Liver transplantation for hepatocellular carcinoma in the world: the Taiwan experience

Comparing CLIF-C ACLF, CLIF-C ACLFlactate, and CLIF-C ACLF-D Prognostic Scores in Acute-on-Chronic Liver Failure Patients by a Single-Center ICU Experience

Patients with liver cirrhosis have a higher risk of developing acute-on-chronic liver failure (ACLF). Poor prognosis with a high rate of short-term mortality leads to limited opportunities for further liver transplantation. Thus, precise prognostic evaluation of patients with ACLF is necessary before transplant surgery. In this study, a total of one hundred and thirty-five patients with ACLF admitted to the hepato-gastroenterologic intensive care unit (ICU) for intensive monitoring and treatment at Chang-Gung Memorial Hospital (CGMH, Linkou, Taiwan) were screened from November 2012 to April 2015 and tracked until April 2017. Three new prognostic scores of ACLF, including CLIF-C ACLF (Chronic Liver Failure Consortium Acute-on-chronic Liver Failure score), CLIF-C ACLF-D (CLIF-C ACLF Development score), and CLLF-C ACLF_lactate (lactate-adjusted CLIF-C ACLF score) were compared. The primary outcome considered was overall mortality. Mortality predictions at 28, 90, 180, and 365 days were also calculated. By area under the receiver operating characteristic curve (AUROC) analysis, the CLIF-C ACLF and CLIF-C ACLF-D scores were superior to CLIF-C ACLF_lactate scores in predicting 28-day mortality. The CLIF-C ACLF-D score had the highest AUROC in predicting overall mortality as well as at 90, 180, and 365 days. In conclusion, our study demonstrates that CLIF-C ACLF and CLIF-C ACLF-D scores are significant predictors of outcome in critical patients with liver cirrhosis and ACLF. The CLIF-C ACLF-D score may have a superior predictive power for the prediction of 3-month, 6-month, and one-year mortality.

Clinical characteristics and prognosis of HCC occurrence after antiviral therapy for HCV patients between sustained and non-sustained responders

BACKGROUND

Hepatitis C virus (HCV)-infected patients who achieved sustained virologic response (SVR) may still develop hepatocellular carcinoma (HCC). The characteristic of HCC and the prognosis between SVR and non-SVR patients were not well known.

METHODS

Among 1884 HCV-infected patients who were treated with pegylated IFN plus ribavirin therapies, 122 patients developed HCC during follow-up were enrolled in this study. Laboratory data were collected before and at least 1 year after IFN-based therapy, as well as the latest follow-up.

RESULTS

Both SVR and non-SVR patients had similar risk factors to develop HCC, but with a little difference. Liver cirrhosis plays a key role in HCC occurrence in both groups. Among the patients who developed HCC, non-SVR patients had significantly higher total bilirubin, higher FIB-4, lower pre-treatment platelet count, higher pre-treatment AFP levels and higher proportion of cirrhosis than SVR patients before occurrence of HCC. After curative treatment, SVR patients had lower recurrence and longer overall survival than non-SVR patients by Kaplan-Meier analysis. Multivariate analysis revealed that APRI ≥0.7 was the independent risk factor for HCC recurrence; and AFP ≥20 ng/ml post IFN therapy, as well as HCC recurrence were the independent risk factors of mortality.

CONCLUSION

Liver cirrhosis plays a key role in HCC occurrence after antiviral therapies. SVR patients may have lower HCC recurrence and longer survival rates than non-SVR patients. Only APRI was associated with HCC recurrence; and post-IFN AFP and HCC recurrence were predictive of subsequent mortality independently.

Addition of alfa fetoprotein to traditional criteria for hepatocellular carcinoma improves selection accuracy in liver transplantation

OBJECTIVES

Liver transplantation in hepatocellular cancer (HCC) is curative only for a selection of patients. Commonly used criteria are mostly based on tumor size and number. However, patients within criteria do have tumor recurrences after transplantation and patients outside criteria are excluded even though some could benefit from transplantation. The tumor marker alpha fetoprotein (AFP) is associated with poor outcome and has already been reported to improve selection. We investigated the hypothesis that AFP level combined with traditional selection criteria could ameliorate the selection accuracy for liver transplantation in HCC.

MATERIALS AND METHODS

A retrospective national cohort study in 336 patients who had liver transplantation for HCC in Sweden 1996-2014.

RESULTS

AFP cut-off levels of 20, 100, 1000 and >1000 ng/mL stratified both survival and tumor recurrence, with estimated 5-year survival rates of 74, 61, 49 and 31%, respectively. A simple score, combining three risk levels according to Milan and UCSF fulfillment with three levels of AFP, increased predictive accuracy. A high score identified 35 at-risk patients with estimated post-transplant 5-year survival rate of only 29% compared to 50% for 76 patients excluded by UCSF. More patients were within the combined score cut-off compared to within UCSF, but 5-year survival was similar, 67% versus 66%.

CONCLUSION

AFP combined with traditional selection criteria ameliorates the selection accuracy for liver transplantation in HCC.

Liver transplantation for hepatocellular carcinoma from living-donor vs. deceased donor

With the increasing prevalence of living-donor liver transplantation (LDLT), the possible increased recurrence rate of hepatocellular carcinoma (HCC) in LDLT recipients in comparison with deceased-donor liver transplantation (DDLT) recipients has become a matter of debate. The aim of this review is to encompass current opinions and clinical reports regarding differences in the outcome, especially the recurrence of HCC, between LDLT and DDLT. In reviewing literatures, some studies reported increased recurrence rates among LDLT recipients, a majority of authors, including large database studies, reported comparable recurrence-free survival and recurrence rates between LDLT and DDLT. The postulated reasons for the increased recurrence in LDLT were the effect of graft regeneration on tumor progression, fast-tracking of patients into liver transplantation, and the more aggressive tumor characteristics in LDLT, however, many Asian LDLT centers have reported the comparable outcomes with those of DDLT in Western countries, even with the expanded criteria for HCC. In the absence of a prospective study regarding the use of LDLT versus DDLT for HCC patients, there is no evidence to support the higher HCC recurrence after LDLT than DDLT, and LDLT remains a reasonable treatment option for HCC patients with cirrhosis, especially in Asian countries where the number of deceased donor is scarce.

Repeated-measures implication of hepatocellular carcinoma biomarkers in living donor liver transplantation

Objective

Hepatocellular carcinoma (HCC) and its recurrence are major problems in living donor liver transplantation (LDLT). Several biomarkers have been used to investigate this event. We conducted a prospective controlled study to determine the activities of the basic fibroblast growth factor (FGF-2), survivin, Ki67, endostatin, and vascular endothelial growth factor (VEGF) in different conditions before, early after, and late after LDLT with and without HCC recurrence.

Methods

Fifty patients with virus-related HCC who underwent LDLT were enrolled in this 2-year cross-sectional study. During the study period, recurrent HCC was identified in 9 patients (study group, n = 9) and 41 patients (control group, n = 41) had no recurrence after LDLT. The mean time to HCC recurrence was 587.11 ± 398.64 days (range, 90–1352 days). Microvascular invasion (MVI) was found in 66.7% (6/9) of the recipients, as determined on pathological examination. The serum biomarkers were investigated by using enzyme-linked immunosorbent assay at the different LDLT stages.

Results

The serum levels of the biomarkers significantly correlated with LDLT and HCC recurrence in the repeated-measures analysis (F = 31.676, P = 0.000). Significant differences were observed in the effects of all biomarkers (F = 85.313, P = 0.000) and the time to HCC recurrence after LDLT (F = 3.178, P = 0.046). The biomarkers, ordered by the observed power of the test for HCC recurrence after LDLT, were FGF-2 (1.000) > survivin (0.999) > Ki67 (0.949) > endostatin (0.411) > VEGF (0.305).

Conclusions

Different biomarker activities may be implicated in the pathogenesis of HCC recurrence after LDLT. Oncogenes may not exist in the new graft but may still be present in the peripheral blood. The timing of HCC recurrence and impact of MVI in the explanted liver requires confirmation in larger studies with a longer follow-up.

Liver transplantation for hepatocellular carcinoma

Hepatitis B is endemic in many regions of Asia, including China, Korea and India. This results in a heavy burden of hepatocellular carcinoma (HCC) because hepatitis B virus is a major risk factor in the development of the disease. In addition, the incidence of hepatitis-C-related HCC is on the rise in the United States. HCC patients with poor liver function reserve are not suitable candidates for resection, and liver transplantation (LT) has emerged as the treatment of choice for small unresectable HCCs. To treat more HCC patients with LT, the standard patient selection criteria have been expanded at a number of centers. Careful and well-considered selection of patients is the key to success in LT for HCC. Although tumor size and tumor number are used to predict whether transplantation is likely to be successful, the weighting that should be attached these two parameters has not been determined. In addition to the size and number of lesions, the morphology of HCC is also predictive of its behavior. Well-circumscribed lesions, in general, are less aggressive than those with poorly defined borders. On the waiting list for LT, HCC patients compete with liver failure patients. It is essential that the criteria used for selecting HCC patients for LT should be easily applicable and fair to other transplant candidates. In the face of the scarcity of deceased-donor livers and the inevitable risks for living liver donors, a predictably low rate of recurrence of HCC after LT is mandatory.

Impact of preoperative α-fetoprotein level on disease-free survival after liver transplantation for hepatocellular carcinoma

BACKGROUND

Preoperative α-fetoprotein (AFP) levels may have an influence on disease-free survival (DFS) of patients after liver transplantation for hepatocellular carcinoma (HCC) located on a cirrhotic liver.

METHODS

Between 2000 and 2009, two groups were distinguished according to preoperative AFP level: normal-level group (<10 ng/ml) and increased-level group (>10 ng/ml). The increased-level group was further divided into three levels of preoperative AFP: 10-150, 150-500, and ≥ 500 ng/ml. DFS and recurrence rates were compared. All patients underwent transplantation using the preoperative 5/5 criteria.

RESULTS

Of the 122 patients in this study, 63 had normal and 59 had increased preoperative AFP. There were no differences between the two groups concerning perioperative or pathologic data. Those with an increased preoperative AFP level had a significantly shorter 5-year DFS, and their recurrence rate was higher than that of the normal AFP group. The 5-year DFS and recurrence rates were 71 and 4 %, respectively, for those with normal AFP; 57 and 10 %, respectively, for those with AFP 10-150 ng/ml; 46 and 24 %, respectively, for those with AFP 150-500 ng/ml; and 28 and 62 %, respectively, for those with AFP ≥ 500 ng/ml.

CONCLUSIONS

This study shows the prognostic value of preoperative AFP levels on DFS after a liver transplant for HCC in a population of patients undergoing transplantation with the same preoperative criteria.

Systematic review: the prognostic role of alpha-fetoprotein following liver transplantation for hepatocellular carcinoma

BACKGROUND

Liver transplantation (LT) offers a possible cure for carefully selected patients with hepatocellular carcinoma (HCC). Studies report that preoperative alpha-fetoprotein (AFP) is a prognostic indicator that can predict survival and recurrence in these patients.

AIM

To undertake a systematic review of available literature on preoperative AFP as a predictor of survival and recurrence following LT for HCC.

METHODS

A literature search was performed using Medline, Embase, Cochrane Library, CINAHL and Google scholar databases to identify studies reporting AFP as a prognostic marker in LT for HCC. Primary outcomes of interest were overall survival and recurrence. Secondary outcomes were correlation of pre-LT AFP with vascular invasion and grade of tumour differentiation.

RESULTS

A total of 13 studies met the inclusion criteria (12,159 patients). The majority were male (9603, 78.9%). All were observational studies and only one prospective. Methodological quality was rated as poor for all studies, with selection and observer bias apparent for most cohorts. Reported survival rates and recurrence rates varied widely between the studies although overall demonstrated better outcomes for those with lower (<1000 ng/mL) pre-LT AFP levels. Similarly, rates of vascular invasion and poor tumour differentiation were higher in those with high pre-LT AFP levels.

CONCLUSIONS

A quantity of AFP >1000 ng/mL is associated with poorer outcomes from liver transplantation for hepatocellular carcinoma. The quality of studies was generally poor and precluded valid statistical meta-analysis. There is a need to improve the performance and reporting of primary prognostic studies to facilitate high quality systematic review and meta-analysis.