanghai Jiao Tong University, Shanghai, China
| | - Baojie Shi
- Department of General Surgery, Shanghai Jiao Tong University Affiliated First People's Hospital, 85 Wu Jing Road, 200080, China
| | - PuSen Wang
- Department of General Surgery, Shanghai Jiao Tong University Affiliated First People's Hospital, 85 Wu Jing Road, 200080, China
| | - ChunGuang Wang
- Department of General Surgery, Shanghai Jiao Tong University Affiliated First People's Hospital, 85 Wu Jing Road, 200080, China
| | - Junwei Fan
- Department of General Surgery, Shanghai Jiao Tong University Affiliated First People's Hospital, 85 Wu Jing Road, 200080, China
| | - Hongcheng Sun
- Department of General Surgery, Shanghai Jiao Tong University Affiliated First People's Hospital, 85 Wu Jing Road, 200080, China
| | - Peiwen Wang
- Department of Gastroenterology, Shanghai Jiao Tong University Affiliated First People's Hospital, 85 Wu Jing Road, 200080, China
| | - Xuebin Qin
- Department of Neuroscience, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Zhihai Peng
- Department of General Surgery, Shanghai Jiao Tong University Affiliated First People's Hospital, 85 Wu Jing Road, 200080, China
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Ampuero J, Simón M, Montoliú C, Jover R, Serra MÁ, Córdoba J, Romero-Gómez M. Minimal hepatic encephalopathy and critical flicker frequency are associated with survival of patients with cirrhosis. Gastroenterology 2015; 149:1483-9. [PMID: 26299413 DOI: 10.1053/j.gastro.2015.07.067] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/29/2015] [Accepted: 07/17/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Minimal hepatic encephalopathy (MHE) is associated with falls, traffic accidents, and overt HE. However, the association with survival is controversial. We assessed the effects of MHE on the long-term survival of patients with cirrhosis. METHODS We performed a prospective study of 117 consecutive patients with cirrhosis seen at a tertiary hospital in Seville, Spain (estimation cohort), followed by a validation study of 114 consecutive patients with cirrhosis seen at 4 hospitals in Spain from January 2004 through December 2007. Patients were examined every 6 months at outpatient clinics through December 2013 (follow-up periods of 5 ± 2.8 y and 4.4 ± 3.9 y for each group, respectively). Cirrhosis was identified by liver biopsy, ultrasound, endoscopic analysis, and biochemical parameters. Liver dysfunction was determined based on model for end-stage liver disease (MELD) and Child-Pugh scores. All patients were administered the critical flicker frequency (CFF) test and psychometric hepatic encephalopathy scores were used to detect MHE. Survival curves were compared using the log-rank test and multivariable analysis was performed using Cox proportional hazards models. RESULTS The distributions of Child-Pugh scores were as follows: 66% class A, 31% class B, and 3% class C in the estimation cohort, and 50% class A, 32% class B, and 18% class C in the validation cohort. In the estimation cohort, 24 of 35 patients (68.6%) with a CFF score less than 39 Hz survived for 5 years, whereas 50 of 61 patients (82%) with a CFF score of 39 Hz or higher survived during the follow-up period (log-rank score, 5.07; P = .024). Psychometric hepatic encephalopathy scores did not correlate with survival. In multivariable analysis, older age (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.02-1.12; P = .009), CFF score less than 39 Hz (HR, 4.36; 95% CI, 1.67-11.37; P = .003), and MELD score (HR, 1.40; 95% CI, 1.21-1.63; P = .0001) were associated independently with survival during the follow-up period. In the validation cohort, CFF score less than 39 Hz and MELD score also were associated with patient survival during the follow-up period. MHE had no effect on the survival of patients with MELD scores less than 10 (among patients with CFF scores ≥39 Hz, 94.5% survived for 5 years vs 91.9% of patients with CFF scores <39 Hz; log-rank score, 0.64; P = .423). Fewer patients with MELD scores of 10-15 and MHE survived for 5 years (44.4%; 12 of 27) than those with MELD scores greater than 15 without MHE (61.5%; 8 of 13) (P < .05). Only 2 of 12 patients (16.7%) with MELD scores of 15 or higher and MHE survived for 5 years (log-rank score, 90.56; P = .0001). CONCLUSIONS MHE is associated with a reduced 5-year survival rate of patients with cirrhosis. Evaluation of MHE could help predict survival times and outcomes of patients with specific MELD scores. The CFF could help physicians determine prognoses of patients with cirrhosis.
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Affiliation(s)
- Javier Ampuero
- Unit for the Clinical Management of Digestive Diseases and Centro de Investigación Biomédica de Enfermedades Hepáticas y Digestivas, Valme University Hospital, Sevilla, Spain
| | - Macarena Simón
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | | | - Rodrigo Jover
- Gastroenterology Department, Hospital General Universitario, Alicante, Spain
| | | | - Juan Córdoba
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - Manuel Romero-Gómez
- Unit for the Clinical Management of Digestive Diseases and Centro de Investigación Biomédica de Enfermedades Hepáticas y Digestivas, Valme University Hospital, Sevilla, Spain.
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Azzam AZ. Liver transplantation as a management of hepatocellular carcinoma. World J Hepatol 2015; 7:1347-1354. [PMID: 26052380 PMCID: PMC4450198 DOI: 10.4254/wjh.v7.i10.1347] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 10/26/2014] [Accepted: 04/07/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide and has a poor prognosis if untreated. It is ranked the third among the causes of cancer-related death. There are multiple etiologic factors that can lead to HCC. Screening for early HCC is challenging due to the lack of well specific biomarkers. However, early diagnosis through successful screening is very important to provide cure rate. Liver transplantation (LT) did not gain wide acceptance until the mid-1980s, after the effective immunosuppression with cyclosporine became available. Orthotopic LT is the best therapeutic option for early, unresectable HCC. It is limited by both, graft shortage and the need for appropriate patient selection. It provides both, the removal of tumor and the remaining cirrhotic liver. In Milan, a prospective cohort study defined restrictive selection criteria known as Milan criteria (MC) that led to superior survival for transplant patients in comparison with any other previous experience with transplantation or other options for HCC. When transplantation occurs within the established MC, the outcomes are similar to those for nonmalignant liver disease after transplantation. The shortage of organs from deceased donors has led to the problems of long waiting times and dropouts. This has led to the adoption of extended criteria by many centers. Several measures have been taken to solve these problems including prioritization of patients with HCC, use of pretransplant adjuvant treatment, and living donor LT.
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Salvalaggio PR, Felga G, Axelrod DA, Della Guardia B, Almeida MD, Rezende MB. List and liver transplant survival according to waiting time in patients with hepatocellular carcinoma. Am J Transplant 2015; 15:668-77. [PMID: 25650130 DOI: 10.1111/ajt.13011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 09/10/2014] [Accepted: 09/11/2014] [Indexed: 01/25/2023]
Abstract
The time that patients with hepatocellular carcinoma (HCC) can safely remain on the waiting list for liver transplantation (LT) is unknown. We investigated whether waiting time on the list impacts transplant survival of HCC candidates and transplant recipients. This is a single-center retrospective study of 283 adults with HCC. Patients were divided in groups according to waiting-list time. The main endpoint was survival. The median waiting time for LT was 4.9 months. The dropout rates at 3-, 6-, and 12-months were 6.4%, 12.4%, and 17.7%, respectively. Mortality on the list was 4.8%, but varied depending of the time on the list. Patients who waited less than 3-months had an inferior overall survival when compared to the other groups (p = 0.027). Prolonged time on the list significantly reduced mortality in this analysis (p = 0.02, HR = 0.28). Model for End Stage Liver Disease (MELD) score at transplantation did also independently impact overall survival (p = 0.03, HR = 1.06). MELD was the only factor that independently impacted posttransplant survival (p = 0.048, HR = 1.05). We conclude that waiting time had no relation with posttransplant survival. It is beneficial to prolong the waiting list time for HCC candidates without having a negative impact in posttransplant survival.
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Screening for liver cancer during transplant waiting list: a multicenter study from South America. Eur J Gastroenterol Hepatol 2015; 27:355-60. [PMID: 25563142 DOI: 10.1097/meg.0000000000000272] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Surveillance during liver transplantation (LT) waiting list has scarcely been reported in South America. We aimed to describe hepatocellular carcinoma (HCC) surveillance during the LT waiting list in the daily practice. PATIENTS AND METHODS A multicenter retrospective analysis in cirrhotic patients was carried out. All patients underwent an ultrasound (US) every 6 months and the last pre-LT US was compared with explanted liver findings. A false-negative case was considered when incidentally found HCC (iHCC) was detected, whereas a false-positive case was considered when HCC diagnosed before LT (cHCC) was not confirmed in the explanted liver. US performance was assessed after excluding cHCC patients referred to transplant evaluation. RESULTS Of 643 patients, 129 had HCC, of whom 92 had cHCC (71.3%) and 37 had iHCC (28.7%). Five patients (5.4%) had nonconfirmed cHCC (n=3 regenerative nodules, n=1 biliary hamartoma, and n=1 cholangiocarcinoma). Patients with iHCC had a higher MELD score (23±10 vs. 15±10; P<0.0001), and were more frequently Child-Pugh C (62.2 vs. 36.6%; P=0.006) compared with patients with cHCC. The number of US performed during waiting list was 1.7±1.6 (median 1.0). During transplant waiting list, the sensitivity and specificity of US were 33 and 99%, with positive and negative predictive values of 0.89 and 0.93, respectively. Multivariate analysis showed that the strongest variable related to iHCC finding was pre-LT Child-Pugh C status (OR 3.5; P=0.004). CONCLUSION Screening for liver cancer remains an important issue during transplant waiting list. However, the US screening method should be reviewed particularly for Child-Pugh C patients.
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Chapman WC, Klintmalm G, Hemming A, Vachharajani N, Majella Doyle MB, DeMatteo R, Zaydfudim V, Chung H, Cavaness K, Goldstein R, Zendajas I, Melstrom LG, Nagorney D, Jarnagin W. Surgical treatment of hepatocellular carcinoma in North America: can hepatic resection still be justified? J Am Coll Surg 2015; 220:628-37. [PMID: 25728142 DOI: 10.1016/j.jamcollsurg.2014.12.030] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND The incidence of hepatocellular cancer (HCC) is increasing dramatically worldwide. Optimal management remains undefined, especially for well-compensated cirrhosis and HCC. STUDY DESIGN This retrospective analysis included 5 US liver cancer centers. Patients with surgically treated HCC between 1990 and 2011 were analyzed; demographics, tumor characteristics, and survival rates were included. RESULTS There were 1,765 patients who underwent resection (n = 884, 50.1%) or transplantation (n = 881, 49.9%). Overall, 248 (28.1%) resected patients were transplant eligible (1 tumor <5 cm or 2 to 3 tumors all <3 cm, no major vascular invasion); these were compared with 496 transplant patients, matched based on year of transplantation and tumor status. Overall survivals at 5 and 10 years were significantly improved for transplantation patients (74.3% vs 52.8% and 53.7% vs 21.7% respectively, p < 0.001), with greater differences in disease-free survival (71.8% vs 30.1% at 5 years and 53.4% vs 11.7% at 10 years, p < 0.001). Ninety-seven of the 884 (11%) resected patients were within Milan criteria and had cirrhosis; these were compared with the 496 transplantation patients, with similar results to the overall group. On multivariate analysis, type of surgery was an independent variable affecting all survival outcomes. CONCLUSIONS The increasing incidence of HCC stresses limited resources. Although transplantation results in better long-term survival, limited donor availability precludes widespread application. Hepatic resection will likely remain a standard therapy in selected patients with HCC. In this large series, only about 10% of patients with cirrhosis were transplant-eligible based on tumor status. Although liver transplantation results are significantly improved compared with resection, transplantation is available only for a minority of patients with HCC.
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Affiliation(s)
- William C Chapman
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO.
| | | | - Alan Hemming
- Department of Surgery, University of California San Diego Health System, San Diego, CA
| | - Neeta Vachharajani
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO
| | - Maria B Majella Doyle
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO
| | - Ron DeMatteo
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Victor Zaydfudim
- Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Haniee Chung
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO
| | | | | | - Ivan Zendajas
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Laleh G Melstrom
- Department of Surgery, The Cancer Institute of New Jersey, Rutgets Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - William Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Rodríguez-Castro KI, De Martin E, Gambato M, Lazzaro S, Villa E, Burra P. Female gender in the setting of liver transplantation. World J Transplant 2014; 4:229-242. [PMID: 25540733 PMCID: PMC4274594 DOI: 10.5500/wjt.v4.i4.229] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/27/2014] [Accepted: 07/15/2014] [Indexed: 02/05/2023] Open
Abstract
The evolution of liver diseases to end-stage liver disease or to acute hepatic failure, the evaluation process for liver transplantation, the organ allocation decision-making, as well as the post-transplant outcomes are different between female and male genders. Women’s access to liver transplantation is hampered by the use of model for end-stage liver disease (MELD) score, in which creatinine values exert a systematic bias against women due to their lower values even in the presence of variable degrees of renal dysfunction. Furthermore, even when correcting MELD score for gender-appropriate creatinine determination, a quantifiable uneven access to transplant prevails, demonstrating that other factors are also involved. While some of the differences can be explained from the epidemiological point of view, hormonal status plays an important role. Moreover, the pre-menopausal and post-menopausal stages imply profound differences in a woman’s physiology, including not only the passage from the fertile age to the non-fertile stage, but also the loss of estrogens and their potentially protective role in delaying liver fibrosis progression, amongst others. With menopause, the tendency to gain weight may contribute to the development of or worsening of pre-existing metabolic syndrome. As an increasing number of patients are transplanted for non-alcoholic steatohepatitis, and as the average age at transplant increases, clinicians must be prepared for the management of this particular condition, especially in post-menopausal women, who are at particular risk of developing metabolic complications after menopause.
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35
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Halazun KJ, Patzer RE, Rana AA, Verna EC, Griesemer AD, Parsons RF, Samstein B, Guarrera JV, Kato T, Brown RS, Emond JC. Standing the test of time: outcomes of a decade of prioritizing patients with hepatocellular carcinoma, results of the UNOS natural geographic experiment. Hepatology 2014; 60:1957-62. [PMID: 24954365 DOI: 10.1002/hep.27272] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/17/2014] [Indexed: 01/28/2023]
Abstract
UNLABELLED Priority is given to patients with hepatocellular carcinoma (HCC) to receive liver transplants, potentially causing significant regional disparities in organ access and possibly outcomes in this population. Our aim was to assess these disparities by comparing outcomes in long waiting time regions (LWTR, regions 5 and 9) and short waiting time regions (SWTR regions 3 and 10) by analyzing the United Network for Organ Sharing (UNOS) database. We analyzed 6,160 HCC patients who received exception points in regions 3, 5, 9, and 10 from 2002 to 2012. Data from regions 5 and 9 were combined and compared to data from regions 3 and 10. Survival was studied in three patient cohorts: an intent-to-treat cohort, a posttransplant cohort, and a cohort examining overall survival in transplanted patients only (survival from listing to last posttransplant follow-up). Multivariate analysis and log-rank testing were used to analyze the data. Median time on the list in the LWTR was 7.6 months compared to 1.6 months for SWTR, with a significantly higher incidence of death on the waiting list in LWTR than in SWTR (8.4% versus 1.6%, P < 0.0001). Patients in the LWTR were more likely to receive loco-regional therapy, to have T3 tumors at listing, and to receive expanded-criteria donor (ECD) or donation after cardiac death (DCD) grafts than patients in the SWTR (P < 0.0001 for all). Survival was significantly better in the LWTR compared to the SWTR in all three cohorts (P < 0.0001 for all three survival points). Being listed/transplanted in an SWTR was an independent predictor of poor patient survival on multivariate analysis (P < 0.0001, hazard ratio = 1.545, 95% confidence interval 1.375-1.736). CONCLUSION This study provides evidence that expediting patients with HCC to transplant at too fast a rate may adversely affect patient outcomes.
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Affiliation(s)
- Karim J Halazun
- Emory Transplant Center, Emory University Hospital, Atlanta, GA
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36
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Menon KV, Hakeem AR, Heaton ND. Review article: liver transplantation for hepatocellular carcinoma - a critical appraisal of the current worldwide listing criteria. Aliment Pharmacol Ther 2014; 40:893-902. [PMID: 25155143 DOI: 10.1111/apt.12922] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 01/16/2014] [Accepted: 07/27/2014] [Indexed: 12/08/2022]
Abstract
BACKGROUND Liver transplantation (LT) plays an important role in the management of patients with hepatocellular carcinoma (HCC). Although early results following LT for HCC were poor, since the introduction of the Milan criteria in 1996 morphological criteria have since been well established. Thereafter, various expansions of the Milan criteria were introduced worldwide. Listing criteria for LT for HCC in the United Kingdom (UK) initially conformed to the Milan criteria but were re-defined in 2009 by expansion of the Milan criteria. AIMS To look at the evidence in literature on listing criteria and management of HCC worldwide in comparison with the UK. Secondly, we aim to review worldwide vs. UK literature on prioritisation models, loco-regional therapy protocols and role of alpha-fetoprotein (AFP) in LT for HCC. METHODS An electronic literature search with Medline was carried out to identify articles related to LT for HCC. RESULTS Although various expansions of the Milan criteria have been described, they remain the gold standard against which other criteria are measured. The UK criteria are an expansion of the Milan criteria that go beyond Milan and University of California, San Francisco (UCSF) criteria. The current UK listing criteria for LT for HCC when compared to the worldwide criteria have a worse survival benefit (projected 5-year survival between 35-50%) when plotted on the metroticket calculator. CONCLUSIONS In keeping with most transplant centres worldwide, the UK have adopted expansions to Milan to allow more patients to benefit from LT. However, currently, as it stands the UK criteria when plotted in the modification of the Metroticket model project worse survival that would seem unjustified.
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Affiliation(s)
- K V Menon
- Institute of Liver Studies, Kings College Hospital, London, UK
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Liver transplant for hepatocellular cancer: very small tumors, very large tumors, and waiting time. Clin Liver Dis 2014; 18:603-12. [PMID: 25017078 DOI: 10.1016/j.cld.2014.05.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The role of liver transplant for treatment of early hepatocellular cancer (HCC) is no longer contested. However, its benefit relative to other therapies for patients with very early (<2 cm) HCC is still a matter of debate. Twenty years after the establishment of the Milan criteria, we are beginning to realize that the number and size of tumors may not be the best metric by which to prognosticate outcomes and allocate organs. A better assessment of tumor aggressiveness is clearly needed.
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Samoylova ML, Dodge JL, Yao FY, Roberts JP. Time to transplantation as a predictor of hepatocellular carcinoma recurrence after liver transplantation. Liver Transpl 2014; 20:937-44. [PMID: 24797145 PMCID: PMC4394747 DOI: 10.1002/lt.23902] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 03/12/2014] [Accepted: 04/18/2014] [Indexed: 12/30/2022]
Abstract
In the United States, there are significant geographic disparities in the time to transplantation for patients with hepatocellular carcinoma (HCC); it is possible that rapid transplantation contributes to higher rates of posttransplant HCC recurrence because there is insufficient time for the tumor biology to manifest. In this study, we compared HCC recurrence in rapid transplant patients and their slower transplant counterparts. We identified adult liver transplantation (LT) candidates in the Organ Procurement and Transplantation Network/United Network for Organ Sharing (UNOS) data set who were granted an initial exception for an HCC diagnosis between January 1, 2006 and September 30, 2010 and underwent transplantation in the same time window. Patients were followed until HCC recurrence, non-HCC-related death, or last follow-up. The cumulative incidence of HCC recurrence was compared for patients waiting ≤ 120 days and patients waiting >120 days from an HCC exception to LT. The association between the risk of posttransplant recurrence and the wait time was further evaluated via competing risks regression with the Fine and Gray model. For 5002 LT recipients with HCC, the median wait time from an exception to LT was 77 days, and it varied from 30 to 169 days by UNOS region. The cumulative incidence of posttransplant HCC recurrence was 3.3% [95% confidence interval (CI) = 2.8%-3.8%] and 5.6% (95% CI = 5.0%-6.3%) within 1 and 2 years, respectively. The rate of observed recurrence within 1 year of transplantation was significantly lower for patients waiting >120 days versus patients waiting ≤ 120 days (2.2% versus 3.9%, P = 0.002); however, the difference did not persist at 2 years (5.0% versus 5.9%, P = 0.09). After we accounted for clinical factors, the HCC recurrence risk was reduced by 40% for patients waiting >120 days (subhazard ratio = 0.6, P = 0.005). In conclusion, the risk of HCC recurrence within the first year after transplantation may be lessened by the institution of a mandatory waiting time after an exception is granted.
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Affiliation(s)
- Mariya L. Samoylova
- Department of Surgery (Division of Transplant Surgery), University of California San Francisco, San Francisco, CA
| | - Jennifer L. Dodge
- Department of Surgery (Division of Transplant Surgery), University of California San Francisco, San Francisco, CA
| | - Francis Y. Yao
- Department of Surgery (Division of Transplant Surgery), University of California San Francisco, San Francisco, CA,Department of Medicine (Division of Gastroenterology), University of California San Francisco, San Francisco, CA
| | - John Paul Roberts
- Department of Surgery (Division of Transplant Surgery), University of California San Francisco, San Francisco, CA
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39
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Chung H, Chapman WC. Liver transplantation for hepatocellular carcinoma: how far have we come and what is the future? Hepat Oncol 2014; 1:309-321. [DOI: 10.2217/hep.14.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY: Liver transplantation is the best treatment for hepatocellular carcinoma in the setting of chronic liver disease, completely removing malignancy and underlying diseased liver tissue. Technical aspects of liver transplantation have improved over the years, along with outcomes. But challenges continue in the areas of expanding existing indications for transplant with limited organ supply, calling for optimization of patient selection and the development of alternative or adjunctive treatment options. Expansion of existing transplant criteria will help identify patients most likely to have good outcomes. Locoregional and systemic treatments showing therapeutic promise are being investigated for use in achieving acceptable oncologic effect. Improvements in post-transplant treatment and continued attempts to enlarge the donor pool will continue to provide avenues for further improvements in outcomes.
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Affiliation(s)
- Haniee Chung
- Washington University in St Louis, 660 S Euclid Avenue, St Louis, MO 63110, USA
| | - William C Chapman
- Washington University in St Louis, 660 S Euclid Avenue, St Louis, MO 63110, USA
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40
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Tsien C, Garber A, Narayanan A, Shah SN, Barnes D, Eghtesad B, Fung J, McCullough AJ, Dasarathy S. Post-liver transplantation sarcopenia in cirrhosis: a prospective evaluation. J Gastroenterol Hepatol 2014; 29:1250-7. [PMID: 24443785 PMCID: PMC4024321 DOI: 10.1111/jgh.12524] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/27/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM Pre-transplant sarcopenia (reduced skeletal muscle mass) predicts poor outcome in cirrhosis. In contrast, whether muscle mass increases post-orthotopic liver transplantation (OLT) is not known and was studied prospectively. METHODS Consecutive patients who underwent a comprehensive nutritional evaluation in a liver transplant nutrition clinic were included. Core abdominal muscle area was measured on abdominal computed tomography obtained pre- and post-OLT. Age- and gender-based controls were used to define sarcopenia. Measures of body composition pre-transplant were correlated with computed tomography measurements. Predictors and clinical impact of post-OLT change in muscle area were examined. In three subjects post-OLT and three controls, expression of genes regulating skeletal muscle mass were quantified. RESULTS During the study period, 53 patients (M:F 41:12; age 56.9 ± 7.5 years) were followed up after OLT for 19.3 ± 9 months. Five patients died and another five had acute graft rejection. Pre-OLT sarcopenia was present in 33 (66.2%). Pre-transplant clinical characteristics including Child's score, MELD score, and nutritional status or post-transplantation immunosuppression regimen did not predict post-transplant change in muscle mass. New onset post-OLT sarcopenia developed in 14 patients. Loss of muscle mass post-OLT increased risk of diabetes mellitus and a trend toward higher mortality. Skeletal muscle expression of myostatin was higher and that of ubiquitin proteasome proteolytic components lower post-OLT than in controls. CONCLUSIONS Post-transplantation sarcopenia is common and could not be attributed to pre-transplant characteristics or the type or duration of post-OLT immunosuppression. Post-transplant sarcopenia contributes to adverse consequences and strategies targeting myostatin may be beneficial.
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Affiliation(s)
- Cynthia Tsien
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH
| | - Ari Garber
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH
| | - Arvind Narayanan
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH
| | - Shetal N Shah
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland OH
| | - David Barnes
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH
| | - Bijan Eghtesad
- Department of Transplant Surgery, Cleveland Clinic, Cleveland OH
| | - John Fung
- Department of Transplant Surgery, Cleveland Clinic, Cleveland OH
| | - Arthur J McCullough
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH
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Section 4. Further Expanding the Criteria for HCC in Living Donor Liver Transplantation. Transplantation 2014; 97 Suppl 8:S17-20. [DOI: 10.1097/01.tp.0000446268.26771.59] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Naugler WE, Schlansky B, Orloff SL. Who should undergo liver transplantation for hepatocellular carcinoma? Ablate, wait … and see! Hepat Oncol 2014; 1:165-168. [PMID: 30190949 PMCID: PMC6095151 DOI: 10.2217/hep.14.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Willscott E Naugler
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Barry Schlansky
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Susan L Orloff
- Division of Abdominal Organ Transplantation, Oregon Health & Science University, Portland, OR 97239, USA
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Kornberg A. Liver Transplantation for Hepatocellular Carcinoma beyond Milan Criteria: Multidisciplinary Approach to Improve Outcome. ISRN HEPATOLOGY 2014; 2014:706945. [PMID: 27335840 PMCID: PMC4890913 DOI: 10.1155/2014/706945] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 01/03/2014] [Indexed: 12/12/2022]
Abstract
The implementation of the Milan criteria (MC) in 1996 has dramatically improved prognosis after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Liver transplantation has, thereby, become the standard therapy for patients with "early-stage" HCC on liver cirrhosis. The MC were consequently adopted by United Network of Organ Sharing (UNOS) and Eurotransplant for prioritization of patients with HCC. Recent advancements in the knowledge about tumor biology, radiographic imaging techniques, locoregional interventional treatments, and immunosuppressive medications have raised a critical discussion, if the MC might be too restrictive and unjustified keeping away many patients from potentially curative LT. Numerous transplant groups have, therefore, increasingly focussed on a stepwise expansion of selection criteria, mainly based on tumor macromorphology, such as size and number of HCC nodules. Against the background of a dramatic shortage of donor organs, however, simple expansion of tumor macromorphology may not be appropriate to create a safe extended criteria system. In contrast, rather the implementation of reliable prognostic parameters of tumor biology into selection process prior to LT is mandatory. Furthermore, a multidisciplinary approach of pre-, peri-, and posttransplant modulating of the tumor and/or the patient has to be established for improving prognosis in this special subset of patients.
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Affiliation(s)
- A. Kornberg
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, D-81675 Munich, Germany
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Pinero F, Mendizabal M, Casciato P, Galdame O, Quiros R, Bandi J, Mullen E, Andriani O, Santibañes ED, Podestá LG, Gadano A, Silva M. Is recurrence rate of incidental hepatocellular carcinoma after liver transplantation similar to previously known HCC? Towards a predictive recurrence score. Ann Hepatol 2014. [DOI: 10.1016/s1665-2681(19)30884-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Matkowskyj KA, Bai H, Liao J, Zhang W, Li H, Rao S, Omary R, Yang GY. Aldoketoreductase family 1B10 (AKR1B10) as a biomarker to distinguish hepatocellular carcinoma from benign liver lesions. Hum Pathol 2013; 45:834-43. [PMID: 24656094 DOI: 10.1016/j.humpath.2013.12.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 11/30/2013] [Accepted: 12/04/2013] [Indexed: 12/15/2022]
Abstract
Hepatocellular carcinoma (HCC) is one of the most common highly aggressive malignant tumors worldwide. Aldoketoreductase 1B10 (AKR1B10) was first isolated from HCC and further identified to be over-expressed in many cancers from various organs. AKR1B10 contributes to detoxification of xenobiotics by lipid peroxidation and metabolizes physiological substrates such as farnesal, retinal, and carbonyls. Metabolizing these lipid substrates plays a crucial role in promoting carcinogenesis. In the present study, immunohistochemical analysis was performed to determine the prevalence/pattern of AKR1B10 expression in HCC and its usefulness to differentiate benign liver lesions from HCC. Oncogenic function of AKR1B10 was examined in hepatocellular carcinoma cells in vitro using Western blotting and shRNA knockdown approaches, with emphasis on cell apoptosis and response to chemotherapy. Immunohistochemistry analysis revealed AKR1B10 was overexpressed in 97% (86/89) of hepatocellular carcinomas, with minimal to no expression in adjacent hepatic tissue, while hepatic adenomas and focal nodular hyperplasia did not exhibit expression of AKR1B10. shRNA-mediated silencing of AKR1B10 expression in hepatocellular carcinoma cells resulted in (1) increased cell apoptosis, (2) decreased colony formation and size, and (3) enhanced cytoreductive response following exposure to doxorubicin chemotherapy. Our findings provide first time evidence that AKR1B10 is a unique biomarker involved in hepatocellular carcinogenesis via modulation of proliferation, cell apoptosis and chemoresistance and is a potential promising biomarker to differentiate HCCs from benign hepatic lesions.
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Affiliation(s)
- Kristina A Matkowskyj
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA; Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Han Bai
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA; Department of Infectious Disease, Shengjing Hospital, China Medical University, Shenyang 110004, China
| | - Jie Liao
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Wanying Zhang
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Haonan Li
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Sambasiva Rao
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Reed Omary
- Department of Radiology and Radiological Sciences, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA.
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Charlton M. The lethal and enduring inequity of deceased donor liver allocation policy for hepatocellular carcinoma in the United States. Am J Transplant 2013; 13:2794-6. [PMID: 24119018 DOI: 10.1111/ajt.12442] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 07/09/2013] [Accepted: 07/22/2013] [Indexed: 01/25/2023]
Affiliation(s)
- M Charlton
- Hepatology and Liver Transplantation, Intermountain Medical Center, Murray, UT
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Schuetz C, Dong N, Smoot E, Elias N, Schoenfeld DA, Markmann JF, Yeh H. HCC patients suffer less from geographic differences in organ availability. Am J Transplant 2013; 13:2989-95. [PMID: 24011291 PMCID: PMC3833452 DOI: 10.1111/ajt.12441] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 05/22/2013] [Accepted: 06/06/2013] [Indexed: 01/25/2023]
Abstract
It has been suggested that the number of exception model for end-stage liver disease (MELD) points for hepatocellular carcinoma (HCC) overestimates mortality risk. Average MELD at transplant, a measure of organ availability, correlates with mortality on an intent-to-treat basis and varies by donation service area (DSA). We analyzed Scientific Registry of Transplant Recipients data from 2005 to 2010, comparing transplant and death parameters for patients transplanted with HCC exception points to patients without HCC diagnosis (non-HCC), to determine whether the two groups were impacted differentially by DSA organ availability. HCC candidates are transplanted at higher rates than non-HCC candidates and are less likely to die on the waitlist. Overall risk of death trends downward by 1% per MELD point (p = 0.65) for HCC, but increases by 7% for non-HCC patients (p < 0.0001). The difference in the change of mortality with MELD is statistically significant between HCC and non-HCC candidates p < 0.0001. Posttransplant risk of death trends downward by 2% per MELD point (p = 0.28) for HCC patients, but increases by 3% per MELD point in non-HCC patients (p = 0.027), with the difference being statistically significant with p < 0.005. In summary, increasing wait time impacts HCC candidates less than non-HCC candidates and under increased competition for donor organs, HCC candidates' advantage increases.
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Affiliation(s)
- C. Schuetz
- Department of Surgery, Division of Transplantation, Massachusetts General Hospital, Boston, MA
| | - N. Dong
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA
| | - E. Smoot
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA
| | - N. Elias
- Department of Surgery, Division of Transplantation, Massachusetts General Hospital, Boston, MA
| | - D. A. Schoenfeld
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA
| | - J. F. Markmann
- Department of Surgery, Division of Transplantation, Massachusetts General Hospital, Boston, MA
| | - H. Yeh
- Department of Surgery, Division of Transplantation, Massachusetts General Hospital, Boston, MA,Corresponding author: Heidi Yeh,
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Donahue LA, Kulik L, Baker T, Ganger DR, Gupta R, Memon K, Abecassis MM, Salem R, Lewandowski RJ. Yttrium-90 radioembolization for the treatment of unresectable hepatocellular carcinoma in patients with transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 2013; 24:74-80. [PMID: 23273699 DOI: 10.1016/j.jvir.2012.09.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 09/23/2012] [Accepted: 09/26/2012] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To evaluate the toxicity and response to radioembolization with yttrium-90 ((90)Y) glass microspheres in patients with hepatocellular carcinoma (HCC) and existing transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS For treatment of unresectable HCC, 12 patients with a patent TIPS underwent a total of 21 infusions of (90)Y. Toxicity within 90 days of treatment was assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE v4.0). Imaging response within the index lesion was assessed using the World Health Organization (WHO) and European Association for the Study of the Liver (EASL) guidelines. Survival was calculated using the Kaplan-Meier method. RESULTS All patients had a patent TIPS on imaging before treatment. Clinical toxicities included fatigue (83%), encephalopathy (33%), and abdominal pain (25%). Three patients (25%) experienced new grade 3 or 4 bilirubin toxicity. Imaging response was achieved in 50% and 67% of patients according to WHO and EASL criteria. Six patients (50%) went on to liver transplantation. Median survival censored for liver transplantation was 498 days (95% confidence interval [CI],100-800 d), and uncensored median survival was 827 days (95% CI, 250-2,400 d). CONCLUSIONS (90)Y radioembolization may be a safe and effective treatment for patients with unresectable HCC and existing TIPS. This minimally embolic therapy may be particularly useful as a bridge to curative liver transplantation.
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Affiliation(s)
- Laurence A Donahue
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois 60611, USA
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Park SK, Jung YK, Chung DH, Kim KK, Park YH, Lee JN, Kwon OS, Kim YS, Choi DJ, Kim JH. Factors influencing hepatocellular carcinoma prognosis after hepatectomy: a single-center experience. Korean J Intern Med 2013; 28:428-38. [PMID: 23864801 PMCID: PMC3712151 DOI: 10.3904/kjim.2013.28.4.428] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Revised: 07/16/2012] [Accepted: 10/05/2012] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Recurrence after hepatic resection is one of the most important factors impacting the prognosis and survival of patients with hepatocellular carcinoma (HCC). We identified prognostic factors affecting overall survival (OS) and disease-free survival (DFS) in patients with HCC after hepatic resection. METHODS This study was of a retrospective cohort design, and 126 patients who underwent hepatic resection for HCC at Gachon University Gil Medical Center between January 2005 and December 2010 were enrolled. Various clinical, laboratory, and pathological data were evaluated to determine the prognostic factors affecting OS and DFS. RESULTS Two- and 4-year OS and 2- and 4-year DFS were 78.1% and 65% and 51.1% and 26.6%, respectively. In a multivariate analysis, preoperative α-fetoprotein (> 400 ng/mL), tumor size (≥ 5 cm), multiple tumors (two or more nodules), presence of portal vein invasion, modified Union for International Cancer Control (UICC) stage III/IV, and Barcelona Clinic Liver Cancer (BCLC) stage B/C were independent prognostic factors affecting a shorter OS. In the multivariate analysis, presence of microvascular invasion, modified UICC stage III/IV, and BCLC stage B/C were independent prognostic factors for a shorter DFS. CONCLUSIONS The presence of vascular invasion was an independent poor prognostic factor for OS and DFS in patients with HCC after hepatic resection. Thus, close postoperative surveillance for early detection of recurrence and additional treatments are urgently needed in patients with vascular invasion after hepatic resection.
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Affiliation(s)
- Sung Keun Park
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Dong Hae Chung
- Department of Pathology, Gachon University Gil Medical Center, Incheon, Korea
| | - Keon Kuk Kim
- Department of Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Yeon Ho Park
- Department of Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Jung Nam Lee
- Department of Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Oh Sang Kwon
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yun Soo Kim
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Duck Joo Choi
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ju Hyun Kim
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality in the world. Early detection and timely treatment of HCC is critical for better patient outcomes. Curative therapy consists of surgical hepatic resection or liver transplantation (LTx); however, both are restricted to explicit selective criteria. Liver resection is the gold standard of treatment for noncirrhotic patients but can be done in only a small fraction of cirrhotic patients depending on synthetic dysfunction, degree of portal hypertension, and number and location(s) of tumor(s). Therefore, the best treatment modality in cirrhotic patients with HCC is LTx as it will cure both HCC and the underlying cirrhosis. The limitation to offer transplant to all cirrhotic patients with HCC is the shortage of available donor organs. While these patients are waiting for transplant, their tumors may progress and develop distant metastases and may lead to patients losing their candidacy for LTx. Various ablation therapies can be used to treat HCC, prevent tumor progression, and thus, avoid patients losing the option of LTx. Future directions to improve HCC patient outcomes include advancement in tumor gene analysis and histopathology for better prediction of tumor behavior, improved immunosuppression regimens to reduce tumor recurrence in the posttransplant setting, and efficient use of an expanded donor pool that includes living donor organs. This paper will review the current methods of HCC diagnosis, selection for either hepatic resection or LTx, and will also summarize posttreatment outcomes. We will suggest future directions for the field as we strive to improve outcomes for our HCC patients.
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