The role and limitation of living donor liver transplantation for hepatocellular carcinoma

Survival benefit of living donor liver transplant for patients with hepatocellular carcinoma

With the increasing incidence of hepatocellular carcinoma (HCC) in both the United States and globally, the role of liver transplantation in management continues to be an area of active conversation as it is often considered the gold standard in the treatment of HCC. The use of living donor liver transplantation (LDLT) and the indications in the setting of malignancy, both generally and in HCC specifically, are frequently debated. In terms of both overall survival and recurrence-free survival, LDLT is at least equivalent to DDLT, especially when performed for disease within Milan criteria. Emerging and compelling evidence suggests that LDLT is superior to DDLT in treating HCC as there is a significant decrease in waitlist mortality. As the oncologic indications for liver transplantation continue to expand and the gap between organ demand and organ availability continues to worsen, high volumes centers should consider using LDLT to shrink the ever-expanding waitlist.

Surgical Strategies for Recurrent Hepatocellular Carcinoma after Resection: A Review of Current Evidence

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, and both liver resection and liver transplantation are considered potentially curative options. However, high recurrence rates affect the prognosis depending both on the primary HCC pathology characteristics or on the type and time of the relapse. While great attention has been usually posted on treatment algorithms for the first HCC, treatment algorithms for recurrent HCC (rHCC) are lacking. In these cases, surgery still represents a curative option with both redo hepatectomy and/or salvage liver transplantation, which are considered valid treatments in selected patients. In the current era of personalised medicine with promises of new systemic-targeted immuno-chemotherapies, we wished to perform a narrative review of the literature on the role of surgical strategies for rHCC.

Cost-effectiveness of combination antiviral treatment with extended duration for hepatitis B e antigen (HBeAg)-negative chronic hepatitis B in China

Background

Hepatitis B surface antigen clearance or seroconversion is rarely achieved for patients using nucleoside analogs or pegylated interferon alpha monotherapy approaches. Several recent studies have confirmed the benefit of a combination of these two approaches for selected chronic hepatitis B patients. However, few reports have investigated long-term outcomes or health economic evaluation for hepatitis B surface antigen clearance. The aim of this study was to perform a cost-effectiveness analysis of the long-term use of this combination strategy among selected hepatitis B e antigen-negative patients.

Methods

Drawing on experience in China, we used a Markov model to simulate disease progression among a population of hepatitis B e antigen-negative chronic hepatitis B patients with surface antigen levels of ≤1,000 IU/mL through a discrete series of health states. We compared nucleoside analog monotherapy to the combination strategy over a prolonged period. We measured lifetime costs, quality-adjusted life-years and incremental cost-effectiveness ratios.

Results

The combination therapy produced 15.8 quality-adjusted life-years, and cost US dollars (USD) 45,032 per patient. The monotherapy gave 13.9 quality-adjusted life-years, and had a cost of USD 52,064. The incremental cost-effectiveness ratio of the monotherapy (USD −3,755 per quality-adjusted life-year) did not obtain extended dominance over combination therapy. The most cost-effective option was combination therapy among patients with hepatitis B surface antigen levels of ≤10 IU/mL, which had the lowest calculated cost of USD 35,318 and most quality-adjusted life-years (16.7).

Conclusions

A long-term combination treatment strategy for selected hepatitis B e antigen-negative chronic hepatitis B patients may prolong quality-adjusted life-years compared with nucleoside analog monotherapy. Chronic hepatitis B patients with a hepatitis B surface antigen level of ≤10 IU/mL were the most cost-effective population under this strategy.

Extracellular vesicles from in vivo liver tissue accelerate recovery of liver necrosis induced by carbon tetrachloride

Extracellular vesicles (EVs) are nano-sized vesicles composed of proteolipid bilayers carrying various molecular signatures of the cells. As mediators of intercellular communications, EVs have gained great attention as new therapeutic agents in the field of nanomedicine. Therefore, many studies have explored the roles of cell-derived EVs isolated from cultured hepatocytes or stem cells as inducer of liver proliferation and regeneration under various pathological circumstances. However, study investigating the role of EVs directly isolated from liver tissue has not been performed. Herein, to understand the pathophysiological role and to investigate the therapeutic potential of in vivo liver EVs, we isolated EVs from both normal and carbon tetrachloride (CCl4)-induced damaged in vivo liver tissues. The in vivo EVs purified from liver tissues display typical features of EVs including spherical morphology, nano-size, and enrichment of tetraspanins. Interestingly, administration of both normal and damaged liver EVs significantly accelerated the recovery of liver tissue from CCl4-induced hepatic necrosis. This restorative action was through the induction of hepatocyte growth factor at the site of the injury. These results suggest that not only normal liver EVs but also damaged liver EVs play important pathophysiological roles of maintaining homeostasis after tissue damage. Our study, therefore, provides new insight into potentially developing in vivo EV-based therapeutics for preventing and treating liver diseases.

Hepatocellular carcinoma recurrence in living and deceased donor liver transplantation: a systematic review and meta-analysis

Supplemental Digital Content is available in the text

Background:

Although a number of technical problems and donor safety issues associated with living donor liver transplantation (LDLT) have been resolved, some initial clinical studies showed an increased risk of hepatocellular carcinoma (HCC) recurrence in LDLT. This meta-analysis was conducted to assess differences in tumor recurrence between LDLT and deceased donor liver transplantation (DDLT).

Methods:

After systematic retrievals of studies about LDLT and DDLT for HCC, articles were selected with a rationale of emphasizing inter-group comparability. Results from multivariate analyses were combined and discussed together with univariate analyses. In subgroup analysis, the impact of organ allocation policy was taken into consideration.

Results:

Seven articles were included in the meta-analysis. Overall, a salient result that emerged from the seven studies was a significant increased risk of HCC recurrence in the LDLT group than in the DDLT group (P = 0.01). The most significant increase in hazard ratio was found in studies where organs tended to be allocated to non-tumor patients.

Conclusions:

An increased risk for HCC recurrence in LDLT as compared with DDLT patients was found. The relatively shorter preoperative observation windows in LDLT may lead to fewer cases of HCC with invasive features being screened out, which may provide a possible explanation for the high rates of HCC recurrence.

Living or deceased organ donors in liver transplantation for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

The outcomes of living donor liver transplantation (LDLT) versus deceased donor liver transplantation (DDLT) for HCC patients were not well defined and it was necessary to reassess.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, Google Scholar and WanFang database for eligible studies. Perioperative and survival outcomes of HCC patients underwent LDLT were pooled and compared to those underwent DDLT.

RESULTS

Twenty-nine studies with 5376 HCC patients were included. For HCC patients underwent LDLT and DDLT, there were comparable rates of overall survival (OS) (1-year, RR = 1.04, 95%CI = 1.00-1.09, P = 0.03; 3-year, RR = 1.03, 95%CI = 0.96-1.11, P = 0.39; 5-year, RR = 1.04, 95%CI = 0.95-1.13, P = 0.43), disease free survival (DFS) (1-year, RR = 1.00, 95%CI = 0.95-1.05, P = 0.99; 3-year, RR = 1.00, 95%CI = 0.94-1.08, P = 0.89; 5-year, RR = 1.01, 95%CI = 0.93-1.09, P = 0.85), recurrence (1-year, RR = 1.41, 95%CI = 0.72-2.77, P = 0.32; 3-year, RR = 0.89, 95%CI = 0.57-1.39, P = 0.60; and 5-year, RR = 0.85, 95%CI = 0.56-1.31, P = 0.47), perioperative mortality within 3 months (RR = 0.89, 95%CI = 0.50-1.59, p = 0.70) and postoperative complication (RR = 0.99, 95%CI = 0.70-1.39, P = 0.94). LDLT was associated with better 5-year intention-to-treat patient survival (ITT-OS) than DDLT (RR = 1.11, 95% CI = 1.01-1.22, P = 0.04).

CONCLUSION

This meta-analysis suggested that LDLT was not inferior to DDLT in consideration of comparable perioperative and survival outcomes. However, in terms of 5-year ITT-OS, LDLT was a possibly better choice for HCC patients.

Liver transplantation for hepatocellular carcinoma with live donors or extended criteria donors: a propensity score-matched comparison

Background

To compare patient survival after liver transplantation (LT) for hepatocellular carcinoma (HCC) from live donors (LD) or extended criteria donors (ECD).

Methods

Data from consecutive LT procedures for HCC involving either LD or ECD were reviewed. Patient survival was our primary outcome. Re-transplantation (Re-LT), ischemic type bile lesions (ITBL), and tumor recurrence represented secondary outcomes. The primary outcome was statistically analyzed using Kaplan-Meier estimates and Cox proportional hazards regression; logistic regression analyses were used for statistical analysis of the secondary outcomes. Propensity score was calculated based on patient age, sex, hepatitis C viral infection (HCV), laboratory model for end-stage liver disease (labMELD) score, bridging treatment, Milan criteria, α-fetoprotein levels, and tumor grade.

Results

The study evaluated 109 recipients undergoing LT from either LD (n=57) or ECD (n=52). LT procedure (hazard ratio [HR] 2.349, 95% confidence interval [CI] 1.151-4.794, P=0.0190), age (HR 1.075, 95%CI 1.020-1.133, P=0.0074) and labMELD score (HR 1.082, 95%CI 1.021-1.147, P=0.0075) reached significance by Cox proportional hazards regression. After adjustment with the propensity score (stratification with 5 strata), the LT procedure was still significant (HR 2.401, 95%CI 1.114-5.175, P=0.0253). Tumor grade (odds ratio [OR] 9.628, 95%CI 1.120-82.752, P=0.0391), labMELD score (OR 1.224, 95%CI 1.019-1.471, P=0.0306), and Milan criteria (OR 6.375, 95%CI 1.239-32.796, P=0.0267) gained statistical significance by logistic regression analysis for Re-LT, ITBL, and tumor recurrence, respectively.

Conclusions

LT for HCC showed superior patient survival with ECD rather than LD grafts. Re-LT, ITBL, and tumor recurrence showed no significant differences between the two groups. However, the diverging criteria for the definition of ECD grafts represent a considerable limitation for the wide application of this policy.

Optimizing hepatectomy for hepatocellular carcinoma in Asia-patient selection and special considerations

Hepatocellular carcinoma (HCC) is a common affliction in Asia. The treatment of HCC depends on the tumor status as well as the underlying liver function. Resection is the cornerstone of surgical management of HCC. For those unfit to undergo resection, local ablative therapy is a viable alternative. For patients with multiple small unresectable HCCs, liver transplantation offers another option, having the simultaneous benefit of removing the cancer in addition to replacing the pre-malignant and cirrhotic liver together. However, the paucity of liver grafts limits the applicability of this operation. In assessing for the appropriate treatment, the traditional TNM staging is not widely applied to HCC. Conventionally, doctors in the West have relied on the Barcelona staging system. Asian surgeons, on the other hand, have long adopted a more aggressive approach for their patients. Borne out of the need for a system which better suited Asian patients, the Hong Kong guidelines have been established. For the surgical resection of HCC, considerations must take into account issues regarding the tumor, the underlying liver and the patient. For the tumor, the size, the presence vascular invasion and presence of extra-hepatic metastasis will determine operability. Another important issue is the liver function and, by extension, the estimated residual liver volume after resection. Thirdly, patient factors i.e., fitness to undergo general anesthesia must be properly assessed. With improved surgical technique and better patient selection, peri-operative morbidity and long-term survival results after operation have improved drastically over the past decades.

Long-term survival comparison between primary transplant and upfront curative treatment with salvage transplant for early stage hepatocellular carcinoma

BACKGROUND

Whether primary liver transplantation (PLT) or upfront curative treatment with salvage liver transplantation (SLT) is a better treatment option for early hepatocellular carcinoma (HCC) is controversial. This study aims to compare the long-term survival starting from the time of primary treatment between the two approaches for early HCC using propensity score matching (PSM) analysis.

METHODS

From 1995 to 2014, 175 patients with early HCC undergoing either PLT (n = 149) or SLT (n = 26) were retrospectively reviewed in a prospectively collected database. Patients' demographic data, tumor characteristics, short-term and long-term outcome were compared between two groups after PSM.

RESULTS

After matching, the baseline characteristics were comparable between mPLT group (n = 45) and mSLT group (n = 25). The tumor recurrence rate after transplant was significantly higher in mSLT group than mPLT group (28% vs. 15.6%). Calculating from the time of primary treatment, the 1, 3, and 5-year overall survival rates were comparable between mPLT group (97.8%, 91.1% and 86.3%) and mSLT group (100%, 95% and 85%). However, the 1, 3, and 5-year recurrence-free survival rates were significantly better in mPLT group than mSLT group (95.6% vs. 90%, 86.6% vs. 80% and 84.3% vs. 70%). SLT approach and high pre-treatment serum alpha-fetoprotein level (>200 ηg/mL) were poor prognostic factors for recurrence-free survival after transplant.

CONCLUSIONS

PLT may be a better treatment option for early HCC, whereas SLT approach for HCC should be cautiously considered under the circumstance of organ shortage.

The International Liver Transplantation Society Living Donor Liver Transplant Recipient Guideline

Living donor liver transplantation (LDLT) has been increasingly embraced around the world as an important strategy to address the shortage of deceased donor livers. The aim of this guideline, approved by the International Liver Transplantation Society (ILTS), is to provide a collection of expert opinions, consensus, and best practices surrounding LDLT. Recommendations were developed from an analysis of the National Library of Medicine living donor transplantation indexed literature using the Grading of Recommendations Assessment, Development and Evaluation methodology. Writing was guided by the ILTS Policy on the Development and Use of Practice Guidelines (www.ilts.org). Intended for use by physicians, these recommendations support specific approaches to the diagnostic, therapeutic, and preventive aspects of care of living donor liver transplant recipients.

Compared to cadaveric liver transplantation, live donor LT (LDLT) is challenged by ethical, medical and surgical considerations, many of which are still unresolved. The aim of this guideline is to provide a collection of expert opinions, consensus, and best practices surrounding LDLT.

Evidence-Based Surveillance Imaging Schedule After Liver Transplantation for Hepatocellular Carcinoma Recurrence

BACKGROUND

There is presently no evidence-based recommendation for surveillance of recurrent hepatocellular carcinoma after liver transplantation (LT). We aim to evaluate and develop evidence-based alternate surveillance imaging schedules for post-LT hepatocellular carcinoma patients.

METHODS

Imaging and pathologic reports for consecutive post-LT patients followed up by regular surveillance imaging from a single institution's prospective database were evaluated with institutional review board approval. Outcome variable was time to diagnosis of first recurrence post-LT by surveillance imaging. Recurrence-free survival times from alternative surveillance schedules were compared with the existing schedule (every 3 months) using a parametric frailty model. Expected delay (EpD) in diagnosis compared to the existing schedule was also computed for the alternate surveillance schedules. A P value less than 0.05 was considered to indicate a significant difference.

RESULTS

One hundred twenty-five patients (108 men; 59.4 ± 16.6 years) underwent 1953 computed tomography and 255 magnetic resonance imaging scans. Recurrence-free survival time was not significantly different in the first 5 years after LT when the imaging interval was extended from current every 3 months to every 6 months (P = 0.786, EpD = 55 days). This alternative schedule incurred 10 (50.0%) fewer surveillance scans than the 20 in the original schedule, and a corresponding reduction in radiation dose (if involved) and cost during the 5-year follow-up period.

CONCLUSIONS

In conclusion, modeled alternative surveillance schedules have the potential to reduce the frequency of scans without compromising surveillance benefits.

Cost-Effectiveness Comparison Between the Response-Guided Therapies and Monotherapies of Nucleos(t)ide Analogues for Chronic Hepatitis B Patients in China

BACKGROUND AND OBJECTIVE

Nucleos(t)ide analogue (NA) monotherapies are typically used as the primary treatment for chronic hepatitis B (CHB) patients, including lamivudine (LAM), telbivudine (TBV), adefovir (ADV), entecavir (ETV) and tenofovir (TDF). For high-resistance NAs (LAM, TBV, ADV), they can generate excellent clinical outcomes by using response-guided therapy; however, their pharmacoeconomic profiles remain unclear in China. We aimed to evaluate the cost effectiveness between response-guided therapies and monotherapies of NAs for Chinese hepatitis B e-antigen (HBeAg)-positive and -negative CHB patients.

METHODS

We constructed a Markov model to simulate CHB progression associated with 12 treatment strategies using effectiveness and cost data from the published literature. We measured the lifetime costs, quality adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). One-way sensitivity (especially to extend the range of the TDF price) and probabilistic sensitivity analyses were used to explore the uncertainties of the model.

RESULTS

For both HBeAg-positive and -negative patients, no treatment strategy generated the lowest lifetime costs (US$31,185-US$31,338) and QALYs (7.54-7.58). ETV and TDF monotherapies were not dominated by other treatments, whereas, the ICER of ETV monotherapy was the lowest (US$6112/QALY-US$8533/QALY). For each high-resistance NA, compared with its monotherapy, the ICERs of its response-guided therapies were below the willingness-to-pay threshold of US$22,833/QALY. Additionally, TDF monotherapy was the preferred treatment when its price dropped to US$1820/year or lower.

CONCLUSION

Among 12 treatment strategies evaluated, ETV monotherapy is the most cost-effective treatment for treatment-naive CHB patients in China. The response-guided therapies of high-resistance NAs are more cost-effective than their monotherapies.

Stereotactic Body Radiotherapy for Inoperable Liver Tumors: Results of a Single Institutional Experience

OBJECTIVES

Stereotactic body radiation therapy (SBRT) is an emerging treatment option for liver tumors unsuitable for ablation or surgery. We report our experience with SBRT in the treatment of liver tumors.

MATERIALS AND METHODS

Patients with primary or secondary liver cancer were identified in our local SBRT database. Patients were included irrespective of prior liver-directed therapies. The primary endpoint of our review was in-field local control (LC). Secondary endpoints were progression-free survival (PFS), overall survival (OS), and toxicity.

RESULTS

From 2009 to 2015, a total of 71 liver lesions in 68 patients were treated with SBRT (three patients had two liver lesions treated). The median age was 71 years (27-89 years). Hepatocellular carcinoma (HCC) was the diagnosis in 23 patients (34%), with the grade of Child-Pugh A (52%), B (39%), or C (nine percent) cirrhosis. Six patients (nine percent) had intrahepatic cholangiocarcinoma (IHC). The remaining 39 patients (57%) had metastatic liver lesions. Colorectal adenocarcinoma was the most common primary tumor type (81%). The median size for HCC, IHC, and metastatic lesions was 5 cm (2-9 cm), 3.6 cm (2-4.9 cm), and 4 cm (1-8 cm), respectively. The median prescribed dose was 45 Gy (16-50 Gy). Median follow-up was 11.5 months (1-45 months). Actuarial one-year in-field LC for HCC and metastatic lesions was 85% and 64% respectively (p= 0.66). At one year, the actuarial rate of new liver lesions was 40% and 26%, respectively, (p=0.58) for HCC and metastases. Only six patients with IHC were treated with SBRT in this study - in these patients, one-year LC was 78% with new liver lesions in 53%. The SBRT treatments were well tolerated. The side effects included common criteria for adverse events (CTCAE) v4 grade 1 acute gastrointestinal toxicity in three patients, grade 3 nausea in one patient, and grade 3 acute dermatitis in another patient. Two patients had grade 5 toxicity. Radiation pneumonitis was observed in one patient two months post-SBRT treatment, and another patient was suspected to have had radio-induced liver disease (RILD) two months after SBRT. No late toxicity was seen.

CONCLUSION

SBRT is a well-tolerated and effective alternative treatment option for selected patients with primary and metastatic liver tumors.

Short- and long-term impact of reoperation for complications after major hepatectomy for hepatocellular carcinoma

BACKGROUND

The impact of reoperation for complications after major liver resection for hepatocellular carcinoma was evaluated.

METHODS

In this retrospective study covering 25 years, patients with reoperation for complications after major liver resection for hepatocellular carcinoma were compared with patients without reoperation in terms of demographics, tumor characteristics, operative details, postoperative results, oncologic outcomes, and survival. Reasons for reoperation were also investigated.

RESULTS

Forty-nine out of 1,092 patients underwent reoperation within a median of 0.2 days (range, 0-6.9 days) after hepatectomy. Patients with and without reoperation had similar baseline characteristics and liver function. Nonetheless, patients with reoperation had a higher indocyanine green retention rate at 15 minutes (12.55% vs 10.5%, P = .015), more operative blood loss (1.4 L vs 1 L, P = .012), a higher blood transfusion rate (44.9% vs 29.2%, P = .029), longer hospital stay (21 days vs 11 days, P < .001), a higher hospital mortality (38.8% vs 3.0%, P < .001), and a higher 90-day mortality (38.8% vs 4.7%, P < .001). Hemorrhage was the most common cause for reoperation (26/49, 53.1%), mainly resulting from coagulopathic bleeding from raw areas (12/26, 46.2%) and bleeding from diaphragmatic veins (6/26, 23.1%). However, reoperation did not affect 5-year overall survival (50.2% vs 48.3%, P = .468).

CONCLUSION

Postoperative hemorrhage was associated with a high mortality, signifying the importance of meticulous hemostasis and careful perioperative management. Oncologic outcomes, however, were not affected by reoperation.

Cost-effectiveness analysis of tenofovir disoproxil fumarate for treatment of chronic hepatitis B in China

BACKGROUND

Tenofovir disoproxil fumarate (TDF) is newly available for treatment of chronic hepatitis B patients in China. To date, no study has been conducted to examine the cost-effectiveness of this treatment. The aim of this study was to estimate the cost-effectiveness of TDF versus four oral nucleos(t)ide analogs [lamivudine (LAM), adefovir (ADV), telbivudine (LdT), and entecavir (ETV)] and from a pharmacoeconomic perspective to assess current drug pricing for TDF.

METHODS

Based on Chinese healthcare perspectives, a Markov model was applied to simulate the lifetime (40-year time span) costs and quality-adjusted life-years (QALYs) for five different monotherapy strategies. Two kinds of rescue combination strategies (base-case: LAM + ADV then ETV + ADV; alternative: directly using ETV + ADV) were separately considered for treatment of patients refractory to monotherapy. Model parameters (including disease transition, cost, and utility) were obtained from previous Chinese population studies. Both branded and generic drugs were separately analyzed. Study model uncertainties were assessed by one-way and probabilistic sensitivity analyses. Two-way sensitivity analysis was used to explore uncertainties between efficacy and price of TDF.

RESULTS

In the base-case analysis, the lowest lifetime cost and the best cost-effectiveness ratio were obtained by ETV, which was considered the reference treatment. LAM, ADV, and LdT treatments had significantly greater costs and lower efficacies. Compared to ETV, TDF was more effective but also more expensive. The incremental cost-effectiveness ratios of TDF versus ETV were much higher than the willing-to-pay threshold of $20,466 US dollars (USD) per QALY gained (3 × gross domestic product per capita of China, 2014). TDF would be the most cost-effective strategy if the annual cost did not exceed $2260 USD and $1600 USD for branded and generic drugs, respectively.

CONCLUSIONS

For Chinese chronic hepatitis B patients, ETV is still the most cost-effective strategy over TDF and other nucleos(t)ide analogs, with a threshold of $20,466 USD/QALY gained.

Living vs. deceased-donor liver transplantation for patients with hepatocellular carcinoma

With the scarcity of deceased donor liver grafts, living donor liver transplantation (LDLT) is gaining popularity as an alternative to deceased donor liver transplantation (DDLT) for patients with hepatocellular carcinoma (HCC). However, as the evidence of cases of LDLT accumulates, several authors have reported higher HCC recurrence rates after LDLT. The suggested reasons for the higher recurrence rates following LDLT are related to the small-for-size graft in LDLT, surgical procedures that are specific to LDLT, and the fast-track to LDLT. Fast-tracking to LDLT may not allow sufficient time for evaluation of the biological aggressiveness of tumors, which may result in high recurrence rates due to inclusion of patients with more inherently aggressive tumors. Actually, some studies that reported higher recurrence rates with LDLT included a larger number of cases of HCC with microvascular invasion or poorly differentiated HCC. In order to exclude biologically aggressive HCC preoperatively, selection criteria incorporating tumor markers, such as alpha-fetoprotein (AFP) and des-gamma-carboxyprothrombin (DCP), as well as morphological tumor number and size have been proposed. With more reliable selection criteria incorporating biological markers to eliminate biologically aggressive HCC, LDLT can be a viable treatment option for patients with HCC, providing similar recurrence rates as those achieved with DDLT.

Bridging and downstaging therapy in patients suffering from hepatocellular carcinoma waiting on the list of liver transplantation

Hepatocellular carcinoma (HCC) is a common primary malignancy worldwide especially in the patients with the background of chronic liver disease. Liver transplantation (LT) is the only curative treatment effective for both malignancy as well as the cirrhosis and portal hypertension. Unfortunately, living donor is not always possible and the deceased graft is scarce. Neoadjuvant therapies, therefore, have been developed as a downstaging treatment to try to downstage the tumor within the transplant criteria, or as a bridging therapy to control the tumor growth in patients while waiting in the transplant list. This paper reviewed the common modalities used as bridging and downstaging therapies for patients suffering from HCC before undergoing LT.

Cost-effectiveness comparison of lamivudine plus adefovir combination treatment and nucleos(t)ide analog monotherapies in Chinese chronic hepatitis B patients

BACKGROUND/AIM

Lamivudine (LAM) plus adefovir (ADV) combination therapy is clinically efficacious for treating chronic hepatitis B (CHB) patients in China, but no pharmacoeconomic evaluations of this strategy are available. The aim of this study was to examine the cost-effectiveness of LAM plus ADV combination treatment compared with five other nucleos(t)ide analog monotherapies (LAM, ADV, telbivudine [TBV], entecavir [ETV], and tenofovir [TDF]).

METHODS

To simulate the lifetime (40-year time span) costs and quality-adjusted life-years (QALYs) for different therapy options, a Markov model that included five initial monotherapies and LAM plus ADV combination as an initial treatment was developed. Two kinds of rescue combination strategies (base-case: LAM + ADV then ETV + ADV; alternative: direct use of ETV + ADV) were considered separately for treating patients refractory to initial therapy. One-way and probabilistic sensitivity analyses were used to explore model uncertainties.

RESULTS

In base-case analysis, ETV had the lowest lifetime cost and served as the reference therapy. Compared to the reference, LAM, ADV, and TBV had higher costs and lower efficacy, and were completely dominated by ETV. LAM plus ADV combination therapy or TDF was more efficacious than ETV, but also more expensive. Although the incremental cost-effectiveness ratios of combination therapy or TDF were both higher than the willingness-to-pay threshold of $20,466/QALY gained for the reference treatment, in an alternative scenario analysis LAM plus ADV combination therapy would be the preferable treatment option.

CONCLUSION

ETV and LAM plus ADV combination therapy are both cost-effective strategies for treating Chinese CHB patients.

Cost-effectiveness analysis of antiviral therapies for hepatitis B e antigen-positive chronic hepatitis B patients in China

BACKGROUND AND OBJECTIVE

Several antiviral therapies are now available for patients with chronic hepatitis B (CHB), but the most cost-effective strategy for Chinese patients is unclear. The aim of this study was to estimate the long-term cost effectiveness of the antiviral treatments (lamivudine, adefovir, telbivudine and entecavir) for hepatitis B e antigen (HBeAg)-positive CHB patients in China.

METHODS

A Markov model was used to simulate the life-time (41-year time span) costs and effectiveness associated with antiviral treatments from the perspective of Chinese healthcare. Relative model parameters were derived from Chinese population studies. Costs and effectiveness were discounted at 5 %. The highest retail prices for generic and branded drug prices were also considered. Probabilistic sensitivity analysis and one-way sensitivity analysis were used to explore model uncertainties.

RESULTS

In the base-case analysis, the least quality-adjusted life years (QALYs) were obtained with adefovir as the reference strategy. Lamivudine generated the highest incremental cost-effectiveness ratio (ICER), with an additional US$35,000 needed to gain one additional QALY for generic drugs and US$36,000 for branded drugs. Entecavir had the lowest ICER of US$7,600 and US$9,100, respectively. The projected 10-year cumulative incidences of compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma (HCC) and mortality for entecavir were lower than the other strategies. In probabilistic sensitivity analyses, entecavir was the preferred option at a threshold of US$18,924 per QALY.

CONCLUSIONS

In patients with HBeAg-positive CHB in China, entecavir is a cost-effective option compared with other therapies for CHB.

Recurrence of hepatocellular carcinoma after liver transplantation: an update

Liver transplantation is the only curative alternative for selected patients with hepatocellular carcinoma (HCC) who are not eligible for resection and/or with decompensated cirrhosis. According to Milan criteria the 5-year survival rate is 70-85%, with a recurrence-free survival of 75%. However, HCC recurrence rate after liver transplantation remains a significant problem in the clinical practice. The prognosis in patients with HCC recurrence is poor. The treatment of choice for HCC recurrence is surgery, but it seems that a systemic treatment based on combination of an mTOR inhibitor with sorafenib can be used. Data on safety and efficacy are limited, clinical monitoring is necessary. The aim of this review is to underline the main concerns, pitfalls and warnings for these patients.

Strategies to increase the resectability of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is best treated by liver transplantation, but the applicability of transplantation is greatly limited. Tumor resection in partial hepatectomy is hence resorted to. However, in most parts of the world, only 20%-30% of HCCs are resectable. The main reason for such a low resectability is a future liver remnant too small to be sufficient for the patient. To allow more HCC patients to undergo curative hepatectomy, a variety of ways have been developed to increase the resectability of HCC, mainly ways to increase the future liver remnants in patients through hypertrophy. They include portal vein embolization, sequential transarterial chemoembolization and portal vein embolization, staged hepatectomy, two-staged hepatectomy with portal vein ligation, and Associating Liver Partition and Portal Vein Ligation in Staged Hepatectomy. Herein we review, describe and evaluate these different ways, ways that can be life-saving.

Liver transplantation as a management of hepatocellular carcinoma

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.

Living donor liver transplantation does not increase tumor recurrence of hepatocellular carcinoma compared to deceased donor transplantation

AIM: To compare the recurrence-free survival (RFS) and overall survival (OS) of hepatitis B virus (HBV)-positive hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT).

METHODS: We retrospectively collected clinical data from 408 liver cancer patients from February 1999 to September 2012. We used the chi-squared test or Fisher’s exact test to analyze the characteristics of LDLT and DDLT. Kaplan-Meier analysis was used to compare the RFS and OS in HCC.

RESULTS: Three hundred sixty HBV-positive patients (276 DDLT and 84 LDLT) were included in this study. The mean follow-up time was 27.1 mo (range 1.1-130.8 mo). One hundred eighty-five (51.2%) patients died during follow-up. The 1-, 3-, and 5-year RFS rates for LDLT were 85.2%, 55.7%, and 52.9%, respectively; for DDLT, the RFS rates were 73.2%, 49.1%, and 45.3% (P = 0.115). The OS rates were similar between the LDLT and DDLT recipients, with 1-, 3-, and 5-year survival rates of 81.8%, 49.5%, and 43.0% vs 69.5%, 43.0%, and 38.3%, respectively (P = 0.30). The outcomes of HCC according to the Milan criteria after LDLT and DDLT were not significantly different (for LDLT: 1-, 3-, and 5-year RFS: 94.7%, 78.7%, and 78.7% vs 89.2%, 77.5%, and 74.5%, P = 0.50; for DDLT: 86.1%, 68.8%, and 68.8% vs 80.5%, 62.2%, and 59.8% P = 0.53).

CONCLUSION: The outcomes of LDLT for HCC are not worse compared to the outcomes of DDLT. LDLT does not increase tumor recurrence of HCC compared to DDLT.

Good longterm survival after primary living donor liver transplantation for solitary hepatocellular carcinomas up to 8 cm in diameter

OBJECTIVES

There is controversy over whether hepatocellular carcinoma (HCC) should be primarily treated with living donor liver transplantation (LDLT) if liver resection (LR) can be effective. This retrospective study was conducted to compare survival outcomes in patients treated with either modality for solitary HCC measuring ≤8 cm in diameter.

METHODS

Outcomes in patients with solitary HCC primarily treated by LDLT were analysed. Patients with solitary HCC of similar sizes with or without microvascular invasion primarily treated with LR were selected at a ratio of 6 : 1 for comparison.

RESULTS

In-hospital mortality amounted to 0% and 1.3% in the LDLT (n = 50) and LR (n = 300) groups, respectively (P = 0.918). Complication rates were 34% and 20% in the LDLT and LR groups, respectively (P = 0.027). Rates of 1-, 3-, 5- and 10-year overall survival were 98%, 94%, 89% and 83%, respectively, in the LDLT group and 95%, 85%, 76% and 56%, respectively, in the LR group (P = 0.013). Rates of 1-, 3-, 5- and 10-year disease-free survival were 96%, 90%, 87% and 81%, respectively, in the LDLT group and 81%, 64%, 57% and 40%, respectively, in the LR group (P < 0.0001).

CONCLUSIONS

Living donor liver transplantation surpassed LR in survival outcomes, achieving a 10-year overall survival rate 1.5 times as high and a 10-year disease-free survival rate twice as high as those facilitated by LR. However, it entailed more complications, in addition to the inevitable risks to the donor.

High-intensity focused ultrasound ablation: An effective bridging therapy for hepatocellular carcinoma patients

AIM: To analyze whether high-intensity focused ultrasound (HIFU) ablation is an effective bridging therapy for patients with hepatocellular carcinoma (HCC).

METHODS: From January 2007 to December 2010, 49 consecutive HCC patients were listed for liver transplantation (UCSF criteria). The median waiting time for transplantation was 9.5 mo. Twenty-nine patients received transarterial chemoembolization (TACE) as a bringing therapy and 16 patients received no treatment before transplantation. Five patients received HIFU ablation as a bridging therapy. Another five patients with the same tumor staging (within the UCSF criteria) who received HIFU ablation but not on the transplant list were included for comparison. Patients were comparable in terms of Child-Pugh and model for end-stage liver disease scores, tumor size and number, and cause of cirrhosis.

RESULTS: The HIFU group and TACE group showed no difference in terms of tumor size and tumor number. One patient in the HIFU group and no patient in the TACE group had gross ascites. The median hospital stay was 1 d (range, 1-21 d) in the TACE group and two days (range, 1-9 d) in the HIFU group (P < 0.000). No HIFU-related complication occurred. In the HIFU group, nine patients (90%) had complete response and one patient (10%) had partial response to the treatment. In the TACE group, only one patient (3%) had response to the treatment while 14 patients (48%) had stable disease and 14 patients (48%) had progressive disease (P = 0.00). Seven patients in the TACE group and no patient in the HIFU group dropped out from the transplant waiting list (P = 0.559).

CONCLUSION: HIFU ablation is safe and effective in the treatment of HCC for patients with advanced cirrhosis. It may reduce the drop-out rate of liver transplant candidate.

Tolerance of high-intensity focused ultrasound ablation in patients with hepatocellular carcinoma

Background

High-intensity focused ultrasound (HIFU) ablation is a relatively new, noninvasive way of ablation for treating hepatocellular carcinoma (HCC). Emerging evidence has shown that it is effective for the treatment of HCC, even in patients with poor liver function. There is currently no data on the safety limit of HIFU ablation in patients with cirrhosis. However, this information is vital for the selection of appropriate patients for the procedure. We analyzed HCC patients who had undergone HIFU ablation and determined the lower limit of liver function and other patient factors with which HCC patients can tolerate this treatment modality.

Methods

Preoperative variables of 100 patients who underwent HIFU ablation for HCC were analyzed to identify the risk factors in HIFU intolerance in terms of stress-induced complications. Factors that may contribute to postablation complications were compared.

Results

Thirteen (13 %) patients developed a total of 18 complications. Morbidity was mainly due to skin and subcutaneous tissue injuries (n = 9). Five patients had first-degree skin burn, one had second-degree skin burn, and three had third-degree skin burn. Four complications were grade 3a in the Clavien classification and 14 were below this grade. Univariate analysis showed that age (p = 0.022) was the only independent factor in HIFU intolerance.

Conclusions

HIFU ablation is generally well tolerated in HCC patients with cirrhosis. It is safe for Child-Pugh A and B patients and selected Child-Pugh C patients. With this new modality, HCC patients who were deemed unsalvageable by other surgical means in the past because of simultaneous Child-Pugh B or C disease now have a new hope.

Neutrophil-lymphocyte ratio reflects hepatocellular carcinoma recurrence after liver transplantation via inflammatory microenvironment

BACKGROUND & AIMS

Although the Milan criteria (MC) have been used to select liver transplantation candidates among patients with hepatocellular carcinoma (HCC), many patients exceeding the MC have shown good prognosis. Preoperative neutrophil-lymphocyte ratio (NLR) is a predictor of patient prognosis, but its mechanism has never been clarified.

METHODS

We assessed outcomes in 158 patients who had undergone living-donor liver transplantation (LDLT) for HCC. Recurrence-free survival (RFS) was determined in patients with high (≥ 4) and low (<4) NLR. Levels of expression of vascular endothelial growth factor (VEGF), interleukin (IL)-8, IL-17, CD68, and CD163 were measured.

RESULTS

The 5-year RFS rate was significantly lower in patients with high (n=26) than with low (n=132) NLR (30.3% vs. 89.0%, p<0.0001), in patients with high (n=15) than with low (n=79) NLR who met the MC (73.6% vs. 100%, p=0.0008) and in patients with high (n=11) than with low (n=53) NLR who exceeded the MC (0% vs. 76.1%, p=0.0002). Tumor expression of VEGF, IL8, IL-17, CD68, and CD163 was similar in the high and low NLR groups, but serum and peritumoral IL-17 levels were significantly higher in the high-NLR group (p=0.01 each). The density of peritumoral CD163 correlated with the density of peritumoral IL-17-producing cells (p=0.04) and was significantly higher in the high-NLR group (p=0.005).

CONCLUSIONS

NLR predicts outcomes after LDLT for HCC via the inflammatory tumor microenvironment. Combined with the MC, NLR may be a new criterion for LDLT candidates with HCC.

Living donor liver transplantation for hepatocellular carcinoma

Liver transplantation (LT) may be the best curative treatment that offers a chance of cure for the tumor and the underlying cirrhosis by complete extirpation of both. In Asia, where the supply of cadaveric grafts remains scarce and the incidence of HCC combined with chronic hepatitis B virus (HBV)- and hepatitis C virus (HCV)-related liver disease is high, adult living donor liver transplantation (LDLT) has been settled upon as a practical alternative to deceased-donor liver transplantation (DDLT). Even in Western countries, where adequate access to DDLT is feasible for HCC patients satisfying the Milan criteria, the necessity for LDLT is well established in particular for more advanced HCC patients who are disadvantaged by current allocation algorithms for grafts from deceased donors due to organ shortage, increasing waiting lists, and the expectation that many patients listed for LT will die while awaiting a suitable organ. In the field of LDLT in Asia, numerous technical innovations were achieved to secure donor safety, as well as to ensure patient survival. The experience with LDLT for HCC has been progressively increasing in many Asian countries to date. Although there are questions regarding the higher recurrence of HCC after LDLT than after DDLT, the application of the Milan and UCSF criteria to LDLT in high-volume multicenter cohorts from Japan and Korea has resulted in patient survival outcomes very similar to those following DDLT. Recently, inclusion of biologic tumor markers such as alpha fetoprotein (AFP), protein induced by vitamin K antagonist II (PIVKA II), and positive positron emission tomography (PET) in addition to parameters of tumor morphology might be the key to establishing the best criteria for LDLT for HCC. As pretransplant treatments, most LDLT centers in Asia cannot adopt the strategy of bridging therapy under scarcity of cadaveric organ donation but have to use those multi-modality treatments as a salvage intending for primary curative treatment or a downstaging therapy before LDLT. After LDLT, basically there is no difference in the management strategy for HCC recurrence between DDLD and LDLT.

Recurrence of hepatocellular cancer after liver transplantation: the role of primary resection and salvage transplantation in East and West

BACKGROUND & AIMS

Greater tumor aggressiveness and different management modalities of hepatocellular cancer (HCC) before liver transplantation (LT) may explain the higher recurrence rates reported in Asia. This study investigates the prognostic factors for HCC recurrence in a Western and an Eastern HCC patient cohort in order to analyze the respective roles of tumor- and management-related factors on the incidence of post-LT HCC recurrence.

METHODS

Data of 273 HCC patients, transplanted during the period January 1999-March 2009, were obtained from the Rome Inter-University Liver Transplant Consortium (n=157) and Hong Kong University (n=116) databases. Median follow-up was 4.3 years (range: 0.2-12). Recurrence rate and multivariate logistic regression analysis was performed on the entire population and on Milan criteria-in (MC-in) patients.

RESULTS

Multivariate analysis on the entire population identified four independent risk factors for post-LT HCC recurrence: microvascular invasion (odds ratio, OR=4.88; p=0.001), poor tumor grading (OR=6.86; p=0.002), diameter of the largest tumor (OR=4.72; p=0.05), and previous liver resection (LR) (OR=3.34; p=0.04). After removal of LR, only tumor-related variables were independent risk factors for recurrence. When only MC-in patients were analyzed, no difference was observed between the two cohorts in terms of recurrence rate after LR patient removal.

CONCLUSIONS

LR followed by salvage "for HCC recurrence" LT represents the main reason for a higher HCC recurrence rate in the Hong Kong patients, but not LR followed by salvage "for liver failure" LT in the Roman group. This approach towards HCC before LT may not be universally applicable. The precise patient background must be taken into account in order to identify the best pre-LT strategy.

(18)F-FDG-PET/CT predicts early tumor recurrence in living donor liver transplantation for hepatocellular carcinoma

The prognosis including (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) for the early recurrence for hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT) was not well established. Consecutive patients who underwent (18)F-FDG-PET/CT and subsequent LDLT for HCC from March 2005 to June 2011 were enrolled. The 191 patients with a median follow-up of 26.1 months were evaluated. There were 20 patients (10.5%) with early recurrence (≤6 months), 18 patients (9.4%) with late recurrence (>6 months), and 153 patients (80.1%) with no recurrence. Fifty-five patients (28.8%) displayed increased PET/CT tumor uptake. Three-year overall and disease-free survival for PET/CT-positive patients were 65.5% and 57.1%, respectively, while PET/CT-negative patients showed respective values of 89.8% and 86.8% (P = 0.001 vs. P < 0.001). Tumor variables associated with PET/CT-positive finding were preoperative AFP level, Milan, UCSF criteria, maximum tumor size, total tumor size, differentiation, vascular invasion, and serosal invasion. PET/CT-positive status was identified as an independent prognostic factor for disease-free survival influencing early recurrence in multivariable analysis (HR 3.945, 95% CI 1.196-13.016, P = 0.024). (18)F-FDG-PET/CT is an independent and significant predictor of early tumor recurrence in LDLT for HCC.

Is there an advantage of living over deceased donation in liver transplantation?

Living donor liver transplantation (LDLT) is a well-established strategy to decrease the mortality in the waiting list and recent studies have demonstrated its value even in patients with low MELD score. However, LDLT is still under a high level of scrutiny because of its technical complexity and ethical challenges as demonstrated by a decline in the number of procedures performed in the last decade in Western Countries. Many aspects make LDLT different from deceased donor liver transplantation, including timing of transplantation, procedure-related complications as well as immunological factors that may affect graft outcomes. Our review suggests that in selected cases, LDLT offers significant advantages over deceased donor liver transplantation and should be used more liberally.

Hepatocellular carcinoma: focus on different aspects of management

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third cause of cancer-related mortality worldwide. Its incidence is clearly arising comprised by the prevalence of major risk factors mainly hepatitis B and hepatitis C. The population at risk is composed of chronic liver patients at the stage of extensive fibrosis or cirrhosis. The monitoring programs of this population have allowed early detection of disease management to promote a radical therapy. Understanding the carcinogenic process and the mastery of the staging systems remain essential keys in diagnosis and treatment of HCC. Recent advances in diagnosis and new treatments have made important impacts on the disease by increasing survival rates and improving quality of life for HCC patients. This paper outlines the different management aspects of HCC which include epidemiology, prevention, carcinogenesis, staging systems, diagnosis, surveillance, and the treatment.

Late recurrence of hepatocellular carcinoma after liver transplantation

Background

Long-term survival of patients with hepatocellular carcinoma (HCC) after liver transplantation is affected mainly by recurrence of HCC. There is the opinion that the chance of recurrence after 2 years post-transplantation is remote, and therefore lifelong surveillance is not justified because of limited resources. The aims of the present study were to determine the rate of late HCC recurrence (≥2 years after transplantation) and to compare the long-term patient survival outcomes between cases of early recurrence (<2 years after transplantation) and late recurrence.

Patients

A total of 139 adult HCC patients having liver transplantation during the period from July 1994 to December 2007 were included in the analysis. The median follow-up period was 55 months. Thirty-two patients received deceased-donor grafts and 107 received living-donor grafts.

Results

Hepatocellular carcinoma recurrence occurred in 24 (17.3%) patients, among them 22 (86%) had living-donor grafts and 7 (5%) developed late recurrence. Patients in the early recurrence group and patients in the late recurrence group had comparable demographics and disease pathology. The former group, when compared with the latter, had significantly worse overall survival at 3 years (13.3 versus 100%) and 5 years (6.67 versus 71.4%) (log-rank test; p < 0.001).

Conclusions

Both early recurrence and late recurrence of HCC after liver transplantation were not uncommon, mostly detected at a subclinical stage. Regular and long-term surveillance with imaging and blood tests is essential for early detection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term outcomes after resection versus transplantation for hepatocellular carcinoma within UCSF criteria

PURPOSE

We compared the long-term outcomes of resection and transplantation for hepatocellular carcinoma (HCC) while satisfying the University of California at San Francisco criteria.

METHODS

HCC patients who underwent liver resection (n = 746) and transplantation (n = 54) between 2001 and 2007 were reviewed. Overall and disease-free survival rates were evaluated using the Kaplan-Meier estimator, and independent prognostic factors were determined using the Cox proportional regression model. The presence of cirrhosis was used to divide the patients into groups. The patients who received primary transplantation were further analyzed.

RESULTS

Nine years after surgery, the patients' overall survival was similar in the resection and transplantation groups (75.9 and 77.2%, respectively). Furthermore, the recurrence rate in the resection group was higher than that in the transplantation group (65 vs. 34.4%; adjusted hazard ratio, 3.27; range, 1.76-6.08), especially for cirrhosis patients (adjusted hazard ratio, 4.28; range, 2.14-8.56). The results suggested that noncirrhotic patients who underwent resection had a better survival advantage than primary liver transplant recipients did (adjusted hazard ratio, 0.46; range, 0.18-1.21). However, noncirrhotic patients had higher recurrence rates (59.2 vs. 15.8%; adjusted hazard ratio, 3.98; range, 1.26-12.58). Similar trends were noted in patients with hepatitis B virus infection and/or a single tumor.

CONCLUSIONS

Long-term survival rates after liver transplantation and resection were similar, but the latter was associated with a higher recurrence rate.

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

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

CONCLUSION

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

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

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

[Liver transplantation in patients with hepatocellular carcinoma]

Hepatocellular carcinoma (HCC) is the third most common malignancy, with a new incidence of more than 11,000 cases per year and the second most common cause of malignancy-related death in Korean males. In Korea, more than 80% of all HCCs have developed from hepatitis B virus (HBV)-related cirrhotic livers. Liver transplantation (LT) is the only treatment that offers a chance of cure for HCC and the underlying liver cirrhosis simultaneously, but the availability of liver grafts and the aggressiveness of tumor recurrence are critical limiting factors of LT for HCC patients. The serious shortage of deceased-donors on strong demand for LT leads to the development of living-donor LT (LDLT) as a practical alternative replacing deceased-donor LT. Considering that HCC recurrence is the most common cause of posttransplant patient death, recipient candidates should be prudently selected through objectively established criteria. Uniquely, some Asian major LDLT centers challenged the Milan criteria, accepting a much higher number of HCC nodules instead of tumor size expansion. The eligibility criteria of LDLT for HCC are likely to be expanded more than before, but it still requires further qualified risk-benefit analyses. The development of new effective treatment modalities for HCC recurrence will reasonably expand the selection criteria further wide without the expense of recurrence rate. This article is mainly focused on the role of LT for HCC and discussed on the validity of currently available indication criteria.

Current controversies surrounding liver transplantation for hepatocellular carcinoma

Liver transplantation (LT) for hepatocellular carcinoma (HCC) has progressed rapidly over the last decade from a futile therapy to the first choice therapy for suitable patients. Excellent outcomes of LT for HCC can be largely attributed to the use of the Milan Criteria, which have restricted LT to patients with early stage tumors. These criteria may be conservative, and it is likely that a subset of patients with tumors beyond these criteria can have acceptable outcomes. However, there is currently insufficient data to accept more liberal criteria as a standard of care, and a higher quality evidence base must be achieved to prevent poor utilization of valuable donor liver resources. In the future, it is probable that more sophisticated selection criteria will emerge incorporating aspects of tumor biology beyond tumor size and number. Dropout from the waiting list due to tumor progression remains a clinical challenge particularly in regions with prolonged waiting times. Priority allocation using HCC MELD points is a practical and transparent solution that has successfully reduced waitlist dropout for HCC patients. Further refinements of the HCC MELD point system are required to ensure equity of access to LT for non-HCC patients and prioritization of HCC patients with the highest risk of dropout. Improving the evidence base for pre-LT locoregional therapy to prevent waitlist dropout is an urgent and difficult challenge for the LT community. In the interim transplant clinicians must restrict the use of these therapies to those patients who are most likely to benefit from them.

Prospective study on the outcome of patients with hepatocellular carcinoma registered for living donor liver transplantation: how long can they wait?

BACKGROUND.: In countries where cadaveric organ donation is limited, living donor liver transplantation (LDLT) has been reserved as a rescue option for the patients with uncontrollable hepatocellular carcinoma (HCC). PATIENTS AND METHODS.: Between March 2002 and June 2006, 56 patients with HCC had been registered as a LDLT candidate after HCC cannot be treated conventionally. We compared the survival rates between the patients who underwent LDLT (living donor liver transplantation group: LT, n=29) and those who did not undergo LDLT (no transplantation group: NLT, n=27). In the NLT group, we examined the periods suitable for resection or ablation (from first diagnosis to registration), suitable for LDLT, and unsuitable for LDLT. RESULTS.: Even among the patients who did not meet Milan criteria (LT: n=10, NLT: n=16), 1- and 3-year survival rates were significantly higher in the LT group than in the NLT group: 90.0% and 60.0% vs. 75.0% and 8.3%, respectively (P=0.046). In the NLT group, the median periods suitable for resection or ablation, suitable for LDLT, and unsuitable for LDLT were 28.9, 12.2, and 3.5 months, respectively. CONCLUSIONS.: LDLT is acceptable for the patients who gave up the conventional treatment. Approximately 12 months remain for the LDLT candidates with HCC to decide to undergo it.

Liver transplantation for hepatocellular carcinoma

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

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

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