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AFP score and metroticket 2.0 perform similarly and could be used in a "within-ALL" clinical decision tool. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 5:100644. [PMID: 36691474 PMCID: PMC9860475 DOI: 10.1016/j.jhepr.2022.100644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/01/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Abstract
Background & Aims Two recently developed composite models, the alpha-fetoprotein (AFP) score and Metroticket 2.0, could be used to select patients with hepatocellular carcinoma (HCC) who are candidates for liver transplantation (LT). The aim of this study was to compare the predictive performance of both models and to evaluate the net risk reclassification of post-LT recurrence between them using each model's original thresholds. Methods This multicenter cohort study included 2,444 adult patients who underwent LT for HCC in 47 centers from Europe and Latin America. A competing risk regression analysis estimating sub-distribution hazard ratios (SHRs) and 95% CIs for recurrence was used (Fine and Gray method). Harrell's adapted c-statistics were estimated. The net reclassification index for recurrence was compared based on each model's original thresholds. Results During a median follow-up of 3.8 years, there were 310 recurrences and 496 competing events (20.3%). Both models predicted recurrence, HCC survival and survival better than Milan criteria (p <0.0001). At last tumor reassessment before LT, c-statistics did not significantly differ between the two composite models, either as original or threshold versions, for recurrence (0.72 vs. 0.68; p = 0.06), HCC survival, and overall survival after LT. We observed predictive gaps and overlaps between the model's thresholds, and no significant gain on reclassification. Patients meeting both models ("within-ALL") at last tumor reassessment presented the lowest 5-year cumulative incidence of HCC recurrence (7.7%; 95% CI 5.1-11.5) and higher 5-year post-LT survival (70.0%; 95% CI 64.9-74.6). Conclusions In this multicenter cohort, Metroticket 2.0 and the AFP score demonstrated a similar ability to predict HCC recurrence post-LT. The combination of these composite models might be a promising clinical approach. Impact and implications Composite models were recently proposed for the selection of liver transplant (LT) candidates among individuals with hepatocellular carcinoma (HCC). We found that both the AFP score and Metroticket 2.0 predicted post-LT HCC recurrence and survival better than Milan criteria; the Metroticket 2.0 did not result in better reclassification for transplant selection compared to the AFP score, with predictive gaps and overlaps between the two models; patients who met low-risk thresholds for both models had the lowest 5-year recurrence rate. We propose prospectively testing the combination of both models, to further optimize the LT selection process for candidates with HCC.
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Liver Transplant Imaging prior to and during the COVID-19 Pandemic. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7768383. [PMID: 35036437 PMCID: PMC8753253 DOI: 10.1155/2022/7768383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 12/23/2021] [Indexed: 02/08/2023]
Abstract
Background The suspension of the surgical activity, the burden of the infection in immunosuppressed patients, and the comorbidities underlying end-stage organ disease have impacted transplant programs significantly, even life-saving procedures, such as liver transplantation. Methods A review of the literature was conducted to explore the challenges faced by transplant programs and the adopted strategies to overcome them, with a focus on indications for imaging in liver transplant candidates. Results Liver transplantation relies on an appropriate imaging method for its success. During the Coronavirus Disease 2019 (COVID-19) pandemic, chest CT showed an additional value to detect early signs of SARS-CoV-2 infection and other screening modalities are less accurate than radiology. Conclusion There is an emerging recognition of the chest CT value to recommend its use and help COVID-19 detection in patients. This examination appears highly sensitive for liver transplant candidates and recipients, who otherwise would have not undergone it, particularly when asymptomatic.
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3
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Degroote H, Piñero F, Costentin C, Notarpaolo A, Boin IF, Boudjema K, Baccaro C, Chagas AL, Bachellier P, Ettorre GM, Poniachik J, Muscari F, Di Benedetto F, Duque SH, Salame E, Cillo U, Gadano A, Vanlemmens C, Fagiuoli S, Rubinstein F, Burra P, Cherqui D, Silva M, Van Vlierberghe H, Duvoux C. International study on the outcome of locoregional therapy for liver transplant in hepatocellular carcinoma beyond Milan criteria. JHEP Rep 2021; 3:100331. [PMID: 34485882 PMCID: PMC8405981 DOI: 10.1016/j.jhepr.2021.100331] [Citation(s) in RCA: 3] [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: 01/24/2021] [Revised: 05/28/2021] [Accepted: 06/16/2021] [Indexed: 12/13/2022] Open
Abstract
Background & Aims Good outcomes after liver transplantation (LT) have been reported after successfully downstaging to Milan criteria in more advanced hepatocellular carcinoma (HCC). We aimed to compare post-LT outcomes in patients receiving locoregional therapies (LRT) before LT according to Milan criteria and University of California San Francisco downstaging (UCSF-DS) protocol and 'all-comers'. Methods This multicentre cohort study included patients who received any LRT before LT from Europe and Latin America (2000-2018). We excluded patients with alpha-foetoprotein (AFP) above 1,000 ng/ml. Competing risk regression analysis for HCC recurrence was conducted, estimating subdistribution hazard ratios (SHRs) and corresponding 95% CIs. Results From 2,441 LT patients, 70.1% received LRT before LT (n = 1,711). Of these, 80.6% were within Milan, 12.0% within UCSF-DS, and 7.4% all-comers. Successful downstaging was achieved in 45.2% (CI 34.8-55.8) and 38.2% (CI 25.4-52.3) of the UCSF-DS group and all-comers, respectively. The risk of recurrence was higher for all-comers (SHR 6.01 [p <0.0001]) and not significantly higher for the UCSF-DS group (SHR 1.60 [p = 0.32]), compared with patients remaining within Milan. The all-comers presented more frequent features of aggressive HCC and higher tumour burden at explant. Among the UCSF-DS group, an AFP value of ≤20 ng/ml at listing was associated with lower recurrence (SHR 2.01 [p = 0.006]) and better survival. However, recurrence was still significantly high irrespective of AFP ≤20 ng/ml in all-comers. Conclusions Patients within the UCSF-DS protocol at listing have similar post-transplant outcomes compared with those within Milan when successfully downstaged. Meanwhile, all-comers have a higher recurrence and inferior survival irrespective of response to LRT. Additionally, in the UCSF-DS group, an ALP of ≤20 ng/ml might be a novel tool to optimise selection of candidates for LT. Clinical trial number This study was registered as part of an open public registry (NCT03775863). Lay summary Patients with more extended HCC (within the UCSF-DS protocol) successfully downstaged to the conventional Milan criteria do not have a higher recurrence rate after LT compared with the group remaining in the Milan criteria from listing to transplantation. Moreover, in the UCSF-DS patient group, an ALP value equal to or below 20 ng/ml at listing might be a novel tool to further optimise selection of candidates for LT.
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Key Words
- AC, all-comers
- AFP, alpha-foetoprotein
- All-comers
- Alpha-foetoprotein
- DS, downstaging
- Downstaging
- EASL, European Association for the Study of the Liver
- HCC, hepatocellular carcinoma
- HR, hazard ratio
- Hepatocellular carcinoma
- ITT, intention to treat
- LR, liver resection
- LRT, locoregional therapies
- LT, liver transplantation
- MC, Milan criteria
- MVI, microvascular invasion
- PEI, percutaneous ethanol ablation
- RFA, radiofrequency ablation
- SHR, subdistribution hazard ratio
- TACE, transarterial chemoembolisation
- UCSF downstaging protocol
- UCSF-DS, University of California San Francisco downstaging
- UNOS, United Network for Organ Sharing
- WL, waiting list
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Affiliation(s)
- Helena Degroote
- Department of Hepatology and Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Federico Piñero
- Hospital Universitario Austral, School of Medicine, Austral University, Argentina.,Argentina and Latin American Liver Research Educational and Awareness Network (LALREAN)
| | - Charlotte Costentin
- Grenoble Alpes University; Institute for Advanced Biosciences, Research Center UGA/Inserm U 1209/CNRS 5309; Gastroenterology, Hepatology and GI Oncology Department, Digidune, Grenoble Alpes University Hospital; 38700 La Tronche, France
| | | | - Ilka F Boin
- Hospital das Clinicas UNICAMP Campiñas, Campiñas, Brazil
| | - Karim Boudjema
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou Hospital Rennes 1 University, Rennes, France
| | | | - Aline Lopes Chagas
- Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Philippe Bachellier
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplant, Hôpital de Hautepierre, CHU de Strasbourg, France
| | | | - Jaime Poniachik
- Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Fabrice Muscari
- Digestive Surgery and Transplant Unit, Hôpital Rangueil, Toulouse, France
| | - Fabrio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of General Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | - Sergio Hoyos Duque
- Hospital Pablo Tobón Uribe y Grupo de Gastrohepatología de la Universidad de Antioquía, Medellín, Colombia
| | | | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Padova University Hospital, Padua, Italy
| | - Adrián Gadano
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Stefano Fagiuoli
- Gastroenterology, Hepatology and Transplantation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fernando Rubinstein
- Instituto de Efectividad Clínica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padua, Italy
| | - Daniel Cherqui
- Paul Brousse Hospital, APHP - University Paris Saclay, Villejuif, France
| | - Marcelo Silva
- Hospital Universitario Austral, School of Medicine, Austral University, Argentina.,Argentina and Latin American Liver Research Educational and Awareness Network (LALREAN)
| | - Hans Van Vlierberghe
- Department of Hepatology and Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Christophe Duvoux
- Liver and Medical Liver Transplant Unit, Hospital Henri Mondor, University of Paris-Est, Creteil, France
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4
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Piñero F, Tanno M, Aballay Soteras G, Tisi Baña M, Dirchwolf M, Fassio E, Ruf A, Mengarelli S, Borzi S, Fernández N, Ridruejo E, Descalzi V, Anders M, Mazzolini G, Reggiardo V, Marciano S, Perazzo F, Spina JC, McCormack L, Maraschio M, Lagues C, Gadano A, Villamil F, Silva M, Cairo F, Ameigeiras B. Argentinian clinical practice guideline for surveillance, diagnosis, staging and treatment of hepatocellular carcinoma. Ann Hepatol 2021; 19:546-569. [PMID: 32593747 DOI: 10.1016/j.aohep.2020.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/05/2020] [Accepted: 06/10/2020] [Indexed: 02/08/2023]
Abstract
The A.A.E.E.H has developed this guideline for the best care of patients with hepatocellular carcinoma (HCC) from Argentina. It was done from May 2018 to March 2020. Specific clinical research questions were systematically searched. The quality of evidence and level of recommendations were organized according to GRADE. HCC surveillance is strongly recommended with abdominal ultrasound (US) every six months in the population at risk for HCC (cirrhosis, hepatitis B or hepatitis C); it is suggested to add alpha-feto protein (AFP) levels in case of inexeperienced sonographers. Imaging diagnosis in patients at risk for HCC has high specificity and tumor biopsy is not mandatory. The Barcelona Clinic Liver Cancer algorithm is strongly recommended for HCC staging and treatment-decision processes. Liver resection is strongly recommended for patients without portal hypertension and preserved liver function. Composite models are suggested for liver transplant selection criteria. Therapies for HCC with robust clinical evidence include transarterial chemoembolization (TACE) and first to second line systemic treatment options (sorafenib, lenvatinib, regorafenib, cabozantinib and ramucirumab). Immunotherapy with nivolumab and pembrolizumab has failed to show statistical benefit but the novel combination of atezolizumab plus bevacizumab has recently shown survival benefit over sorafenib in frontline.
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Affiliation(s)
- Federico Piñero
- Hepatology and Liver Unit, Hospital Universitario Austral, School of Medicine, Austral University, B1629HJ Buenos Aires, Argentina.
| | - Mario Tanno
- Hospital Centenario de Rosario, Santa Fe, Argentina
| | | | - Matías Tisi Baña
- Internal Medicine and Epidemiology Department, Hospital Universitario Austral, School of Medicine, Austral University, B1629HJ Buenos Aires, Argentina
| | | | | | - Andrés Ruf
- Hospital Privado de Rosario, Santa Fe, Argentina
| | | | - Silvia Borzi
- Instituto Rossi, La Plata, Buenos Aires, Argentina
| | | | - Ezequiel Ridruejo
- Hepatology and Liver Unit, Hospital Universitario Austral, School of Medicine, Austral University, B1629HJ Buenos Aires, Argentina; Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Ciudad de Buenos Aires, Argentina
| | | | | | - Guillermo Mazzolini
- Hepatology and Liver Unit, Hospital Universitario Austral, School of Medicine, Austral University, B1629HJ Buenos Aires, Argentina
| | | | | | | | | | | | | | - Cecilia Lagues
- Hepatology and Liver Unit, Hospital Universitario Austral, School of Medicine, Austral University, B1629HJ Buenos Aires, Argentina
| | | | | | - Marcelo Silva
- Hepatology and Liver Unit, Hospital Universitario Austral, School of Medicine, Austral University, B1629HJ Buenos Aires, Argentina
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5
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Maccali C, Chagas AL, Boin I, Quiñonez E, Marciano S, Vilatobá M, Varón A, Anders M, Hoyos Duque S, Lima AS, Menendez J, Padilla-Machaca M, Poniachik J, Zapata R, Maraschio M, Chong Menéndez R, Muñoz L, Arufe D, Figueroa R, Soza A, Fauda M, Perales SR, Vergara Sandoval R, Bermudez C, Beltran O, Arenas Hoyos I, McCormack L, Mattera FJ, Gadano A, Parente García JH, Tani CM, Augusto Carneiro D'Albuquerque L, Carrilho FJ, Silva M, Piñero F. Recurrence of hepatocellular carcinoma after liver transplantation: Prognostic and predictive factors of survival in a Latin American cohort. Liver Int 2021; 41:851-862. [PMID: 33217193 DOI: 10.1111/liv.14736] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/20/2020] [Accepted: 11/16/2020] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIM Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) has a poor prognosis, and the adjusted effect of different treatments on post-recurrence survival (PRS) has not been well defined. This study aims to evaluate prognostic and predictive variables associated with PRS. METHODS This Latin American multicenter retrospective cohort study included HCC patients who underwent LT between the years 2005-2018. We evaluated the effect of baseline characteristics at time of HCC recurrence diagnosis and PRS (Cox regression analysis). Early recurrences were those occurring within 12 months of LT. To evaluate the adjusted treatment effect for HCC recurrence, a propensity score matching analysis was performed to assess the probability of having received any specific treatment for recurrence. RESULTS From a total of 1085 transplanted HCC patients, the cumulative incidence of recurrence was 16.6% (CI 13.5-20.3), with median time to recurrence of 13.0 months (IQR 6.0-26.0). Factors independently associated with PRS were early recurrence (47.6%), treatment with sorafenib and surgery/trans-arterial chemoembolization (TACE). Patients who underwent any treatment presented "early recurrences" less frequently, and more extrahepatic metastasis. This unbalanced distribution was included in the propensity score matching, with correct calibration and discrimination (receiving operator curve of 0.81 [CI 0.72;0.88]). After matching, the adjusted effect on PRS for any treatment was HR of 0.2 (0.10;0.33); P < .0001, for sorafenib therapy HR of 0.4 (0.27;0.77); P = .003, and for surgery/TACE HR of 0.4 (0.18;0.78); P = .009. CONCLUSION Although early recurrence was associated with worse outcome, even in this population, systemic or locoregional treatments were associated with better PRS.
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Affiliation(s)
- Claudia Maccali
- São Paulo Clinics Liver Cancer Group - Hospital das Clínicas Complex, Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Aline L Chagas
- São Paulo Clinics Liver Cancer Group - Hospital das Clínicas Complex, Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Ilka Boin
- Unit of Liver Transplantation, State University of Campinas, Campinas, Brazil
| | | | | | - Mario Vilatobá
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", México
| | | | | | - Sergio Hoyos Duque
- Hospital Pablo Tobón Uribe and Gastrohepatology Group, Universidad de Antioquia, Medellín, Colombia
| | - Agnaldo S Lima
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | | | - Rodrigo Zapata
- Clinica Alemana, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | | | | | | | - Diego Arufe
- Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | | | - Alejandro Soza
- Department of Gastroenterology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Martín Fauda
- Hospital Universitario Austral, Buenos Aires, Argentina
| | - Simone R Perales
- Unit of Liver Transplantation, State University of Campinas, Campinas, Brazil
| | | | - Carla Bermudez
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Isabel Arenas Hoyos
- Hospital Pablo Tobón Uribe and Gastrohepatology Group, Universidad de Antioquia, Medellín, Colombia
| | | | | | - Adrián Gadano
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Claudia Megumi Tani
- São Paulo Clinics Liver Cancer Group - Hospital das Clínicas Complex, Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- São Paulo Clinics Liver Cancer Group - Hospital das Clínicas Complex, Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Flair J Carrilho
- São Paulo Clinics Liver Cancer Group - Hospital das Clínicas Complex, Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Marcelo Silva
- Hospital Universitario Austral, Buenos Aires, Argentina.,Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires, Argentina
| | - Federico Piñero
- Hospital Universitario Austral, Buenos Aires, Argentina.,Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires, Argentina
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6
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Piñero F, Thompson M, Marín JI, Silva M. Lenvatinib as first-line therapy for recurrent hepatocellular carcinoma after liver transplantation: Is the current evidence applicable to these patients? World J Transplant 2020; 10:297-306. [PMID: 33312891 PMCID: PMC7708877 DOI: 10.5500/wjt.v10.i11.297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/09/2020] [Accepted: 09/22/2020] [Indexed: 02/05/2023] Open
Abstract
Liver transplantation (LT) is one of the leading curative therapies for hepatocellular carcinoma (HCC). Despite recent optimization of transplant selection criteria, including alpha-feto protein, HCC recurrence after LT is still the leading cause of death in these patients. During the last decades, effective systemic treatments for HCC, including tyrosine kinase inhibitors and immunotherapy, have been approved. We describe the clinical scenario of a patient with recurrence of HCC five years after LT, who received lenvatinib as first-line systemic therapy to introduce systemic treatment options in this clinical setting. In this opinion review, we detail first and second-line systemic treatment options, focusing on those feasible for patients with recurrent HCC after LT. Several trials have evaluated new drugs to treat HCC patients in first and second-line therapy, but patients with recurrent HCC after LT have been excluded from these trials. Consequently, most of the evidence comes from observational retrospective studies. Whether tyrosine kinase inhibitors will remain the primary therapeutic approach in these patients, due to a relative contraindication for immunotherapy, may be clarified in the near future.
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Affiliation(s)
- Federico Piñero
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires B1629HJ, Argentina
- Hospital Universitario Austral, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires B1629HJ, Argentina
- Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires B1629HJ, Argentina
| | - Marcos Thompson
- Hospital Universitario Austral, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires B1629HJ, Argentina
| | - Juan Ignacio Marín
- Hepatology and Liver Transplantation Unit, Hospital Pablo Tobón Uribe, Medellín 240, Colombia
| | - Marcelo Silva
- Hospital Universitario Austral, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires B1629HJ, Argentina
- Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires B1629HJ, Argentina
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7
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Piñero F, Boin I, Chagas A, Quiñonez E, Marciano S, Vilatobá M, Santos L, Anders M, Hoyos Duque S, Soares Lima A, Menendez J, Padilla M, Poniachik J, Zapata R, Maraschio M, Chong Menéndez R, Muñoz L, Arufe D, Figueroa R, Mendizabal M, Hurtado Gomez S, Stucchi R, Maccali C, Vergara Sandoval R, Bermudez C, McCormack L, Varón A, Gadano A, Mattera J, Rubinstein F, Carrilho F, Silva M. Direct-Acting Antivirals and Hepatocellular Carcinoma: No Evidence of Higher Wait-List Progression or Posttransplant Recurrence. Liver Transpl 2020; 26:640-650. [PMID: 32133773 DOI: 10.1002/lt.25744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/23/2019] [Accepted: 01/19/2020] [Indexed: 12/17/2022]
Abstract
The association between direct-acting antivirals (DAAs) and hepatocellular carcinoma (HCC) wait-list progression or its recurrence following liver transplantation (LT) remains uncertain. We evaluated the impact of DAAs on HCC wait-list progression and post-LT recurrence. This Latin American multicenter retrospective cohort study included HCC patients listed for LT between 2012 and 2018. Patients were grouped according to etiology of liver disease: hepatitis C virus (HCV) negative, HCV+ never treated with DAAs, and HCV+ treated with DAAs either before or after transplantation. Multivariate competing risks models were conducted for both HCC wait-list progression adjusted by a propensity score matching (pre-LT DAA effect) and for post-LT HCC recurrence (pre- or post-LT DAA effect). From 994 included patients, 50.6% were HCV-, 32.9% were HCV+ never treated with DAAs, and 16.5% were HCV+ treated with DAAs either before (n = 66) or after LT (n = 98). Patients treated with DAAs before LT presented similar cumulative incidence of wait-list tumor progression when compared with those patients who were HCV+ without DAAs (26.2% versus 26.9%; P = 0.47) and a similar HCC-related dropout rate (12.1% [95% CI, 0.4%-8.1%] versus 12.9% [95% CI, 3.8%-27.2%]), adjusted for baseline tumor burden, alpha-fetoprotein values, HCC diagnosis after listing, bridging therapies, and by the probability of having received or not received DAAs through propensity score matching (subhazard ratio [SHR], 0.9; 95% CI, 0.6-1.6; P = 0.95). A lower incidence of posttransplant HCC recurrence among HCV+ patients who were treated with pre- or post-LT DAAs was observed (SHR, 0.7%; 95% CI, 0.2%-4.0%). However, this effect was confounded by the time to DAA initiation after LT. In conclusion, in this multicenter cohort, HCV treatment with DAAs did not appear to be associated with an increased wait-list tumor progression and HCC recurrence after LT.
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Affiliation(s)
- Federico Piñero
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina.,Latin American Liver Research Educational and Awareness Network, Pilar, Argentina
| | - Ilka Boin
- Hospital das Clínicas Universidade Estadual do Campiñas (UNICAMP), Sao Paulo, Brazil
| | - Aline Chagas
- Hospital das Clínicas University of São Paulo School of Medicine, Sao Paulo, Brazil
| | | | | | - Mario Vilatobá
- Instituto de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, México
| | | | | | - Sergio Hoyos Duque
- Hospital Tobón Uribe, Medellín, y Grupo de Gastrohepatología, Universidad de Antioquia, Antioquia, Colombia
| | | | | | | | | | - Rodrigo Zapata
- Clínica Alemana, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | | | | | - Linda Muñoz
- Hospital Universitario "Dr. José E. González,", Monterrey, Mexico
| | - Diego Arufe
- Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | | | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina.,Latin American Liver Research Educational and Awareness Network, Pilar, Argentina
| | - Sahara Hurtado Gomez
- Instituto de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, México
| | - Raquel Stucchi
- Hospital das Clínicas Universidade Estadual do Campiñas (UNICAMP), Sao Paulo, Brazil
| | - Claudia Maccali
- Hospital das Clínicas University of São Paulo School of Medicine, Sao Paulo, Brazil
| | | | - Carla Bermudez
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Adrián Gadano
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Flair Carrilho
- Hospital das Clínicas University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Marcelo Silva
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina.,Latin American Liver Research Educational and Awareness Network, Pilar, Argentina
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8
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Bauschke A, Altendorf-Hofmann A, Ardelt M, Kissler H, Tautenhahn HM, Settmacher U. Impact of successful local ablative bridging therapy prior to liver transplantation on long-term survival in patients with hepatocellular carcinoma in cirrhosis. J Cancer Res Clin Oncol 2020; 146:1819-1827. [PMID: 32356179 PMCID: PMC7256027 DOI: 10.1007/s00432-020-03215-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/08/2020] [Indexed: 12/13/2022]
Abstract
Background It has been shown that local ablative procedures enable downsizing, reduce drop-out from the waiting list and improve prognosis after liver transplantation. It is still unclear whether a response to the local ablative therapy is due to a favorable tumor biology or if a real benefit in tumor stabilization exists, particularly in complete pathological response. Method Data of 163 HCC patients who underwent liver transplantation were extracted from our prospectively maintained registry. We analyzed the tumor load, pre-transplant α-fetoprotein levels, child stage aside the application and success of local ablative therapies as bridging procedures before transplantation. Results 87 patients received multiple and/or combined local therapies. In 20 cases, this resulted in a complete remission of the tumor as observed in the explant histology. The other 76 patients underwent no bridging procedure. The observed 5- and 10-year survival rates for patients with bridging were 67% and 47% and without bridging 56% and 46%, respectively. Tumor-related 10-year survival showed a statistically significant difference between both groups (81% versus 59%). In the multivariate analyses bridging, number of lesions and α-fetoprotein level showed an independent statistically significant influence on tumor-related survival in these patients. Conclusions Successful local ablative therapy before liver transplantation is an independent statistically significant factor in long-term tumor-related survival for patients with HCC in cirrhosis and reduces tumor recurrences.
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Affiliation(s)
- Astrid Bauschke
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany.
| | - Annelore Altendorf-Hofmann
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
| | - Michael Ardelt
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
| | - Herman Kissler
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
| | - Hans-Michael Tautenhahn
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
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9
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Kim DG, Lee JG, Joo DJ, Kim SI, Kim MS. Favourable outcome of pathologic downstaging by locoregional treatment for hepatocellular carcinoma in liver transplantation. Sci Rep 2019; 9:10386. [PMID: 31316165 PMCID: PMC6637173 DOI: 10.1038/s41598-019-46871-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 06/27/2019] [Indexed: 02/07/2023] Open
Abstract
No distinct guidelines are available regarding the effect of pretransplant locoregional treatment (LRT) in hepatocellular carcinoma (HCC) staging system. The aim of this study was to investigate the prognosis of pathologic downstaging (PDS) by the exclusion of total necrosis after liver transplantation. We conducted a study of 326 HCC patients who underwent liver transplantation between September 2005 and December 2016. Two hundred twenty-two patients received pretransplant LRT and 102 patients did not. Among the former group, 74 (33.0%) achieved PDS while 150 (67.0%) showed unchanged T stage after the exclusion of total necrosis. Five-year HCC recurrent free survival (RFS) of PDS group (85.1%) was similar to that of the no LRT group (88.8%) but higher than that of the non-PDS group (68.9%; P < 0.001). Based on T stage adjusted with total necrosis and PDS status, RFS was similar in the PDS T1 (82.4%) and non-PDS T1 (86.5%) groups. Non-PDS T2 cancers had worse outcome regardless of the Milan (P = 0.982) or University of California San Francisco criteria (P = 0.466). On preoperative examination, parameters like less than 1 viable tumor, less than 1 cm of tumor size, and less than 20 ng/mL of serum alpha fetoprotein were associated with PDS. This study showed that PDS by LRT was associated with favorable outcome in HCC patients after liver transplantation.
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Affiliation(s)
- Deok Gie Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea. .,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.
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10
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Cho Y, Kim MS, Nam CM, Kang ES. Statin Use is Associated with Decreased Hepatocellular Carcinoma Recurrence in Liver Transplant Patients. Sci Rep 2019; 9:1467. [PMID: 30728421 PMCID: PMC6365496 DOI: 10.1038/s41598-018-38110-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/28/2018] [Indexed: 12/16/2022] Open
Abstract
Statins have been reported to prevent the development of hepatocellular carcinoma (HCC). We examined whether statin therapy is associated with decreased HCC recurrence in patients who underwent liver transplantation for HCC. Three hundred forty-seven patients ≥ 20 years old who underwent liver transplantation for HCC from 2006 to 2016 were enrolled in this study. Statin therapy was defined as the administration of statins for more than 30 days after liver transplantation. One hundred twelve (32.3%) patients treated with statins over 30 days were defined as the statin group, and the remaining 235 (67.7%) were defined as the non-statin group. Several risk factors reported to be associated with HCC recurrence, such as proportion of underlying liver disease, above Milan criteria, differentiation of HCC, vascular invasion, and preoperative alpha-fetoprotein level were not different between the two groups. Time-dependent Cox regression analysis showed that statin treatment was associated with significantly lower recurrence risk of HCC after adjusting for other risk factors (hazard ratio = 0.32, 95% CI = 0.11-0.89).
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Affiliation(s)
- Yongin Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Seok Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea.
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11
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Piñero F, Costa P, Boteon YL, Duque SH, Marciano S, Anders M, Varón A, Zerega A, Poniachik J, Soza A, Padilla Machaca M, Menéndez J, Zapata R, Vilatoba M, Muñoz L, Maraschio M, Podestá LG, McCormack L, Gadano A, Boin ISFF, García P, Silva M. A changing etiologic scenario in liver transplantation for hepatocellular carcinoma in a multicenter cohort study from Latin America. Clin Res Hepatol Gastroenterol 2018; 42:443-452. [PMID: 29773419 DOI: 10.1016/j.clinre.2018.03.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/28/2018] [Accepted: 03/12/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Non-alcoholic fatty liver disease (NAFLD) is an increasing cause of hepatocellular carcinoma (HCC) and liver transplantation (LT). Our study focused on changing trends of liver related HCC etiologies during the last years in Latin America. METHODS From a cohort of 2761 consecutive adult LT patients between 2005 and 2012 in 17 different centers, 435 with HCC were included. Different periods including years 2005-2006, 2007-2008, 2009-2010 and 2011-2012 were considered. Etiology of liver disease was confirmed in the explant. RESULTS Participating LT centers per country included 2 from Brazil (n=191), 5 transplant programs from Argentina (n=98), 2 from Colombia (n=65), 4 from Chile (n=49), 2 from Mexico (n=12), and 1 from Peru (n=11) and Uruguay (n=9). Chronic hepatitis C infection was the leading cause of HCC in the overall cohort (37%), followed by HBV (25%) and alcoholic liver disease (17%). NAFLD and cryptogenic cirrhosis accounted for 6% and 7%, respectively. While HCV decreased from 48% in 2005-06 to 26% in 2011-12, NAFLD increased from 1.8% to 12.8% during the same period, accounting for the third cause of HCC. This represented a 6-fold increase in NAFLD-HCC, whereas HCV had a 2-fold decrease. Patients with NAFLD were older, had lower pre-LT serum AFP values and similar 5-year survival and recurrence rates than non-NAFLD. CONCLUSION There might be a global changing figure regarding etiologies of HCC in Latin America. This epidemiological change on the incidence of HCC in the world, although it has been reported, should still be confirmed in prospective studies.
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Affiliation(s)
- Federico Piñero
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Austral University, School of Medicine, avenue Presidente-Perón 1500, (B1629HJ) Pilar, Buenos Aires, Argentina.
| | - Paulo Costa
- Hospital Federal University of Ceará, Ceara, Brazil
| | | | - Sergio Hoyos Duque
- Hospital Pablo Tobón Uribe and Gastroenterology group from Universidad de Antioquía, Medellín, Colombia
| | | | | | - Adriana Varón
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Alina Zerega
- Sanatorio Allende from Córdoba, Córdoba, Argentina
| | - Jaime Poniachik
- Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Alejandro Soza
- Hospital Universidad Católica de Chile, Santiago de Chile, Chile
| | | | | | - Rodrigo Zapata
- Clinica Alemana de Santiago, Universidad del Desarrollo, Santiago de Chile, Chile; Hospital del Salvador, Universidad de Chile, Santiago de Chile, Chile
| | | | - Linda Muñoz
- Hospital Universitario de Monterrey, Monterrey, Mexico
| | | | - Luis G Podestá
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Austral University, School of Medicine, avenue Presidente-Perón 1500, (B1629HJ) Pilar, Buenos Aires, Argentina
| | | | - Adrian Gadano
- Hospital Italiano from Buenos Aires, Buenos Aires, Argentina
| | | | | | - Marcelo Silva
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Austral University, School of Medicine, avenue Presidente-Perón 1500, (B1629HJ) Pilar, Buenos Aires, Argentina
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12
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Piñero F, Costa P, Boteon YL, Duque SH, Marciano S, Anders M, Varón A, Zerega A, Poniachik J, Soza A, Machaca MP, Menéndez J, Zapata R, Vilatoba M, Muñoz L, Maraschio M, Fauda M, McCormack L, Gadano A, Boin IS, García JHP, Silva M. Results of Liver Transplantation for Hepatocellular Carcinoma in a Multicenter Latin American Cohort Study. Ann Hepatol 2018; 17:256-267. [PMID: 29469048 DOI: 10.5604/01.3001.0010.8648] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Heterogeneous data has been reported regarding liver transplantation (LT) for hepatocellular carcinoma (HCC) in Latin America. We aimed to describe treatment during waiting list, survival and recurrence of HCC after LT in a multicenter study from Latin America. MATERIAL AND METHODS Patients with HCC diagnosed prior to transplant (cHCC) and incidentally found in the explanted liver (iHCC) were included. Imaging-explanted features were compared in cHCC (non-discordant if pre and post-LT were within Milan, discordant if pre-LT was within and post-LT exceeding Milan). RESULTS Overall, 435 patients with cHCC and 92 with iHCC were included. At listing, 81% and 91% of cHCC patients were within Milan and San Francisco criteria (UCSF), respectively. Five-year survival and recurrence rates for cHCC within Milan, exceeding Milan/within UCSF and beyond UCSF were 71% and 16%; 66% and 26%; 46% and 55%, respectively. Locoregional treatment prior to LT was performed in 39% of cHCC within Milan, in 53% beyond Milan/within UCSF and in 83% exceeding UCSF (p < 0.0001). This treatment difference was not observed according to AFP values (≤100, 44%; 101-1,000, 39%, and > 1,000 ng/mL 64%; p = 0.12). Discordant imaging-explanted data was observed in 29% of cHCC, showing lower survival HR 2.02 (CI 1.29; 3.15) and higher recurrence rates HR 2.34 when compared to AFP <100 ng/mL. Serum AFP > 1,000 ng/mL at listing was independently associated with a higher 5-year recurrence rate and a HR of 3.24 when compared to AFP <100 ng/mL. CONCLUSION Although overall results are comparable to other regions worldwide, pre-LT treatment not only considering imaging data but also AFP values should be contemplated during the next years.
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Affiliation(s)
- Federico Piñero
- Hospital Universitario Austral. Austral University, Faculty of Medicine. Argentina
| | - Paulo Costa
- Hospital Federal University of Ceará, Brazil
| | - Yuri L Boteon
- Hospital de Clinicas, State University of Campinas, Brazil
| | - Sergio Hoyos Duque
- Hospital Pablo Tobón Uribe and Gastroenterology group from Universidad de Antioquía, Medellín, Colombia
| | | | | | - Adriana Varón
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | | | | | | | | | | | - Rodrigo Zapata
- Clinica Alemana de Santiago, Universidad del Desarrollo, Chile
| | | | | | | | - Martín Fauda
- Hospital Universitario Austral. Austral University, Faculty of Medicine. Argentina
| | | | | | - Ilka Sf Boin
- Hospital de Clinicas, State University of Campinas, Brazil
| | | | - Marcelo Silva
- Hospital Universitario Austral. Austral University, Faculty of Medicine. Argentina. On behalf of the Latin American Liver Research, Education and Awareness Network (LALREAN)
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Biolato M, Marrone G, Miele L, Gasbarrini A, Grieco A. Liver transplantation for intermediate hepatocellular carcinoma: An adaptive approach. World J Gastroenterol 2017; 23:3195-3204. [PMID: 28566879 PMCID: PMC5434425 DOI: 10.3748/wjg.v23.i18.3195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/12/2017] [Accepted: 04/12/2017] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma is becoming an increasing indication for liver transplantation, but selection and allocation of patients are challenging because of organ shortages. Conventional Milan criteria are the reference for the selection of patients worldwide, but many expanded criteria, like University of California San Francisco criteria and up-to-7 criteria, have demonstrated that survival and recurrence results are lower than those for restricted indications. Correct staging is crucial and should include surrogate markers of biological aggressiveness (α-fetoprotein, response to loco-regional treatments). Successful down-staging can select between patients with tumor burden initially beyond transplantation criteria those with a more favorable biology, provided a 3-mo stability in meeting the transplantation criteria. Allocation rules are constantly adjusted to minimize the imbalance between the priorities of candidates with and without hepatocellular carcinoma, and take into account local donor rate and waitlist dynamics. Recently, Mazzaferro et al proposed a benefit-oriented “adaptive approach”, in which the selection and allocation of patients are based on their response to non-transplantation treatments: low priority for transplantation in case of complete response, high priority in case of partial response or recurrence, and no listing in case of progression beyond transplantation criteria.
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14
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Yang PC, Akamatsu N, Hasegawa K, Kokudo N. Twenty years of Milan criteria: how far do we go. Hepatobiliary Surg Nutr 2017; 5:488-491. [PMID: 28124004 DOI: 10.21037/hbsn.2016.12.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Po-Chih Yang
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, University of Tokyo, Tokyo, Japan
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15
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Charrière B, Maulat C, Suc B, Muscari F. Contribution of alpha-fetoprotein in liver transplantation for hepatocellular carcinoma. World J Hepatol 2016; 8:881-890. [PMID: 27478538 PMCID: PMC4958698 DOI: 10.4254/wjh.v8.i21.881] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 05/30/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Alpha-fetoprotein (AFP) is the main tumor biomarker available for the management of hepatocellular carcinoma (HCC). Although it is neither a good screening test nor an accurate diagnostic tool for HCC, it seems to be a possible prognostic marker. However, its contribution in liver transplantation for HCC has not been fully determined, although its use to predict recurrence after liver transplantation has been underlined by international societies. In an era of organ shortages, it could also have a key role in the selection of patients eligible for liver transplantation. Yet unanswered questions remain. First, the cut-off value of serum AFP above which liver transplantation should not be performed is still a subject of debate. We show that a concentration of 1000 ng/mL could be an exclusion criterion, whereas values of < 15 ng/mL indicate patients with an excellent prognosis whatever the size and number of tumors. Monitoring the dynamics of AFP could also prove useful. However, evidence is lacking regarding the values that should be used. Today, the real input of AFP seems to be its integration into new criteria to select patients eligible for a liver transplantation. These recent tools have associated AFP values with morphological criteria, thus refining pre-existing criteria, such as Milan, University of California, San Francisco, or “up-to-seven”. We provide a review of the different criteria submitted within the past years. Finally, AFP can be used to monitor recurrence after transplantation, although there is little evidence to support this claim. Future challenges will be to draft new international guidelines to implement the use of AFP as a selection tool, and to determine a clear cut-off value above which liver transplantation should not be performed.
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16
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Hong G, Suh KS, Suh SW, Yoo T, Kim H, Park MS, Choi Y, Paeng JC, Yi NJ, Lee KW. Alpha-fetoprotein and (18)F-FDG positron emission tomography predict tumor recurrence better than Milan criteria in living donor liver transplantation. J Hepatol 2016; 64:852-9. [PMID: 26658686 DOI: 10.1016/j.jhep.2015.11.033] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 10/15/2015] [Accepted: 11/25/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Given the organ shortage for liver transplantation (LT) and the limitations of the current morphology-based selection criteria, improved criteria are needed to achieve the maximum benefit of LT for hepatocellular carcinoma (HCC). We hypothesized that a combination of biological markers may better predict the prognosis than the Milan criteria. METHODS HCC patients (n=123) with preoperative data on serum alpha-fetoprotein (AFP) levels and (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) positivity underwent live-donor LT between January 2003 and December 2009. The cut-off values for serum AFP levels (200 ng/ml) and (18)F-FDG PET positivity (1.10) for tumor recurrence were determined by c-statistics using receiver operating characteristic curves. Univariate and multivariate analyses with preoperative variables were performed to find pre-transplant prognostic factors. Disease-free survival rates and overall survival rates were analysed with regard to serum AFP levels and (18)F-FDG PET positivity. RESULTS The 5-year disease-free survival rates and overall survival rates were 80.3% and 81.6% respectively. (18)F-FDG PET positivity (hazard ratio (HR) 9.766, 95% CI 3.557-26.816; p<0.001) and serum AFP level (HR 6.234, 95% CI 2.643-14.707; p<0.001) were the only significant pre-transplant prognostic factors in the multivariate analysis; tumor number and size were not significant. A combination of criteria showed that the biologically high-risk group (AFP level ⩾200 ng/ml and PET-positive) had an HR of 29.069 (95% CI 8.797-96.053; p<0.001) compared with the double-negative group. Use of the Milan criteria yielded an HR of 1.351 (95% CI 0.500-3.652; p=0.553). CONCLUSIONS The combination of the serum AFP level and (18)F-FDG PET data predicted better outcomes than those using the Milan criteria, improving objectivity when adult-to-adult living donor LT is contemplated.
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Affiliation(s)
- Geun Hong
- Department of Surgery, Ewha Womans University, School of Medicine, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University, College of Medicine, South Korea.
| | - Suk-Won Suh
- Department of Surgery, Seoul National University, College of Medicine, South Korea
| | - Tae Yoo
- Department of Surgery, Seoul National University, College of Medicine, South Korea
| | - Hyeyoung Kim
- Department of Surgery, Seoul National University, College of Medicine, South Korea
| | - Min-Su Park
- Department of Surgery, Seoul National University, College of Medicine, South Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University, College of Medicine, South Korea
| | - Jin Chul Paeng
- Department of Nuclear Medicine, Seoul National University, College of Medicine, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University, College of Medicine, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University, College of Medicine, South Korea
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17
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Soriano A, Varona A, Gianchandani R, Moneva ME, Arranz J, Gonzalez A, Barrera M. Selection of patients with hepatocellular carcinoma for liver transplantation: Past and future. World J Hepatol 2016; 8:58-68. [PMID: 26783421 PMCID: PMC4705453 DOI: 10.4254/wjh.v8.i1.58] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 11/18/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
The aim of liver transplantation (LT) for hepatocellular carcinoma (HCC) is to ensure a rate of disease-free survival similar to that of patients transplanted due to benign disease. Therefore, we are forced to adopt strict criteria when selecting candidates for LT and prioritizing patients on the waiting list (WL), to have clarified indications for bridging therapy for groups at risk for progression or recurrence, and to establish certain limits for downstaging therapies. Although the Milan criteria (MC) remain the standard and most employed criteria for indication of HCC patients for LT by far, in the coming years, criteria will be consolidated that take into account not only data regarding the size/volume and number of tumors but also their biology. This criteria will mainly include the alpha fetoprotein (AFP) values and, in view of their wide variability, any of the published logarithmic models for the selection of candidates for LT. Bridging therapy is necessary for HCC patients on the WL who meet the MC and have the possibility of experiencing a delay for LT greater than 6 mo or any of the known risk factors for recurrence. It is difficult to define single AFP values that would indicate bridging therapy (200, 300 or 400 ng/mL); therefore, it is preferable to rely on the criteria of a French AFP model score > 2. Other single indications for bridging therapy include a tumor diameter greater than 3 cm, more than one tumor, and having an AFP slope greater than 15 ng/mL per month or > 50 ng/mL for three months during strict monitoring while on the WL. When considering the inclusion of patients on the WL who do not meet the MC, it is mandatory to determine their eligibility for downstaging therapy prior to inclusion. The upper limit for this therapy could be one lesion up to 8 cm, 2-3 lesions with a total tumor diameter up to 8 cm, or a total tumor volume of 115 cm3. Lastly, liver allocation and the prioritization of patients with HCC on the WL should take into account the recently described HCC model for end-stage liver disease, which considers hepatic function, HCC size and the number and the log of AFP values. This formula has been calibrated with the survival data of non-HCC patients and produces a dynamic and more accurate assessment model.
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18
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San Miguel C, Vílchez A, Villegas T, Granero KM, Becerra A, López MÁ, Expósito M, Fundora Y. Influence of Waiting List in Recurrence Disease of Hepatocellular Carcinoma. Transplant Proc 2015; 47:2636-8. [PMID: 26680057 DOI: 10.1016/j.transproceed.2015.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 10/04/2015] [Accepted: 10/07/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND We describe the results of our liver transplantation (LT) patients for hepatocellular carcinoma (HCC) in 2004 to 2012 to determine the differences on the basis of time on the waiting list to establish the risk of recurrence of liver disease. METHODS Clinical variables were recorded for both donors and recipients as well as variables of diagnosis, the use of transarterial chemoembolization during the waiting list time (WLT), complications, re-transplantation, and exitus. Fifty-eight patients were analyzed. Mean age was 57 ± 8 years (men, 83%; 48 patients). Viral etiology of HCC was 50% (n = 29); alcoholic, 26% (n = 15); and others, 24% (n = 14). RESULTS Exitus was established in 24 patients (41%); only 5 patients (7%) were attributable to HCC. In the cohort of patients with less than 6 months of WLT, we registered both higher rates of downstaging protocols (10.7% vs 7.5%) and tumor size (3 cm vs 2 cm) compared with the other group. Bivariate studies were conducted according to the WLT (WLT <6 months, WLT ≥6 months), finding differences in recurrence of liver disease (P < .05). This fact was confirmed after a binary logistic regression. CONCLUSIONS Our results in a subgroup of less than 6 months of WLT included patients with increased tumor size or presentation of multiple nodes, with a worse prognosis and therefore to be prioritized in the treatment of LT. Therefore, in our population there is a significant risk of tumor recurrence in patients with less WLT for LT, but it cannot be overestimated to all type of patients with HCC.
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Affiliation(s)
- C San Miguel
- General, Digestive Surgery and Liver Transplantation Department, Virgen de las Nieves University Hospital (University Hospital Centre of Granada), Granada, Spain.
| | - A Vílchez
- General, Digestive Surgery and Liver Transplantation Department, Virgen de las Nieves University Hospital (University Hospital Centre of Granada), Granada, Spain
| | - T Villegas
- General, Digestive Surgery and Liver Transplantation Department, Virgen de las Nieves University Hospital (University Hospital Centre of Granada), Granada, Spain
| | - K M Granero
- General, Digestive Surgery and Liver Transplantation Department, Virgen de las Nieves University Hospital (University Hospital Centre of Granada), Granada, Spain
| | - A Becerra
- General, Digestive Surgery and Liver Transplantation Department, Virgen de las Nieves University Hospital (University Hospital Centre of Granada), Granada, Spain
| | - M Á López
- Hepatology Department, Virgen de las Nieves University Hospital (University Hospital Centre of Granada), Granada, Spain
| | - M Expósito
- Department of Research, Virgen de las Nieves University Hospital (University Hospital Centre of Granada), Granada, Spain
| | - Y Fundora
- General, Digestive Surgery and Liver Transplantation Department, Virgen de las Nieves University Hospital (University Hospital Centre of Granada), Granada, Spain
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Pardo F, Pons JA, Briceño J. V Reunión de Consenso de la Sociedad Española de Trasplante Hepático sobre receptores de riesgo elevado, escenarios actuales de inmunosupresión y manejo del hepatocarcinoma en espera de trasplante. Cir Esp 2015; 93:619-37. [DOI: 10.1016/j.ciresp.2015.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 04/17/2015] [Indexed: 12/11/2022]
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20
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V Reunión de Consenso de la Sociedad Española de Trasplante Hepático sobre receptores de riesgo elevado, escenarios actuales de inmunosupresión y manejo del hepatocarcinoma en espera de trasplante. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:600-18. [DOI: 10.1016/j.gastrohep.2015.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/11/2015] [Accepted: 06/30/2015] [Indexed: 12/14/2022]
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Costa PEG, Vasconcelos JBM, Coelho GR, Barros MAP, Neto BAF, Pinto DSR, Júnior JTV, Correia FGS, Garcia JHP. Ten-year experience with liver transplantation for hepatocellular carcinoma in a Federal University Hospital in the Northeast of Brazil. Transplant Proc 2015; 46:1794-8. [PMID: 25131039 DOI: 10.1016/j.transproceed.2014.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatocellular carcinoma (HCC) is the most frequent and important primary liver tumor, with annual worldwide incidence of over 1 million cases, accounting for at least 500,000 deaths per year. The majority of cases of HCC occur in the setting of liver cirrhosis. In this retrospective, descriptive, and analytical study, between May 2002 and April 2012, 664 liver transplantations (LT) were conducted at a Federal University Hospital in the Northeast of Brazil, among which 140 LT were performed in patients with HCC. The tumor was more frequent in men with an average age of 56 years and infected with hepatitis C virus, many with a history of alcohol abuse. Alpha-fetoprotein was not useful in the diagnosis, and imaging methods have failed to diagnose the nodules in 19 patients (13.6%). Transarterial chemoembolization was the most-used bridging therapy to inhibit tumor growth for patients with HCC eligible for transplantation. The implementation of the Model for End Stage Liver Disease score in 2006 brought benefits to these patients. The rate of HCC recurrence after LT was 8.57% and occurred more often in the first 2 years after transplantation, with the liver graft being the most common site. Significant risk factors for recurrence were a long time on the LT waiting list, number of liver nodules over 3.5, and the presence of vascular invasion. In conclusion, LT for HCC leads to excellent long-term survival, with relatively few patients dying from tumor recurrence.
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Affiliation(s)
- P E G Costa
- Department of Surgery, Federal University of Ceará, Ceará, Brazil.
| | | | - G R Coelho
- Department of Surgery, Federal University of Ceará, Ceará, Brazil
| | - M A P Barros
- Department of Surgery, Federal University of Ceará, Ceará, Brazil
| | - B A F Neto
- Department of Surgery, Federal University of Ceará, Ceará, Brazil
| | - D S R Pinto
- Department of Surgery, Federal University of Ceará, Ceará, Brazil
| | - J T V Júnior
- Department of Pathology, Federal University of Ceará, Ceará, Brazil
| | - F G S Correia
- Department of Community Health, Federal University of Ceará, Ceará, Brazil
| | - J H P Garcia
- Department of Surgery, Federal University of Ceará, Ceará, Brazil
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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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Response to Transarterial Chemoembolization in Candidates With Hepatocellular Carcinoma Within Milan Criteria Does not Predict Post-Transplant Disease-Free Survival. Transplant Proc 2014; 46:1799-802. [DOI: 10.1016/j.transproceed.2014.05.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Kia L, Mulcahy MF, Levitsky J. Find it in your heart. Liver Transpl 2013; 19:567-8. [PMID: 23447370 DOI: 10.1002/lt.23626] [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: 12/13/2012] [Accepted: 01/12/2013] [Indexed: 01/12/2023]
Affiliation(s)
- Leila Kia
- Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL
| | - Mary F. Mulcahy
- Division of Hematology and Oncology; Department of Medicine; Chicago IL
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology; Comprehensive Transplant Center; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL
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Ortiz J, Danniel J, Chavez M, Davogustto G. Monitoring for post-transplant hepatocellular carcinoma recurrence. HPB (Oxford) 2012; 14:351; author reply 352. [PMID: 22487073 PMCID: PMC3384855 DOI: 10.1111/j.1477-2574.2012.00449.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Clavien PA, Lesurtel M, Bossuyt PMM, Gores GJ, Langer B, Perrier A. Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report. Lancet Oncol 2012; 13:e11-22. [PMID: 22047762 PMCID: PMC3417764 DOI: 10.1016/s1470-2045(11)70175-9] [Citation(s) in RCA: 739] [Impact Index Per Article: 61.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although liver transplantation is a widely accepted treatment for hepatocellular carcinoma (HCC), much controversy remains and there is no generally accepted set of guidelines. An international consensus conference was held on Dec 2-4, 2010, in Zurich, Switzerland, with the aim of reviewing current practice regarding liver transplantation in patients with HCC and to develop internationally accepted statements and guidelines. The format of the conference was based on the Danish model. 19 working groups of experts prepared evidence-based reviews according to the Oxford classification, and drafted recommendations answering 19 specific questions. An independent jury of nine members was appointed to review these submissions and make final recommendations, after debates with the experts and audience at the conference. This report presents the final 37 statements and recommendations, covering assessment of candidates for liver transplantation, criteria for listing in cirrhotic and non-cirrhotic patients, role of tumour downstaging, management of patients on the waiting list, role of living donation, and post-transplant management.
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Affiliation(s)
- Pierre-Alain Clavien
- Department of Surgery, Swiss HPB and Transplant Centers, University Hospital Zurich, Zurich, Switzerland.
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Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report. Lancet Oncol 2011. [PMID: 22047762 DOI: 10.1016/s1470-2045(1170175-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Although liver transplantation is a widely accepted treatment for hepatocellular carcinoma (HCC), much controversy remains and there is no generally accepted set of guidelines. An international consensus conference was held on Dec 2-4, 2010, in Zurich, Switzerland, with the aim of reviewing current practice regarding liver transplantation in patients with HCC and to develop internationally accepted statements and guidelines. The format of the conference was based on the Danish model. 19 working groups of experts prepared evidence-based reviews according to the Oxford classification, and drafted recommendations answering 19 specific questions. An independent jury of nine members was appointed to review these submissions and make final recommendations, after debates with the experts and audience at the conference. This report presents the final 37 statements and recommendations, covering assessment of candidates for liver transplantation, criteria for listing in cirrhotic and non-cirrhotic patients, role of tumour downstaging, management of patients on the waiting list, role of living donation, and post-transplant management.
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Clavien PA, Lesurtel M, Bossuyt PMM, Gores GJ, Langer B, Perrier A. Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report. Lancet Oncol 2011. [PMID: 22047762 DOI: 10.1016/s1470-2045(11)70175-9.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although liver transplantation is a widely accepted treatment for hepatocellular carcinoma (HCC), much controversy remains and there is no generally accepted set of guidelines. An international consensus conference was held on Dec 2-4, 2010, in Zurich, Switzerland, with the aim of reviewing current practice regarding liver transplantation in patients with HCC and to develop internationally accepted statements and guidelines. The format of the conference was based on the Danish model. 19 working groups of experts prepared evidence-based reviews according to the Oxford classification, and drafted recommendations answering 19 specific questions. An independent jury of nine members was appointed to review these submissions and make final recommendations, after debates with the experts and audience at the conference. This report presents the final 37 statements and recommendations, covering assessment of candidates for liver transplantation, criteria for listing in cirrhotic and non-cirrhotic patients, role of tumour downstaging, management of patients on the waiting list, role of living donation, and post-transplant management.
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Affiliation(s)
- Pierre-Alain Clavien
- Department of Surgery, Swiss HPB and Transplant Centers, University Hospital Zurich, Zurich, Switzerland.
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