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Vitale A, Famularo S, Giannini EG. Methods and Statistical Analysis in a Study of Liver Resection vs Nonsurgical Treatments for Hepatocellular Carcinoma-Reply. JAMA Surg 2024:2824189. [PMID: 39320865 DOI: 10.1001/jamasurg.2024.3928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Affiliation(s)
- Alessandro Vitale
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, Second General Surgical Unit, Padova Teaching Hospital, Padua, Italy
| | - Simone Famularo
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- Gastroenterology Unit, IRCCS Ospedale San Martino, Genoa, Italy
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2
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Vitale A, Trapani S, Russo FP, Miele L, Svegliati Baroni G, Marchesini G, Burra P, Ottoveggio MS, Romagnoli R, Martini S, De Simone P, Carrai P, Cescon M, Morelli MC, De Carlis L, Belli L, Gruttadauria S, Volpes R, Colledan M, Fagiuoli S, Di Benedetto F, De Maria N, Rossi G, Caccamo L, Donato F, Vennarecci G, Di Costanzo GG, Vivarelli M, Carraro A, Sacerdoti D, Ettorre GM, Giannelli V, Agnes S, Gasbarrini A, Rossi M, Ginanni Corradini S, Mazzaferro V, Bhoori S, Manzia TM, Lenci I, Zamboni F, Mameli L, Baccarani U, Toniutto P, Lupo LG, Tandoi F, Rendina M, Andorno E, Giannini EG, Spada M, Billato I, Marchini A, Romano P, Brancaccio G, D'Amico F, Ricci A, Cardillo M, Cillo U. Waiting list mortality and 5-year transplant survival benefit of patients with MASLD: An Italian liver transplant registry study. JHEP Rep 2024; 6:101147. [PMID: 39282226 PMCID: PMC11399673 DOI: 10.1016/j.jhepr.2024.101147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 09/18/2024] Open
Abstract
Background & Aims International consensus has recently introduced a new definition of metabolic dysfunction-associated steatotic liver disease (MASLD). We sought to analyse epidemiological trends, prognostic features, and transplant survival benefits of patients with MASLD and without MASLD waiting for liver transplantation (LT) in Italy. Methods Using the Italian Liver Transplant Registry database, we analysed data from adult patients listed for primary LT attributable to end-stage chronic liver disease between January 2012 and December 2022. Independent multivariable waiting lists and post-transplant survival models were developed for patients with and without hepatocellular carcinoma (HCC). A Monte Carlo simulation was used to create 5-year transplant benefit distributions based on the presence of MASLD, HCC, and model for end-stage liver disease (MELD)-sodium values. Results A total sample of 1,941 patients with MASLD and 11,201 patients without MASLD was considered. A significant increase in the prevalence of MASLD as an indication for LT was observed from 2012 to 2022, for both cohorts with HCC (from 17.7 to 30%) and without HCC (from 9.5 to 11.8%) cohorts. Projections suggest that, as early as next year, MASLD will overcome HCV as the second most common indication for transplantation after alcoholic liver disease in Italy. According to univariate and multivariate analyses, MASLD was not an independent predictive factor for patient survival after transplantation. However, it increased the risk of death for patients on the waiting list without HCC (hazard ratio 1.62, p <0.001). At the same MELD-sodium, the 5-year transplant benefit was higher in patients with non-HCC MASLD, followed by patients with HCC, whereas it was lower in patients without HCC and without MASLD. Conclusions Patients with non-HCC MASLD had an increased waitlist mortality and 5-year transplant survival benefit compared with other candidates. Impact and implications The present research addresses the critical need to understand the evolving landscape of liver transplantation indications, mainly focusing on metabolic dysfunction-associated steatotic liver disease (MASLD) in Italy. Given the significant rise in MASLD cases, these findings highlight that patients with non-HCC MASLD face increased waitlist mortality and benefit more from liver transplantation within 5 years compared with other candidates. The significance of these results lies in their emphasis on the necessity of focusing on patients with MASLD on waiting lists to improve outcomes. By tailoring transplant eligibility criteria and resource allocation, the study provides actionable insights to improve patient survival and optimise liver transplantation practices.
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Affiliation(s)
- Alessandro Vitale
- Azienda Ospedale-Università Di Padova, Università di Padova, Padova, Italy
| | - Silvia Trapani
- Centro Nazionale Trapianti, Istituto Superiore Di Sanitá, Italy
| | | | - Luca Miele
- Fondazione Policlinico Gemelli Irccs, Università Cattolica Del Sacro Cuore, Rome, Italy
| | | | - Giulio Marchesini
- Department of Medical and Surgical Sciences, Alma Mater University, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Patrizia Burra
- Azienda Ospedale-Università Di Padova, Università di Padova, Padova, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Salvatore Agnes
- Fondazione Policlinico Gemelli Irccs, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Antonio Gasbarrini
- Fondazione Policlinico Gemelli Irccs, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Massimo Rossi
- Sapienza Università Di Roma, Policlinico Umberto I, Rome, Italy
| | | | | | - Sherrie Bhoori
- Istituto Nazionale Tumori Milan and University of Milan, Milan, Italy
| | | | | | | | | | - Umberto Baccarani
- Dipartimento Di Area Medica, Università Degli Studi di Udine, Udine, Italy
| | - Pierluigi Toniutto
- Dipartimento Di Area Medica, Università Degli Studi di Udine, Udine, Italy
| | | | | | | | | | | | | | - Ilaria Billato
- Azienda Ospedale-Università Di Padova, Università di Padova, Padova, Italy
| | - Andrea Marchini
- Azienda Ospedale-Università Di Padova, Università di Padova, Padova, Italy
| | - Pierluigi Romano
- Azienda Ospedale-Università Di Padova, Università di Padova, Padova, Italy
| | | | - Francesco D'Amico
- Azienda Ospedale-Università Di Padova, Università di Padova, Padova, Italy
| | - Andrea Ricci
- Centro Nazionale Trapianti, Istituto Superiore Di Sanitá, Italy
| | | | - Umberto Cillo
- Azienda Ospedale-Università Di Padova, Università di Padova, Padova, Italy
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Cabibbo G, Daniele B, Borzio M, Casadei-Gardini A, Cillo U, Colli A, Conforti M, Dadduzio V, Dionisi F, Farinati F, Gardini I, Giannini EG, Golfieri R, Guido M, Mega A, Minozzi S, Piscaglia F, Rimassa L, Romanini L, Pecorelli A, Sacco R, Scorsetti M, Viganò L, Vitale A, Trevisani F. Multidisciplinary Treatment of Hepatocellular Carcinoma in 2023: Italian practice Treatment Guidelines of the Italian Association for the Study of the Liver (AISF), Italian Association of Medical Oncology (AIOM), Italian Association of Hepato-Bilio-Pancreatic Surgery (AICEP), Italian Association of Hospital Gastroenterologists (AIGO), Italian Association of Radiology and Clinical Oncology (AIRO), Italian Society of Pathological Anatomy and Diagnostic Cytology (SIAPeC-IAP), Italian Society of Surgery (SIC), Italian Society of Gastroenterology (SIGE), Italian Society of Medical and Interventional Radiology (SIRM), Italian Organ Transplant Society (SITO), and Association of Patients with Hepatitis and Liver Disease (EpaC) - Part I - Surgical treatments. Dig Liver Dis 2024; 56:223-234. [PMID: 38030455 DOI: 10.1016/j.dld.2023.10.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/07/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
Worldwide, hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death. The remarkable improvements in treating HCC achieved in the last years have increased the complexity of HCC management. Following the need to have updated guidelines on the multidisciplinary treatment management of HCC, the Italian Scientific Societies involved in the management of this cancer have promoted the drafting of a new dedicated document. This document was drawn up according to the GRADE methodology needed to produce guidelines based on evidence. Here is presented the first part of guidelines, focused on the multidisciplinary tumor board of experts and surgical treatments of HCC.
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Affiliation(s)
- Giuseppe Cabibbo
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties PROMISE, University of Palermo, Italy; Gastroenterology Unit, Azienda Ospedaliera Universitaria Policlinico "Paolo Giaccone", Palermo, Italy.
| | - Bruno Daniele
- Oncology Unit, Ospedale del Mare, ASL Napoli 1 Centro, Napoli, Italy
| | - Mauro Borzio
- Centro Diagnostico Italiano (CDI), Milano, Italy
| | - Andrea Casadei-Gardini
- Department of Oncology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy
| | - Umberto Cillo
- General Surgery 2-Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Padua University Hospital, 35128 Padua, Italy
| | - Agostino Colli
- Dipartimento di Medicina Trasfusionale ed Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Vincenzo Dadduzio
- Medical Oncology Unit, "Mons. A.R.Dimiccoli" Hospital, Barletta, ASL BT, Italy
| | - Francesco Dionisi
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute - Rome, Italy
| | - Fabio Farinati
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; Gastroenterology Unit, Azienda Ospedale-Università di Padova, 35128 Padova, Italy
| | - Ivan Gardini
- EpaC Onlus, Italian Liver Patient Association, Turin, Italy
| | - Edoardo Giovanni Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Rita Golfieri
- Alma Mater Studiorum" Bologna University, Bologna, Italy; Radiology Unit Madre Fortunata Toniolo Private Hospital, coordinator of Radiology centers Medipass Bologna, Bologna, Italy
| | - Maria Guido
- Department of Medicine, University of Padova, Padova- Italy
| | - Andrea Mega
- Department of Gastronterology, Regional Hospital Bolzano, Italy
| | - Silvia Minozzi
- Oncology Department, Istituto di Ricerche Farmacologiche Mario Negri, IRCCS, Milano, Italy
| | - Fabio Piscaglia
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy; Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Laura Romanini
- Radiology Unit, Ospedale di Cremona, ASST Cremona, Cremona, Italy
| | - Anna Pecorelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Rodolfo Sacco
- Gastroenterology and Endoscopy Unit, Department of Surgical and Medical Sciences, University of Foggia, 71100 Foggia, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital IRCCS, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Luca Viganò
- Hepatobiliary Unit, Department of Minimally Invasive General & Oncologic Surgery, Humanitas Gavazzeni University Hospital, Viale M. Gavazzeni 21, 24125 Bergamo, Italy; Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090 Milan, Italy
| | - Alessandro Vitale
- General Surgery 2-Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Padua University Hospital, 35128 Padua, Italy
| | - Franco Trevisani
- Department of Medical and Surgical Sciences, University of Bologna, Italy; Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy.
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Giannini EG. Proper assessment and prognostication of patients with hepatocellular carcinoma. Clin Liver Dis (Hoboken) 2024; 23:e0129. [PMID: 38455237 PMCID: PMC10919536 DOI: 10.1097/cld.0000000000000129] [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: 12/19/2023] [Accepted: 01/09/2024] [Indexed: 03/09/2024] Open
Affiliation(s)
- Edoardo G. Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- Department of Internal Medicine, Digestive Diseases Section, Liver Center, Yale University School of Medicine, New Haven, Connecticut, USA
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Angelico R, Siragusa L, Serenari M, Scalera I, Kauffman E, Lai Q, Vitale A. Rescue liver transplantation after post-hepatectomy acute liver failure: A systematic review and pooled analysis. Transplant Rev (Orlando) 2023; 37:100773. [PMID: 37356212 DOI: 10.1016/j.trre.2023.100773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure is a severe complication after major liver resection and is associated with a high mortality rate. Nevertheless, there is no effective treatment for severe liver failure. In such a setting, rescue liver transplantation (LT) is used only in extraordinary cases with unclear results. This systematic review aims to define indication of LT in post-hepatectomy liver failure and post-LT outcomes, in terms of patient and disease-free survivals, to assess the procedure's feasibility and effectiveness. METHODS A systematic review of all English language full-text articles published until September 2022 was conducted. Inclusion criteria were articles describing patients undergoing LT for post-hepatectomy liver failure after liver resection, which specified at least one outcome of interest regarding patient/graft survival, postoperative complications, tumour recurrence and cause of death. A pseudo-individual participant data meta-analysis was performed to analyse data. Study quality was assessed with MINORS system. PROSPERO CRD42022349358. RESULTS Postoperative complication rate was 53.6%. All patients transplanted for benign indications survived. For malignant tumours, 1-, 3- and 5-year overall survival was 94.7%, 82.1% and 74.6%, respectively. The causes of death were tumour recurrence in 83.3% of cases and infection-related in 16.7% of LT recipients. At Cox regression, being transplanted for unconventional malignant indications (colorectal liver metastasis, cholangiocarcinoma) was a risk factor for death HR = 8.93 (95%CI = 1.04-76.63; P-value = 0.046). Disease-free survival differs according to different malignant tumours (P-value = 0.045). CONCLUSIONS Post-hepatectomy liver failure is an emergent indication for rescue LT, but it is not universally accepted. In selected patients, LT can be a life-saving procedure with low short-term risks. However, special attention must be given to long-term oncological prognosis before proceeding with rescue LT in an urgent setting, considering the severity of liver malignancy, organ scarcity, the country's organ allocation policies and the resource of living-related donation.
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Affiliation(s)
- Roberta Angelico
- Department of Surgical Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, 00133 Rome, Italy.
| | - Leandro Siragusa
- Department of Surgical Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Matteo Serenari
- General Surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy; Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Irene Scalera
- Unità di Chirurgia Epatobiliare e Trapianti di Fegato, Azienda Ospedaliero Universitaria -Consorziale Policlinico di Bari, Bari, Italy
| | - Emanuele Kauffman
- Division of General and Transplant Surgery, Pisa University, Pisa, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, AUO Policlinico I of Rome, Rome, Italy
| | - Alessandro Vitale
- Department of Surgical Oncological and Gastroenterological Sciences, Padua University, Padua, Italy
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Di Martino M, Ferraro D, Pisaniello D, Arenga G, Falaschi F, Terrone A, Maniscalco M, Galeota Lanza A, Esposito C, Vennarecci G. Bridging therapies for patients with hepatocellular carcinoma awaiting liver transplantation: A systematic review and meta-analysis on intention-to-treat outcomes. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:429-438. [PMID: 36207763 DOI: 10.1002/jhbp.1248] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/16/2022] [Accepted: 09/08/2022] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Locoregional therapies are commonly used as bridging strategies to decrease the drop-out of patients with hepatocellular carcinoma (HCC) awaiting liver transplantation (LT). The present paper aims to assess the outcomes of bridging therapies in patients with HCC considered for LT according to an intention-to-treat (ITT) survival analysis. MATERIAL AND METHODS Medline and Web of Science databases were searched for reports published before May 2021. Papers assessing adult patients with HCC considered for LT and reporting ITT survival outcomes were included. Two reviewers independently identified, extracted the data, and evaluated the papers according to Newcastle-Ottawa criteria. Outcomes analyzed were: drop-out rate; time on the waiting list; 1-, 3-, and 5-year survival after LT and based on an ITT analysis. RESULTS The search identified 3106 records; six papers (1043 patients) met the inclusion criteria. Patients with HCC, listed for LT and submitted to bridging therapies presented a longer waiting time before LT (MD 3.77, 95% CI 2.07-5.48) in comparison with the non-interventional group. However, they presented a raised post LT after 1-year (OR 2.00, 95% CI 1.18-3.41), 3-years (OR 1.47, 95% CI 1.01-2.15), and 5-years (OR 1.50, 95% CI 1.06-2.13) survival. CONCLUSION Patients submitted to bridging procedures, despite having a longer interval on the waiting list, presented better post-LT survival outcomes. Bridging therapies for selected patients at low risk of post-procedural complications and long expected intervals on the waiting list should be encouraged. However, further clinical trials should confirm the survival benefit of bridging therapies in patients with HCC listed for LT.
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Affiliation(s)
- Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
- Division of Haepatology, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Daniele Ferraro
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Donatella Pisaniello
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Giuseppe Arenga
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Federica Falaschi
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Alfonso Terrone
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Marilisa Maniscalco
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Alfonso Galeota Lanza
- Division of Haepatology, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Ciro Esposito
- Liver Intesive Care Unit, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Giovanni Vennarecci
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
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Zhang X, Cai L, Fang J, Chen F, Pan F, Zhang K, Huang Q, Huang Y, Li D, Lv L, Chen M, Yan R, Lai Y, Peng Y, Wu Z. Efficacy and safety of transarterial chemoembolization plus sorafenib in patients with recurrent hepatocellular carcinoma after liver transplantation. Front Oncol 2023; 12:1101351. [PMID: 36713526 PMCID: PMC9880524 DOI: 10.3389/fonc.2022.1101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023] Open
Abstract
Objectives To explore the benefit and safety of transarterial chemoembolization (TACE) in combination with sorafenib in patients with recurrent hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT). Methods In this multi-center retrospective study, 106 patients with recurrent HCC after OLT were included. Fifty-two patients were treated with TACE plus sorafenib (TS group) and 54 were treated with TACE alone (TC group). Primary and secondary endpoints including overall survival (OS) and progression-free survival (PFS), and safety were assessed. Results The median OS (17 vs 10 months, P=0.035) and PFS (12 vs 6 months, P=0.004) in the TS group were longer than those in the TC group. On multivariate analysis, BCLC stage (HR [hazard ratio]=0.73 [95% CI, 0.27-0.99], P=0.036) and sorafenib medication (HR=2.26 [95% CI, 1.35-3.69], P=0.01) were identified as independent prognostic risk factors for OS. No severe adverse events related to sorafenib were noted in the TS group. Four patients discontinued sorafenib due to intolerance. Conclusion TACE in combination with sorafenib is a feasible regimen to improve the survival with mild toxicity in patients with recurrent HCC after OLT.
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Affiliation(s)
- Xia Zhang
- Department of Hepatobiliary Disease, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Lirong Cai
- Department of Hepatobiliary Disease, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Jian Fang
- Department of Hepatobiliary Disease, The Third People’s Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Fengsui Chen
- Department of Hepatobiliary Disease, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Fan Pan
- Department of Hepatobiliary Surgery, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Kun Zhang
- Department of Hepatobiliary Surgery, Xiang’an Hospital, Xiamen University, Xiamen, China
| | - Qian Huang
- Department of Hepatobiliary Surgery, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Yuju Huang
- Department of Hepatobiliary Disease, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Dongliang Li
- Department of Hepatobiliary Disease, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Lizhi Lv
- Department of Hepatobiliary Surgery, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Man Chen
- Department of Hepatobiliary Disease, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Ruiying Yan
- Department of Hepatobiliary Disease, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Yanhua Lai
- Department of Transplantation, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China,*Correspondence: Zhixian Wu, ; Yonghai Peng, ; Yanhua Lai,
| | - Yonghai Peng
- Department of Oncology, the 900th Hospital of Joint Logistics Support Force, Fujian Medica University, Fuzhou, China,*Correspondence: Zhixian Wu, ; Yonghai Peng, ; Yanhua Lai,
| | - Zhixian Wu
- Department of Hepatobiliary Disease, the 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China,*Correspondence: Zhixian Wu, ; Yonghai Peng, ; Yanhua Lai,
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Textbook Outcome of Laparoscopic Microwave Ablation for Hepatocellular Carcinoma. Cancers (Basel) 2023; 15:cancers15020436. [PMID: 36672385 PMCID: PMC9856576 DOI: 10.3390/cancers15020436] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/28/2022] [Accepted: 01/07/2023] [Indexed: 01/11/2023] Open
Abstract
In the context of spreading interest in textbook outcome (TO) evaluation in different fields, we aimed to investigate an uncharted procedure, that is, laparoscopic microwave ablation (MWA) for hepatocellular carcinoma (HCC). Absence of post-MWA complications, a hospital stay of three days, no mortality nor readmission within 30 days, and complete response of the target lesion at post-MWA CT scan defined TO achievement. Patients treated between January 2014 and March 2021 were retrospectively reviewed, and of the 521 patients eligible for the study, 337 (64.7%) fulfilled all the quality indicators to achieve the TO. The absence of complications was the main limiting factor for accomplishing TO. At multivariable analysis, Child-Pugh B cirrhosis, age of more than 70 years old, three nodules, and MELD score ≥ 15 were associated with decreased probabilities of TO achievement. A score based on these factors was derived from multivariable analysis, and patients were divided into three risk groups for TO achievement. At survival analysis, overall survival (OS) was significantly (p = 0.001) higher in patients who achieved TO than those who did not. Moreover, OS evaluation in the three risk groups showed a trend coherent with TO achievement probability. The present study, having assessed the first TO for laparoscopic MWA for HCC, encourages further broader consensus on its definition and, on its basis, on the development of clinically relevant tools for managing treatment allocation.
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Vitale A, Svegliati-Baroni G, Ortolani A, Cucco M, Dalla Riva GV, Giannini EG, Piscaglia F, Rapaccini G, Di Marco M, Caturelli E, Zoli M, Sacco R, Cabibbo G, Marra F, Mega A, Morisco F, Gasbarrini A, Foschi FG, Missale G, Masotto A, Nardone G, Raimondo G, Azzaroli F, Vidili G, Oliveri F, Pelizzaro F, Ramirez Morales R, Cillo U, Trevisani F, Miele L, Marchesini G, Farinati F. Epidemiological trends and trajectories of MAFLD-associated hepatocellular carcinoma 2002-2033: the ITA.LI.CA database. Gut 2023; 72:141-152. [PMID: 34933916 DOI: 10.1136/gutjnl-2021-324915] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/29/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Metabolic dysfunction-associated fatty liver disease (MAFLD) represents a new inclusive definition of the whole spectrum of liver diseases associated to metabolic disorders. The main objective of this study was to compare patients with MAFLD and non-MAFLD with hepatocellular carcinoma (HCC) included in a nationally representative cohort. METHODS We analysed 6882 consecutive patients with HCC enrolled from 2002 to 2019 by 23 Italian Liver Cancer centres to compare epidemiological and future trends in three subgroups: pure, single aetiology MAFLD (S-MAFLD); mixed aetiology MAFLD (metabolic and others, M-MAFLD); and non-MAFLD HCC. RESULTS MAFLD was diagnosed in the majority of patients with HCC (68.4%). The proportion of both total MAFLD and S-MAFLD HCC significantly increased over time (from 50.4% and 3.6% in 2002-2003, to 77.3% and 28.9% in 2018-2019, respectively, p<0.001). In Italy S-MAFLD HCC is expected to overcome M-MAFLD HCC in about 6 years. Patients with S-MAFLD HCC were older, more frequently men and less frequently cirrhotic with clinically relevant portal hypertension and a surveillance-related diagnosis. They had more frequently large tumours and extrahepatic metastases. After weighting, and compared with patients with non-MAFLD, S-MAFLD and M-MAFLD HCC showed a significantly lower overall (p=0.026, p=0.004) and HCC-related (p<0.001, for both) risk of death. Patients with S-MAFLD HCC showed a significantly higher risk of non-HCC-related death (p=0.006). CONCLUSIONS The prevalence of MAFLD HCC in Italy is rapidly increasing to cover the majority of patients with HCC. Despite a less favourable cancer stage at diagnosis, patients with MAFLD HCC have a lower risk of HCC-related death, suggesting reduced cancer aggressiveness.
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Affiliation(s)
- Alessandro Vitale
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Gianluca Svegliati-Baroni
- Liver Disease and Transplant Unit, Polytechnic University of Marche, Ancona, Italy
- Obesity Center, Polytechnic University of Marche, Ancona, Italy
| | - Alessio Ortolani
- Department of Gastroenterology, Azienda Ospedaliera Marche Nord Pesaro, Pesaro, Italy
| | - Monica Cucco
- Liver Disease and Transplant Unit, Polytechnic University of Marche, Ancona, Italy
- Department of Gastroenterology, Polytechnic University of Marche, Ancona, Italy
| | - Giulio V Dalla Riva
- School of Mathematics and Statistics University of Canterbury, Statistics University of Canterbury, Canterbury, New Zealand
| | - Edoardo G Giannini
- Department of Internal Medicine, Gastroenterology Unit, University of Genova, IRCCS Policlinico San Martino, Genoa, Italy
| | - Fabio Piscaglia
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gianludovico Rapaccini
- Gastroenterology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | | | | | - Marco Zoli
- Department of Medical and Surgical Sciences, Internal Medicine-Zoli Unit, Alma Mater Studiorum - Università di Bologna, Padova, Italy
| | - Rodolfo Sacco
- Gastroenterology and Digestive Endoscopy Unit, Foggia University Hospital, Foggia, Puglia, Italy
| | - Giuseppe Cabibbo
- Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, PROMISE, Gastroenterology & Hepatology Unit, University of Palermo, Palermo, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, Internal Medicine and Hepatology Unit, University of Florence, Florence, Italy
| | - Andrea Mega
- Gastroenterology Unit, Ospedale Generale Regionale di Bolzano, Bolzano, Italy
| | - Filomena Morisco
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University of Naples Federico II, Portici, Italy
| | - Antonio Gasbarrini
- Internal Medicine, Gastroenterology, and Liver Unit, University Hospital Agostino Gemelli, Roma, Lazio, Italy
| | | | - Gabriele Missale
- Infectious Diseases and Hepatology Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Alberto Masotto
- Gastroenterology Unit, IRCCS Ospedale Sacro Cuore Don Calabria, Negrar, Veneto, Italy
| | - Gerardo Nardone
- Department of Clinical Medicine and Surgery, Hepato-Gastroenterology Unit, Federico II University Hospital, Napoli, Italy
| | - Giovanni Raimondo
- Clinical and Experimental Medicine, University Hospital of Messina, Messina, Italy
| | - Francesco Azzaroli
- Division of Gastroenterology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gianpaolo Vidili
- Department of Clinical and Experimental Medicine, Universita degli Studi di Sassari, Sassari, Italy
| | - Filippo Oliveri
- Department of Clinical and Experimental Medicine, Hepatology and Liver Physiopathology Laboratory and Internal Medicine, University of Pisa, Pisa, Italy
| | - Filippo Pelizzaro
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Rafael Ramirez Morales
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Franco Trevisani
- Division of Medical Semeiotics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Miele
- Internal Medicine and Gastroenterology, Fondazione Policlinico Gemelli, Rome, Italy
- Internal Medicine, Universita Cattolica del Sacro Cuore, Roma, Italy
| | - Giulio Marchesini
- Department of Medical & Surgical Sciences, University of Bologna Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Fabio Farinati
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
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10
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Di Martino M, Vitale A, Ferraro D, Maniscalco M, Pisaniello D, Arenga G, Falaschi F, Terrone A, Iacomino A, Galeota Lanza A, Esposito C, Cillo U, Vennarecci G. Downstaging Therapies for Patients with Hepatocellular Carcinoma Awaiting Liver Transplantation: A Systematic Review and Meta-Analysis on Intention-to-Treat Outcomes. Cancers (Basel) 2022; 14:5102. [PMID: 36291885 PMCID: PMC9600776 DOI: 10.3390/cancers14205102] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Locoregional therapies (LRTs) are commonly used to increase the number of potential candidates for liver transplantation (LT). The aim of this paper is to assess the outcomes of LRTs prior to LT in patients with hepatocellular carcinoma (HCC) beyond the listing criteria. Methods: In accordance with the PRISMA guidelines, we searched the Medline and Web of Science databases for reports published before May 2021. We included papers assessing adult patients with HCC considered for LT and reporting intention-to-treat (ITT) survival outcomes. Two reviewers independently identified and extracted the data and evaluated the papers. Outcomes analysed were drop-out rate; time on the waiting list; and 1, 3 and 5 year survival after LT and based on an ITT analysis. Results: The literature search yielded 3,106 records, of which 11 papers (1874 patients) met the inclusion criteria. Patients with HCC beyond the listing criteria and successfully downstaged presented a higher drop-out rate (OR 2.05, 95% CI 1.45−2.88, p < 0.001) and a longer time from the initial assessment to LT than those with HCC within the listing criteria (MD 1.93, 95% CI 0.91−2.94, p < 0.001). The 1, 3 and 5 year survival post-LT and based on an ITT analysis did not show significant differences between the two groups. Patients with HCC beyond the listing criteria, successfully downstaged and then transplanted, presented longer 3 year (OR 3.77, 95% CI 1.26−11.32, p = 0.02) and 5 year overall survival (OS) (OR 3.08, 95% CI 1.15−8.23, p = 0.02) in comparison with those that were not submitted to LT. Conclusions: Patients with HCC beyond the listing criteria undergoing downstaging presented a higher drop-out rate in comparison with those with HCC within the listing criteria. However, the two groups did not present significant differences in 1, 3 and 5 year survival rates based on an ITT analysis. Patients with HCC beyond the listing, when successfully downstaged and transplanted, presented longer 3 and 5-year OS in comparison with those who were not transplanted.
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Affiliation(s)
- Marcello Di Martino
- Department of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, 80128 Napoli, Italy
| | - Alessandro Vitale
- Department of Surgical, Oncological and Gastroenterological Sciences, Padova University, 35121 Padova, Italy
| | - Daniele Ferraro
- Department of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, 80128 Napoli, Italy
| | - Marilisa Maniscalco
- Department of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, 80128 Napoli, Italy
| | - Donatella Pisaniello
- Department of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, 80128 Napoli, Italy
| | - Giuseppe Arenga
- Department of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, 80128 Napoli, Italy
| | - Federica Falaschi
- Department of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, 80128 Napoli, Italy
| | - Alfonso Terrone
- Department of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, 80128 Napoli, Italy
| | - Alessandro Iacomino
- Department of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, 80128 Napoli, Italy
- Department of Surgical, Oncological and Gastroenterological Sciences, Padova University, 35121 Padova, Italy
| | | | - Ciro Esposito
- Liver Intesive Care Unit, Department of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, 80128 Napoli, Italy
| | - Umberto Cillo
- Department of Surgical, Oncological and Gastroenterological Sciences, Padova University, 35121 Padova, Italy
| | - Giovanni Vennarecci
- Department of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, 80128 Napoli, Italy
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11
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Finotti M, Vitale A, Gringeri E, D'Amico FE, Boetto R, Bertacco A, Lonardi S, Bergamo F, Feltracco P, Cillo U. Colon Rectal Liver Metastases: The Role of the Liver Transplantation in the Era of the Transplant Oncology and Precision Medicine. Front Surg 2021; 8:693387. [PMID: 34355016 PMCID: PMC8329096 DOI: 10.3389/fsurg.2021.693387] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022] Open
Abstract
The development of liver metastases in colon rectal cancer has a strong impact on the overall survival (OS) of the patient, with a 5-year survival rate of 5% with palliative treatment. Surgical resection combined with pharmacological treatment can achieve a 5-year OS rate of 31-58%. However, in only 20% of patients with colon rectal liver metastases (CRLMs), liver resection is feasible. In highly selected patients, recent trials and studies proved that liver transplantation (LT) for non-resectable CRLM is a surgical option with an excellent long-term OS. The paper aims to review the indications and outcome of LT for CRLMs, with a special focus on immunosuppressive therapy and the management of local and extrahepatic recurrence after LT.
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Affiliation(s)
- Michele Finotti
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
| | - Alessandro Vitale
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
| | - Enrico Gringeri
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
| | | | - Riccardo Boetto
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
| | - Alessandra Bertacco
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
| | - Sara Lonardi
- Unit of Oncology 1, Department of Oncology, Veneto Institute of Oncology IOV - Istituto di Ricovero e Cura a Carattere Scientifico, Padua, Italy
| | - Francesca Bergamo
- Unit of Oncology 1, Department of Oncology, Veneto Institute of Oncology IOV - Istituto di Ricovero e Cura a Carattere Scientifico, Padua, Italy
| | - Paolo Feltracco
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - Umberto Cillo
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
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12
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Sustained Complete Response after Biological Downstaging in Patients with Hepatocellular Carcinoma: XXL-Like Prioritization for Liver Transplantation or "Wait and See" Strategy? Cancers (Basel) 2021; 13:cancers13102406. [PMID: 34067521 PMCID: PMC8156031 DOI: 10.3390/cancers13102406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/22/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary The XXL trial has recently shown that biological downstaging is an effective strategy to also allow liver transplantation into patients with more advanced hepatocellular carcinoma without alternative curative options. Some potential limits of the XXL downstaging protocol are (a) the rather high downstaging failure rate (i.e., 32%), and (b) the additional prioritization of transplantation for patients with a potential good prognosis without transplant, i.e., those obtaining a complete response to downstaging. In this study, we showed that, using aggressive surgical downstaging, it is possible to considerably decrease the downstaging failure rate. Moreover, we showed that it is possible to avoid an immediate prioritization of transplantation for patients with a sustained complete response to downstaging by applying a “wait and see” policy. This policy seems to spare a relevant number of organs without worsening patient outcome. Abstract The XXL trial represents the first prospective validation of “biological downstaging” in liver transplantation (LT) for hepatocellular carcinoma. The aim of this study was to compare the Padua downstaging protocol to the XXL protocol in terms of downstaging failure rates and patient outcome. A total of 191 patients undergoing aggressive surgical downstaging and potentially eligible for LT from 2012 to 2018 at our center were retrospectively selected according to XXL trial criteria. Unlike the XXL trial, patients with a complete response to downstaging did not receive any prioritization for LT. Downstaging failure was defined as stable progressive disease or post-treatment mortality. The statistical method of “matching-adjusted indirect comparison” was used to match the study group to the XXL population. Downstaging failure rate was considerably lower in the study group than in the XXL trial (12% vs. 32%, d value = |0.683|). The survival curves of our LT group (n = 68) overlapped with those of the LT-XXL group (p = 0.846). Survival curves of non-LT candidates with a sustained complete response (n = 64) were similar to those of transplanted patients (p = 0.281). Our study represents a validation of the current Padua and Italian policies of denying rapid prioritization to patients with complete response to downstaging. Such a policy seems to spare organs without worsening patient outcome.
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13
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Overview of Prognostic Systems for Hepatocellular Carcinoma and ITA.LI.CA External Validation of MESH and CNLC Classifications. Cancers (Basel) 2021; 13:cancers13071673. [PMID: 33918125 PMCID: PMC8037197 DOI: 10.3390/cancers13071673] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 02/07/2023] Open
Abstract
Prognostic assessment in patients with HCC remains an extremely difficult clinical task due to the complexity of this cancer where tumour characteristics interact with degree of liver dysfunction, patient general health status, and a large span of available treatment options. Several prognostic systems have been proposed in the last three decades, both from the Asian and European/North American countries. Prognostic scores, such as the CLIP score and the recent MESH score, have been generated on a solid statistical basis from real life population data, while staging systems, such as the BCLC scheme and the recent CNLC classification, have been created by experts according to recent HCC prognostic evidences from the literature. A third category includes combined prognostic systems that can be used both as prognostic scores and staging systems. A recent example is the ITA.LI.CA prognostic system including either a prognostic score and a simplified staging system. This review focuses first on an overview of the main prognostic systems for HCC classified according to the above three categories, and, second, on a comprehensive description of the methodology required for a correct comparison between different systems in terms of prognostic performance. In this second section the main studies in the literature comparing different prognostic systems are described in detail. Lastly, a formal comparison between the last prognostic systems proposed for each of the above three categories is performed using a large Italian database including 6882 HCC patients in order to concretely apply the comparison rules previously described.
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14
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Cillo U, Vitale A, Volk ML, Frigo AC, Feltracco P, Cattelan A, Brancaccio G, Feltrin G, Angeli P, Burra P, Lonardi S, Trapani S, Cardillo M. Liver Transplantation for T2 Hepatocellular Carcinoma during the COVID-19 Pandemic: A Novel Model Balancing Individual Benefit against Healthcare Resources. Cancers (Basel) 2021; 13:cancers13061416. [PMID: 33808790 PMCID: PMC8003429 DOI: 10.3390/cancers13061416] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 12/22/2022] Open
Abstract
Simple Summary Using Italian national data from more than 8000 patients, we proposed a novel model calculating the net benefit of liver transplantation (individual benefit minus harm to others on the waiting list) in T2 hepatocellular carcinoma (HCC) patients in different scenarios of transplant activity reduction. Our results show that the transplant net benefit is closely related to the decrease in the number of organs, but it is also higher in T2 HCC patients than in non-HCC patients with the same model for end-stage liver disease (MELD) scores. Our model supports liver transplantation for T2 HCC with the highest net benefit also during crises such as COVID-19. Abstract The COVID-19 pandemic caused temporary drops in the supply of organs for transplantation, leading to renewed debate about whether T2 hepatocellular carcinoma (HCC) patients should receive priority during these times. The aim of this study was to provide a quantitative model to aid decision-making in liver transplantation for T2 HCC. We proposed a novel ethical framework where the individual transplant benefit for a T2 HCC patient should outweigh the harm to others on the waiting list, determining a “net benefit”, to define appropriate organ allocation. This ethical framework was then translated into a quantitative Markov model including Italian averages for waiting list characteristics, donor resources, mortality, and transplant rates obtained from a national prospective database (n = 8567 patients). The net benefit of transplantation in a T2 HCC patient in a usual situation varied from 0 life months with a model for end-stage liver disease (MELD) score of 15, to 34 life months with a MELD score of 40, while it progressively decreased with acute organ shortage during a pandemic (i.e., with a 50% decrease in organs, the net benefit varied from 0 life months with MELD 30, to 12 life months with MELD 40). Our study supports the continuation of transplantation for T2 HCC patients during crises such as COVID-19; however, the focus needs to be on those T2 HCC patients with the highest net survival benefit.
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Affiliation(s)
- Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgical, Oncological, and Gastroenterological Sciences, Padua University Hospital, 35128 Padua, Italy;
| | - Alessandro Vitale
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgical, Oncological, and Gastroenterological Sciences, Padua University Hospital, 35128 Padua, Italy;
- Correspondence: ; Tel.: +39-335-8247-099
| | - Michael L. Volk
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, CA 92354, USA;
| | - Anna Chiara Frigo
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy;
| | - Paolo Feltracco
- Section of Anesthesiology and Intensive Care, Department of Medicine—DIMED, Padua University Hospital, 35128 Padua, Italy;
| | - Annamaria Cattelan
- Infectious Diseases Unit, Department of Internal Medicine, Padua University Hospital, 35128 Padua, Italy; (A.C.); (G.B.)
| | - Giuseppina Brancaccio
- Infectious Diseases Unit, Department of Internal Medicine, Padua University Hospital, 35128 Padua, Italy; (A.C.); (G.B.)
| | | | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Padua University Hospital, 35128 Padua, Italy;
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy;
| | - Sara Lonardi
- Veneto Oncologic Institute, IRCCS, 35128 Padua, Italy;
| | - Silvia Trapani
- Italian National Transplant Center, Italian National Institute of Health, 00118 Rome, Italy; (S.T.); (M.C.)
| | - Massimo Cardillo
- Italian National Transplant Center, Italian National Institute of Health, 00118 Rome, Italy; (S.T.); (M.C.)
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15
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Pelizzaro F, Vitale A, Sartori A, Vieno A, Penzo B, Russo FP, Frigo AC, Giannini EG, Piccinnu M, Rapaccini GL, Di Marco M, Caturelli E, Zoli M, Sacco R, Celsa C, Marra F, Mega A, Guarino M, Gasbarrini A, Svegliati-Baroni G, Foschi FG, Olivani A, Masotto A, Coccoli P, Raimondo G, Azzaroli F, Vidili G, Brunetto MR, Trevisani F, Farinati F. Surveillance as Determinant of Long-Term Survival in Non-Transplanted Hepatocellular Carcinoma Patients. Cancers (Basel) 2021; 13:897. [PMID: 33672751 PMCID: PMC7924561 DOI: 10.3390/cancers13040897] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/18/2021] [Indexed: 02/07/2023] Open
Abstract
PURPOSE We aimed at assessing the impact of surveillance on long-term survival in HCC patients. METHODS From the ITA.LI.CA database, we selected 1028 cases with long (≥5 years, LS group) and 2721 controls with short-term survival (<5 years, SS group). The association between surveillance and LS was adjusted for confounders by multivariable logistic regression analysis. Survival of surveilled patients was presented both as observed and corrected for the lead-time bias, and the comparison of survival between surveillance and no surveillance groups was also performed after balancing the baseline characteristics with inverse probability weights (IPW). RESULTS LS patients were more frequently diagnosed under surveillance (p < 0.0001), and had more favorable baseline characteristics. Surveillance was an independent predictor of LS (OR = 1.413, 95% CI 1.195-1.671; p < 0.0001). The observed and the lead-time corrected survival of surveilled patients were significantly longer compared to the survival of not surveilled patients (p < 0.0001 and p = 0.0008, respectively). In IPW adjusted populations, no survival differences were demonstrated between the two groups (p = 0.30). CONCLUSIONS Surveillance, increasing early-stage diagnosis and applicability of curative treatments, is a fundamental determinant of long-term survival in HCC patients. A wide implementation of surveillance programs should be pursued in order to improve HCC patients' prognosis.
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Affiliation(s)
- Filippo Pelizzaro
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (A.S.); (A.V.); (B.P.); (F.P.R.)
| | - Alessandro Vitale
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy;
| | - Anna Sartori
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (A.S.); (A.V.); (B.P.); (F.P.R.)
| | - Andrea Vieno
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (A.S.); (A.V.); (B.P.); (F.P.R.)
| | - Barbara Penzo
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (A.S.); (A.V.); (B.P.); (F.P.R.)
| | - Francesco Paolo Russo
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (A.S.); (A.V.); (B.P.); (F.P.R.)
| | - Anna Chiara Frigo
- Biostatistics Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy;
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genova, IRCCS Policlinico San Martino, 16132 Genova, Italy;
| | - Manuela Piccinnu
- Internal Medicine–Piscaglia Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy;
| | - Gian Ludovico Rapaccini
- Gastroenterology Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy;
| | - Maria Di Marco
- Medicine Unit, Bolognini Hospital, 24068 Seriate, Italy;
| | | | - Marco Zoli
- Internal Medicine–Zoli Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy;
| | - Rodolfo Sacco
- Gastroenterology and Digestive Endoscopy Unit, Foggia University Hospital, 71122 Foggia, Italy;
| | - Ciro Celsa
- Gastroenterology & Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, PROMISE, University of Palermo, 90133 Palermo, Italy;
| | - Fabio Marra
- Internal Medicine and Hepatology Unit, Department of Experimental and Clinical Medicine, University of Firenze, 50121 Firenze, Italy;
| | - Andrea Mega
- Gastroenterology Unit, Bolzano Regional Hospital, 39100 Bolzano, Italy;
| | - Maria Guarino
- Gastroenterology Unit, Department of Clinical Medicine and Surgery, University of Napoli “Federico II”, 80138 Napoli, Italy;
| | - Antonio Gasbarrini
- Internal Medicine and Gastroenterology Unit, Policlinico Gemelli, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | | | | | - Andrea Olivani
- Infectious Diseases and Hepatology Unit, Azienda Ospedaliero-Universitaria di Parma, 43126 Parma, Italy;
| | - Alberto Masotto
- Gastroenterology Unit, Ospedale Sacro Cuore Don Calabria, 37024 Negrar, Italy;
| | - Pietro Coccoli
- Hepato-Gastroenterology Unit, Department of Clinical Medicine and Surgery, University of Napoli “Federico II”, 80138 Napoli, Italy;
| | - Giovanni Raimondo
- Clinical and Molecular Hepatology Unit, Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Francesco Azzaroli
- Gastroenterology Unit, Department of Surgical and Medical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy;
| | - Gianpaolo Vidili
- Clinica Medica Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Azienda Ospedaliero-Universitaria di Sassari, 07100 Sassari, Italy;
| | - Maurizia Rossana Brunetto
- Department of Clinical and Experimental Medicine, Hepatology and Liver Physiopathology Laboratory and Internal Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Franco Trevisani
- Medical Semeiotics Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Fabio Farinati
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; (F.P.); (A.S.); (A.V.); (B.P.); (F.P.R.)
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16
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Ballı T, Ülkü A. Hepatosellüler karsinomada bridging veya downstaging sonrası karaciğer transplantasyonu ile direkt transplantasyon stratejilerinin sağkalım üzerine etkilerinin karşılaştırılması. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.552485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Vitale A, Lai Q. Selection of patients with hepatocellular cancer: a difficult balancing between equity, utility, and benefit. Transl Gastroenterol Hepatol 2017; 2:75. [PMID: 29034348 DOI: 10.21037/tgh.2017.09.04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 09/03/2017] [Indexed: 12/16/2022] Open
Abstract
Although liver transplantation (LT) represents the gold-standard strategy for hepatocellular cancer (HCC), its use is circumscribed by several factors like donor shortage, perioperative complications, or competition with other candidates without HCC. Moreover, different alternative approaches like resection or loco-regional therapies may be attempted in selected cases. The best option for the treatment of an HCC patient is a complex decision, involving several ethical principles including: equity (horizontal equity and vertical equity or urgency), and utility. These principles influence the different phases of the patient selection process for LT: inscription in the waiting list (WL), deciding upon patient priority and drop-out before LT, allocating the liver donor to the best matched recipient. The best end-point for describing the principle of utility is the "transplant benefit" (TB). This concept expresses the survival gain obtained comparing LT with the best alternative therapies (i.e., difference between life years obtained with and without LT). The TB used with a mid-term time horizon (post-transplant 5-10 years), has the intrinsic potential to reach the dignity of an independent LT selection principle. Thus, the present review investigates the role of organ allocation using a TB model with the intent to introduce equity among patients transplanted having HCC or non-tumoral diseases.
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Affiliation(s)
- Alessandro Vitale
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua; Italy
| | - Quirino Lai
- Liver Transplant and Hepatobiliary Surgery Unit, Sapienza University of Rome, Rome, Italy
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Menahem B, Lubrano J, Duvoux C, Mulliri A, Alves A, Costentin C, Mallat A, Launoy G, Laurent A. Liver transplantation versus liver resection for hepatocellular carcinoma in intention to treat: An attempt to perform an ideal meta-analysis. Liver Transpl 2017; 23:836-844. [PMID: 28295992 DOI: 10.1002/lt.24758] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/17/2017] [Indexed: 12/14/2022]
Abstract
This meta-analysis compared the effects of liver transplantation (LT) and liver resection (LR) on overall survival (OS) and disease-free survival (DFS) in patients with hepatocellular carcinoma (HCC) small transplantable HCC or within Milan criteria. Articles comparing LR with LT for HCC, based on Milan criteria or small size, published up to June 2015 were selected, and a meta-analysis was performed. No randomized controlled trial has been published to date comparing survival outcomes in patients with HCC who underwent LR and LT. Nine studies were identified, including 570 patients who underwent LR and 861 who underwent LT. For HCC within the Milan criteria, the 1-year OS rates following LR and LT were 84.5% (473/560) and 84.4% (710/841), respectively (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.71-1.33; P = 0.8), and the 5-year OS rates were 47.9% (273/570) and 59.3% (509/858), respectively (OR, 0.60; 95% CI, 0.35-1.02; P = 0.06). One-year DFS rates were similar (OR, 1.00; 95% CI, 0.39-2.61; P = 1.00), whereas the 3-year DFS rate was significantly lower in the LR group (54.4%, 210/386) than in the LT group (74.2%, 317/427; OR, 0.24; 95% CI, 0.07-0.80; P = 0.02), and the 5-year DFS rate was significantly lower for LR than LT (OR, 0.18; 95% CI, 0.06-0.53; P < 0.01). For small HCCs, the 5-year OS rate was significantly lower for patients who underwent LR than LT (OR, 0.30; 95% CI, 0.19-0.48; P < 0.001). In conclusion, relative to LR, LT in patients with HCC meeting the Milan criteria had no benefits before 10 years for OS. For DFS, the benefit is obtained after 3 years. Liver Transplantation 23 836-844 2017 AASLD.
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Affiliation(s)
- Benjamin Menahem
- Department of Digestive Surgery, University Hospital of Caen, Caen, France.,Normandie Université, UNICAEN, CEA, Centre National de la Recherche Scientifique, Centre Hospitalier Universitaire Caen, INSERM Unités Mixtes de Recherche 1086, Centre François Baclesse, Caen, France
| | - Jean Lubrano
- Department of Digestive Surgery, University Hospital of Caen, Caen, France.,Normandie Université, UNICAEN, CEA, Centre National de la Recherche Scientifique, Centre Hospitalier Universitaire Caen, INSERM Unités Mixtes de Recherche 1086, Centre François Baclesse, Caen, France
| | - Christophe Duvoux
- Department of Hepatology, University Hospital of Henri Mondor, Créteil, France
| | - Andrea Mulliri
- Department of Digestive Surgery, University Hospital of Caen, Caen, France
| | - Arnaud Alves
- Department of Digestive Surgery, University Hospital of Caen, Caen, France
| | - Charlotte Costentin
- Department of Hepatology, University Hospital of Henri Mondor, Créteil, France
| | - Ariane Mallat
- Department of Hepatology, University Hospital of Henri Mondor, Créteil, France
| | - Guy Launoy
- Normandie Université, UNICAEN, CEA, Centre National de la Recherche Scientifique, Centre Hospitalier Universitaire Caen, INSERM Unités Mixtes de Recherche 1086, Centre François Baclesse, Caen, France
| | - Alexis Laurent
- Department of Hepatobiliary Surgery and Liver Transplantation, University Hospital of Henri Mondor, Créteil, France.,Unité INSERM U 1855, University Hospital of Henri Mondor, Créteil, France
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19
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Cillo U, Vitale A, Polacco M, Fasolo E. Liver transplantation for hepatocellular carcinoma through the lens of transplant benefit. Hepatology 2017; 65:1741-1748. [PMID: 28010048 DOI: 10.1002/hep.28998] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 11/29/2016] [Accepted: 12/12/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padua, Italy
| | - Alessandro Vitale
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padua, Italy
| | - Marina Polacco
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padua, Italy
| | - Elisa Fasolo
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padua, Italy
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20
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Akamatsu N, Cillo U, Cucchetti A, Donadon M, Pinna AD, Torzilli G, Kokudo N. Surgery and Hepatocellular Carcinoma. Liver Cancer 2016; 6:44-50. [PMID: 27995087 PMCID: PMC5159722 DOI: 10.1159/000449344] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The optimal surgical strategy for hepatocellular carcinoma (HCC) is under active debate. Bio-markers of the liver functional reserve as well as volumetric analysis of the future liver remnant are essential for safe liver resection of HCC. The present algorithms applied to surgical strategies for HCC are not ideal because many patients who could potentially undergo safe resection are deemed liver transplant candidates in Western countries, whereas the opposite is the case in Eastern countries. In addition, there is too much focus on expanded criteria for patients with HCC to undergo liver transplantation. The transplantation benefit for patients with HCC should be considered based not only on the individual's benefit, but also on the effect of other patients waiting for LT for other indications.
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Affiliation(s)
- Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Organ Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Umberto Cillo
- Unità di Chirurgia Epatobiliare e Trapianto Epatico, Azienda Ospedaliera, Università di Padova, Padova, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences, DIMEC; S. Orsola, Malpighi Hospital; Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Matteo Donadon
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas University and Humanitas Research Hospital, Milan, Italy
| | - Antonio Daniele Pinna
- Department of Medical and Surgical Sciences, DIMEC; S. Orsola, Malpighi Hospital; Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Guido Torzilli
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas University and Humanitas Research Hospital, Milan, Italy
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Organ Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan,*Norihiro Kokudo, MD, PhD Hepato-Pancreatico-Biliary Surgery Division, and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655 (Japan), Tel. +81 3 5800 8841, E-Mail
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21
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Abstract
The main goal of organ allocation systems is to guarantee an equal access to the limited resource of liver grafts for every patients on the waiting list, balancing between the ethical principles of equity, utility, benefit, need, and fairness. The European heath care scenario is very complex, as it is essentially decentralized and each Nation and Regions inside the nation, operate on a significant degree of autonomy. Furthermore the epidemiology of liver diseases and HCC, which is different among European countries, clearly inpacts on indications and priorities. The aims of this review are to analyze liver allocation policies for hepatocellular carcinoma, among different European. The European area considered for this analysis included 5 macro-areas or countries, which have similar policies for liver sharing and allocation: Centro Nazionale Trapianti (CNT) in Italy; Eurotransplant (Germany, the Netherlands, Belgium, Luxembourg, Austria, Hungary, Slovenia, and Croatia); Organizacion Nacional de Transplantes (ONT) in Spain; Etablissement français des Greffes (EfG) in France; NHS Blood & Transplant (NHSBT) in the United Kingdom and Ireland; Scandiatransplant (Sweden, Norway, Finland, Denmark, and Iceland). Each identified area, as network for organ sharing in Europe, adopts an allocation system based either on a policy center oriented or on a policy patient oriented. Priorization of patients affected by HCC in the waiting list for deceased donors liver transplant worldwide is dominated by 2 main principles: urgency and utility. Despite the absence of a common organs allocation policy over the Eurpean countries, long-term survival patients listed for transplant due to HCC are comparable to the long-term survival reported in the UNOS register. However, as the principles of allocation are being re-discussed and new proposals emerge, and the epidemiology of liver disease changes, an effort toward a common system is highly advisable.
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22
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Yegin EG, Oymaci E, Karatay E, Coker A. Progress in surgical and nonsurgical approaches for hepatocellular carcinoma treatment. Hepatobiliary Pancreat Dis Int 2016; 15:234-56. [PMID: 27298100 DOI: 10.1016/s1499-3872(16)60097-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a complex and heterogeneous malignancy, frequently occurs in the setting of a chronically diseased organ, with multiple confounding factors making its management challenging. HCC represents one of the leading causes of cancer-related mortality globally with a rising trend of incidence in some of the developed countries, which indicates the need for better surgical and nonsurgical management strategies. DATA SOURCES PubMed database was searched for relevant articles in English on the issue of HCC management. RESULTS Surgical resection represents a potentially curative option for appropriate candidates with tumors detected at earlier stages and with well-preserved liver function. The long-term outcome of surgery is impaired by a high rate of recurrence. Surgical approaches are being challenged by local ablative therapies such as radiofrequency ablation and microwave ablation in selected patients. Liver transplantation offers potential cure for HCC and also correction of underlying liver disease, and minimizes the risk of recurrence, but is reserved for patients within a set of criteria proposed for a prudent allocation in the shortage of donor organs. Transcatheter locoregional therapies have become the palliative standard allowing local control for intermediate stage patients with noninvasive multinodular or large HCC who are beyond the potentially curative options. The significant survival benefit with the multikinase inhibitor sorafenib for advanced HCC has shifted the direction of research regarding systemic treatment toward molecular therapies targeting the disregulated pathways of hepatocarcinogenesis. Potential benefit is suggested from simultaneous or sequential multimodal therapies, and optimal combinations are being investigated. Despite the striking progress in preclinical studies of HCC immunotherapy and gene therapy, extensive clinical trials are required to achieve successful clinical applications of these innovative approaches. CONCLUSION Treatment decisions have become increasingly complex for HCC with the availability of multiple surgical and nonsurgical therapeutic options and require a comprehensive, multidisciplinary approach.
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Affiliation(s)
- Ender Gunes Yegin
- Department of Gastroenterology, Bozyaka Training and Research Hospital, Izmir 35170, Turkey.
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23
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Vitale A, Farinati F, Burra P, Trevisani F, Giannini EG, Ciccarese F, Piscaglia F, Rapaccini GL, Di Marco M, Caturelli E, Zoli M, Borzio F, Cabibbo G, Felder M, Sacco R, Morisco F, Missale G, Foschi FG, Gasbarrini A, Svegliati Baroni G, Virdone R, Chiaramonte M, Spolverato G, Cillo U. Utility-based criteria for selecting patients with hepatocellular carcinoma for liver transplantation: A multicenter cohort study using the alpha-fetoprotein model as a survival predictor. Liver Transpl 2015; 21:1250-8. [PMID: 26183802 DOI: 10.1002/lt.24214] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/20/2015] [Accepted: 06/03/2015] [Indexed: 02/07/2023]
Abstract
The lifetime utility of liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) is still controversial. The aim of this study was to ascertain when LT is cost-effective for HCC patients, with a view to proposing new transplant selection criteria. The study involved a real cohort of potentially transplantable Italian HCC patients (n = 2419 selected from the Italian Liver Cancer group database) who received nontransplant therapies. A non-LT survival analysis was conducted, the direct costs of therapies were calculated, and a Markov model was used to compute the cost utility of LT over non-LT therapies in Italian and US cost scenarios. Post-LT survival was calculated using the alpha-fetoprotein (AFP) model on the basis of AFP values and radiological size and number of nodules. The primary endpoint was the net health benefit (NHB), defined as LT survival benefit in quality-adjusted life years minus incremental costs (US $)/willingness to pay. The calculated median cost of non-LT therapies per patient was US $53,042 in Italy and US $62,827 in the United States. On Monte Carlo simulation, the NHB of LT was always positive for AFP model values ≤ 3 and always negative for values > 7 in both countries. A multivariate model showed that nontumor variables (patient's age, Child-Turcotte-Pugh [CTP] class, and alternative therapies) had the potential to shift the AFP model threshold of LT cost-ineffectiveness from 3 to 7. LT proved always cost-effective for HCC patients with AFP model values ≤ 3, whereas the cost-ineffectiveness threshold ranged between 3 and 7 using nontumor variables.
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Affiliation(s)
- Alessandro Vitale
- Dipartimento di Chirurgia Generale e Trapianto d'Organo, Unità di Chirurgia Epatobiliare e Trapianti Epatici, Università di Padova, Padova, Italy
| | - Fabio Farinati
- Divisione di Gastroenterologia, Azienda Università di Padova, Padova, Italy
| | - Patrizia Burra
- Divisione di Gastroenterologia, Azienda Università di Padova, Padova, Italy
| | - Franco Trevisani
- Unità di Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, Università di Bologna, Bologna, Italy
| | - Edoardo G Giannini
- Dipartimento di Medicina, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, Università di Bologna, Bologna, Italy
| | | | - Fabio Piscaglia
- Divisione di Chirurgia, Policlinico San Marco, Zingonia, Italy
| | - Gian Lodovico Rapaccini
- Unità di Medicina Interna e Gastroenterologia, Complesso Integrato Columbus, Università Cattolica di Roma, Roma, Italy
| | - Mariella Di Marco
- Divisione di Medicina, Azienda Ospedaliera Bolognini, Seriate, Italy
| | - Eugenio Caturelli
- Unità Operativa di Gastroenterologia, Ospedale Belcolle, Viterbo, Italy
| | - Marco Zoli
- Divisione di Chirurgia, Policlinico San Marco, Zingonia, Italy
| | - Franco Borzio
- Dipartimento di Medicina, Unità di Radiologia, Ospedale Fatebenefratelli, Milano, Italy
| | - Giuseppe Cabibbo
- Dipartimento Biomedico di Medicina Interna e Specialistica, Unità di Gastroenterologia, Università di Palermo, Palermo, Italy
| | - Martina Felder
- Ospedale Regionale di Bolzano, Unità di Gastroenterologia, Bolzano, Italy
| | - Rodolfo Sacco
- Unità Operativa Gastroenterologia e Malattie del Ricambio, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Filomena Morisco
- Dipartimento di Medicina Clinica e Chirurgia, Unità di Gastroenterologia, Università di Napoli Federico II, Napoli, Italy
| | - Gabriele Missale
- Unità di Malattie Infettive ed Epatologia, Azienda Ospedaliero, Universitaria di Parma, Parma, Italy
| | | | - Antonio Gasbarrini
- Unità di Medicina Interna e Gastroenterologia, Policlinico Gemelli, Università Cattolica di Roma, Roma, Italy
| | | | - Roberto Virdone
- Dipartimento Biomedico di Medicina Interna e Specialistica, Unità di Medicina Interna 2, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Maria Chiaramonte
- Unità di Gastroenterologia, Ospedale Sacro Cuore Don Calabria, Negrar, Italy
| | - Gaya Spolverato
- Dipartimento di Chirurgia Generale e Trapianto d'Organo, Unità di Chirurgia Epatobiliare e Trapianti Epatici, Università di Padova, Padova, Italy
| | - Umberto Cillo
- Dipartimento di Chirurgia Generale e Trapianto d'Organo, Unità di Chirurgia Epatobiliare e Trapianti Epatici, Università di Padova, Padova, Italy
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24
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Cillo U, Burra P, Mazzaferro V, Belli L, Pinna AD, Spada M, Nanni Costa A, Toniutto P. A Multistep, Consensus-Based Approach to Organ Allocation in Liver Transplantation: Toward a "Blended Principle Model". Am J Transplant 2015; 15:2552-61. [PMID: 26274338 DOI: 10.1111/ajt.13408] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 05/01/2015] [Accepted: 05/09/2015] [Indexed: 02/06/2023]
Abstract
Since Italian liver allocation policy was last revised (in 2012), relevant critical issues and conceptual advances have emerged, calling for significant improvements. We report the results of a national consensus conference process, promoted by the Italian College of Liver Transplant Surgeons (for the Italian Society for Organ Transplantation) and the Italian Association for the Study of the Liver, to review the best indicators for orienting organ allocation policies based on principles of urgency, utility, and transplant benefit in the light of current scientific evidence. MELD exceptions and hepatocellular carcinoma were analyzed to construct a transplantation priority algorithm, given the inequity of a purely MELD-based system for governing organ allocation. Working groups of transplant surgeons and hepatologists prepared a list of statements for each topic, scoring their quality of evidence and strength of recommendation using the Centers for Disease Control grading system. A jury of Italian transplant surgeons, hepatologists, intensivists, infectious disease specialists, epidemiologists, representatives of patients' associations and organ-sharing organizations, transplant coordinators, and ethicists voted on and validated the proposed statements. After carefully reviewing the statements, a critical proposal for revising Italy's current liver allocation policy was prepared jointly by transplant surgeons and hepatologists.
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Affiliation(s)
- U Cillo
- Hepatobiliary Surgery and Liver Transplant Center, Padova University Hospital, Padova, Italy
| | - P Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - V Mazzaferro
- Hepato-Pancreatic-Biliary Surgery and Oncology National Cancer Institute (Istituto Nazionale Tumori), Milan, Italy
| | - L Belli
- Department of Hepatology and Gastroenterology, Niguarda Hospital, Milan, Italy
| | - A D Pinna
- Department of General Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - M Spada
- Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center in Italy, Palermo, Italy
| | | | - P Toniutto
- Medical Liver Transplant Section, Department of Medical Sciences Experimental and Clinical, University of Udine, Udine, Italy
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Vitale A, Volk M, Cillo U. Urgency, utility, and time horizon of transplant benefit. Liver Transpl 2015; 21:565-6. [PMID: 25641699 DOI: 10.1002/lt.24082] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 12/22/2014] [Indexed: 02/07/2023]
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Toso C, Mazzaferro V, Bruix J, Freeman R, Mentha G, Majno P. Toward a better liver graft allocation that accounts for candidates with and without hepatocellular carcinoma. Am J Transplant 2014; 14:2221-7. [PMID: 25220672 DOI: 10.1111/ajt.12923] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 06/13/2014] [Accepted: 07/06/2014] [Indexed: 01/25/2023]
Abstract
In some countries where the Model for End-Stage Liver Disease (MELD) score is used for graft allocation, selected patients with hepatocellular carcinoma (HCC) receive a fixed number of exception points at listing, and increasing priority on the list by accruing additional exception points at regular time intervals. This system originally aimed at balancing the risks of HCC patients of developing contraindications and of non-HCC patients of dying before transplantation, is not ideal because it appears to offer an advantage to HCC patients, regardless of tumor characteristics and response to loco-regional treatment. Scores modulated by HCC characteristics have been proposed. They are based on a more refined estimate of the risk of pretransplant drop-out or of the posttransplant transplant benefit expressed as the life-years gained for each graft. This review describes the newly proposed systems, and discusses their advantages and drawbacks. We believe that the current exception points allocation should be revised and that drop-out-equivalent or transplant benefit-equivalent models should be studied further. As with all policy changes, these should be done under close monitoring that allows subsequent revisions.
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Affiliation(s)
- C Toso
- Division of Transplant and Abdominal Surgery, Department of Surgery, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland; Hepato-Pancreato-Biliary Centre, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
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27
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Vitale A, Huo TL, Cucchetti A, Lee YH, Volk M, Frigo AC, Cescon M, Tuci F, Pinna AD, Cillo U. Survival Benefit of Liver Transplantation Versus Resection for Hepatocellular Carcinoma: Impact of MELD Score. Ann Surg Oncol 2014; 22:1901-7. [PMID: 25234023 DOI: 10.1245/s10434-014-4099-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND We sought to measure the impact of model for end stage liver disease (MELD) score, tumor staging, and microvascular invasion (MVI) on the relative survival benefit of liver transplantation (LT) versus liver resection (LR) for hepatocellular carcinoma (HCC). METHODS The study population comprised 1,106 HCC patients with cirrhosis undergoing LR from one Eastern (n = 424) and two Western (n = 682) surgical units. Exclusion criteria were very large (>10 cm) tumors, macrovascular invasion, and metastases. We identified three tumor stages: stage I (within Milan, n = 806), stage II (beyond Milan within Up-to-7, n = 123), and stage III (beyond Milan and Up-to-7, n = 177). Patient survival after LR was compared to that predicted after LT by the Metroticket calculator in relationship with staging, MVI, and MELD score using Monte Carlo simulation. RESULTS Two hundred eighty-three patients (26 %) with a MELD score of ≥10 had an acceptable 5-year survival after LR of 47 %, while that of patients with a low MELD score was 67 % (p < 0.0001). Mean 5-year LT benefit was -4.50 months (95 % confidence interval [CI] -4.73 to -4.27) for patients with a MELD score of <10, and 0.81 months (95 % CI 0.58 to 1.04) for those with a MELD score of ≥10. MELD score and MVI were the strongest predictors of transplant survival benefit. LT reached a survival benefit, versus LR only in HCC patients with a MELD score of ≥10 and without MVI (3.08 months, 95 % CI 2.78 to 3.39), whatever the tumor stage. CONCLUSIONS LT proved to be harmful in patients with resectable HCC with a low MELD score (<10) or with aggressive tumors (with MVI). As a result of a shortage of donors, only selected resectable tumors with a MELD score of ≥10 should be considered for transplantation.
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Affiliation(s)
- Alessandro Vitale
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of General Surgery and Organ Transplantation, University Hospital of Padua, Padua, Italy,
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28
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Vitale A, Cucchetti A, Qiao GL, Cescon M, Li J, Ramirez Morales R, Frigo AC, Xia Y, Tuci F, Shen F, Cillo U, Pinna AD. Is resectable hepatocellular carcinoma a contraindication to liver transplantation? A novel decision model based on "number of patients needed to transplant" as measure of transplant benefit. J Hepatol 2014; 60:1165-71. [PMID: 24508550 DOI: 10.1016/j.jhep.2014.01.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 01/08/2014] [Accepted: 01/27/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Number-needed-to-treat is used in assessing the effectiveness of a health-care intervention, and reports the number of patients who need to be treated to prevent one additional bad outcome. Although largely used in medical literature, there are no studies measuring the benefit of liver transplantation (LT) over hepatic resection (HR) for hepatocellular carcinoma (HCC) in terms of "Number of patients needed to transplant (NTT)." EXCLUSION CRITERIA Child-Turcotte-Pugh (CTP) Classes B-C, very large (>10 cm) and multi-nodular (>2 nodules) tumours, macroscopic vascular invasion and extra-hepatic metastases. STUDY POPULATION 1028 HCC cirrhotic patients from one Eastern (n=441) and two Western (n=587) surgical units. Patient survival observed after HR by proportional hazard regression model was compared to that predicted after LT by the Metroticket calculator. The benefit obtainable from LT compared to resection was analysed in relationship with number of nodules (modelled as ordinal variable: single vs. oligonodular), size of largest nodule (modelled as a continuous variable), presence of microscopic vascular invasion (MVI), and time horizon from surgery (5-year vs. 10-year). RESULTS 330 patients were beyond the Milan criteria (32%) and 597 (58%) had MVI. The prevalence of MVI was 52% in patients within Milan criteria and 71% in those beyond (p<0.0001). In the 5-year transplant benefit analysis, nodule size and HCC number were positive predictors of transplant benefit, while MVI had a strong negative impact on NTT. Transplantation performed as an effective therapy (NTT <5) only in oligonodular HCC with largest diameter >3cm (beyond conventional LT criteria) when MVI was absent. The 10-year scenario increased drastically the transplant benefit in all subgroups of resectable patients, and LT became an effective therapy (NTT <5) for all patients without MVI whenever tumor extension and for oligonodular HCC with MVI within conventional LT criteria. CONCLUSIONS Based on NTT analysis, the adopted time horizon (5-year vs. 10-year scenario) is the main factor influencing the benefit of LT in patients with resectable HCC and Child A cirrhosis.
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Affiliation(s)
- A Vitale
- Department of General Surgery and Organ Transplantation, Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital of Padua, Padua, Italy.
| | - A Cucchetti
- Liver and Multi-Organ Transplantation Unit, St. Orsola Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - G L Qiao
- Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - M Cescon
- Liver and Multi-Organ Transplantation Unit, St. Orsola Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - J Li
- Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - R Ramirez Morales
- Department of General Surgery and Organ Transplantation, Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital of Padua, Padua, Italy
| | - A C Frigo
- Biostatistics Unit, University of Padua, Padua, Italy
| | - Y Xia
- Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - F Tuci
- Department of General Surgery and Organ Transplantation, Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital of Padua, Padua, Italy
| | - F Shen
- Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - U Cillo
- Department of General Surgery and Organ Transplantation, Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital of Padua, Padua, Italy
| | - A D Pinna
- Liver and Multi-Organ Transplantation Unit, St. Orsola Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
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Vitale A, Volk ML, De Feo TM, Burra P, Frigo AC, Ramirez Morales R, De Carlis L, Belli L, Colledan M, Fagiuoli S, Rossi G, Andorno E, Baccarani U, Regalia E, Vivarelli M, Donataccio M, Cillo U. A method for establishing allocation equity among patients with and without hepatocellular carcinoma on a common liver transplant waiting list. J Hepatol 2014; 60:290-7. [PMID: 24161408 DOI: 10.1016/j.jhep.2013.10.010] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 09/13/2013] [Accepted: 10/02/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The current organ allocation system for liver transplantation (LT) creates an imbalance between patients with and without hepatocellular carcinoma (HCC). We describe a model designed to re-establish allocation equity among patient groups using transplant benefit as the common endpoint. METHODS We enrolled consecutive adult patients entering the waiting list (WL group, n=2697) and undergoing LT (LT group, n=1702) during the period 2004-2009 in the North Italy Transplant program area. Independent multivariable regressions (WL and LT models) were created for patients without HCC and for those with stage T2 HCC. Monte Carlo simulation was used to create distributions of transplant benefit, and covariates such as Model for End-stage Liver Disease (MELD) and alpha-fetoprotein (AFP) were combined in regression equations. These equations were then calibrated to create an "MELD equivalent" which matches HCC patients to non-HCC patients having the same numerical MELD score. RESULTS Median 5 year transplant benefit was 15.12 months (8.75-25.35) for the non-HCC patients, and 28.18 months (15.11-36.38) for the T2-HCC patients (p<0.001). Independent predictors of transplant benefit were MELD score (estimate=0.89, p<0.001) among non-HCC patients, and MELD (estimate=1.14, p<0.001) and logAFP (estimate=-0.46, p<0.001) among HCC patients. The equation "HCC-MELD"=1.27∗MELD - 0.51∗logAFP+4.59 calculates a numerical score for HCC patients, whereby their transplant benefit is equal to that of non-HCC patients with the same numerical value for MELD. CONCLUSIONS We describe a method for calibrating HCC and non-HCC patients according to survival benefit, and propose that this method has the potential, if externally validated, to restore equity to the organ allocation system.
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Affiliation(s)
| | - Michael L Volk
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, USA
| | - Tullia Maria De Feo
- Organs and Tissue Transplant Immunology Unit, Fond. IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | | | - Luciano De Carlis
- Surgery and Transplantation, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Luca Belli
- Hepatology and Gastroenterology, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Michele Colledan
- Gastroenterology and Transplantation Hepatology, Ospedali Riuniti, Bergamo, Italy
| | - Stefano Fagiuoli
- Gastroenterology and Transplantation Hepatology, Ospedali Riuniti, Bergamo, Italy
| | - Giorgio Rossi
- Liver Transplantation Unit, Fond. IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Vitale A, Volk M, Cillo U. Transplant benefit for patients with hepatocellular carcinoma. World J Gastroenterol 2013; 19:9183-9188. [PMID: 24409046 PMCID: PMC3882392 DOI: 10.3748/wjg.v19.i48.9183] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/29/2013] [Indexed: 02/06/2023] Open
Abstract
Although liver transplantation is theoretically the best treatment for hepatocellular carcinoma (HCC), it is limited by the realities of perioperative complications, and the shortage of donor organs. Furthermore, in many cases there are available alternative treatments such as resection or locoregional therapy. Deciding upon the best option for a patient with HCC is complicated, involving numerous ethical principles including: urgency, utility, intention-to-treat survival, transplant benefit, harm to candidates on waiting list, and harm to living donors. The potential contrast between different principles is particularly relevant for patients with HCC for several reasons: (1) HCC candidates to liver transplantation are increasing; (2) the great prognostic heterogeneity within the HCC population; (3) in HCC patients tumor progression before liver transplantation may significantly impair post transplant outcome; and (4) effective alternative therapies are often available for HCC candidates to liver transplantation. In this paper we suggest that allocating organs by transplant benefit could help balance these competing principles, and also introduce equity between patients with HCC and nonmalignant liver disease. We also propose a triangular equipoise model to help decide between deceased donor liver transplantation, living donor liver transplantation, or alternative therapies.
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Lei JY, Wang WT, Yan LN. "Metroticket" predictor for assessing liver transplantation to treat hepatocellular carcinoma: a single-center analysis in mainland China. World J Gastroenterol 2013; 19:8093-8. [PMID: 24307805 PMCID: PMC3848159 DOI: 10.3748/wjg.v19.i44.8093] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/17/2013] [Accepted: 11/01/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To validate the "Metroticket" predictor using a large cohort of liver transplantation (LT) patients with hepatocellular carcinoma (HCC) in China. METHODS In total, 230 cases of LT for HCC treatment at our center, from July 2000 to August 2008, were included in the present study. The predicted 1-, 3- and 5-year post-LT survival rates were calculated using the Metroticket model (http://89.96.76.14/metroticket/calculator/). The predicted and observed long-term survival rates were then compared and analyzed. RESULTS The predicted survival rates for all 230 cases, as calculated by the Metroticket model, were 64.7% and 56.2% at 3 and 5 years, respectively, and the observed survival rates for these patients were 71.3% and 57.8%, respectively. For the 23 cases with macrovascular invasion, the predicted 5-year survival rate was 43.5%, whereas the observed 5-year survival rate was only 8.7%. For the 42 cases with microvascular invasion but an absence of macrovascular invasion, the predicted 5-year survival rate was 44.9%, and the observed 5-year survival rate was 50%. For the remaining 165 patients without any vascular invasion, the predicted 5-year survival rate was 65.8%, and the observed 5-year survival rate was 66.7%. CONCLUSION The Metroticket model can be used to accurately predict survival in HCC-related LT cases with an absence of macrovascular invasion.
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Pompili M, Francica G, Ponziani FR, Iezzi R, Avolio AW. Bridging and downstaging treatments for hepatocellular carcinoma in patients on the waiting list for liver transplantation. World J Gastroenterol 2013; 19:7515-7530. [PMID: 24282343 PMCID: PMC3837250 DOI: 10.3748/wjg.v19.i43.7515] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 09/30/2013] [Accepted: 10/18/2013] [Indexed: 02/06/2023] Open
Abstract
Several therapeutic procedures have been proposed as bridging treatments for patients with hepatocellular carcinoma (HCC) awaiting liver transplantation (LT). The most used treatments include transarterial chemoembolization and radiofrequency ablation. Surgical resection has also been successfully used as a bridging procedure, and LT should be considered a rescue treatment in patients with previous HCC resection who experience tumor recurrence or post-treatment severe decompensation of liver function. The aims of bridging treatments include decreasing the waiting list dropout rate before transplantation, reducing HCC recurrence after transplantation, and improving post-transplant overall survival. To date, no data from prospective randomized studies are available; however, for HCC patients listed for LT within the Milan criteria, prolonging the waiting time over 6-12 mo is a risk factor for tumor spread. Bridging treatments are useful in containing tumor progression and decreasing dropout. Furthermore, the response to pre-LT treatments may represent a surrogate marker of tumor biological aggressiveness and could therefore be evaluated to prioritize HCC candidates for LT. Lastly, although a definitive conclusion can not be reached, the experiences reported to date suggest a positive impact of these treatments on both tumor recurrence and post-transplant patient survival. Advanced HCC may be downstaged to achieve and maintain the current conventional criteria for inclusion in the waiting list for LT. Recent studies have demonstrated that successfully downstaged patients can achieve a 5-year survival rate comparable to that of patients meeting the conventional criteria without requiring downstaging.
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Lai Q, Avolio AW, Graziadei I, Otto G, Rossi M, Tisone G, Goffette P, Vogel W, Pitton MB, Lerut J. Alpha-fetoprotein and modified response evaluation criteria in solid tumors progression after locoregional therapy as predictors of hepatocellular cancer recurrence and death after transplantation. Liver Transpl 2013; 19:1108-18. [PMID: 23873764 DOI: 10.1002/lt.23706] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 06/12/2013] [Indexed: 02/07/2023]
Abstract
Locoregional therapy (LRT) is being increasingly used for the management of hepatocellular cancer (HCC) in patients listed for liver transplantation (LT). Although several selection criteria have been developed, stratifications of survival according to the pathology of explanted livers and pre-LT LRT are lacking. Radiological progression according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST) and alpha-fetoprotein (AFP) behavior was reviewed for 306 patients within the Milan criteria (MC-IN) and 116 patients outside the Milan criteria (MC-OUT) who underwent LRT and LT between January 1999 and March 2010. A prospectively collected database originating from 6 collaborating European centers was used for the study. Sixty-one patients (14.5%) developed HCC recurrence. For both MC-IN and MC-OUT patients, an AFP slope > 15 ng/mL/month and mRECIST progression were unique independent risk factors for HCC recurrence and patient death. When the radiological Milan criteria (MC) status was combined with radiological and biological progression, MC-IN and MC-OUT patients without risk factors had similarly excellent 5-year tumor-free and patient survival rates. MC-IN patients with at least 1 risk factor had worse outcomes, and MC-OUT patients with at least 1 risk factor had the poorest survival (P < 0.001). In conclusion, both radiological and biological modifications permit documentation of the response to LRT in patients waiting for LT. According to these 2 parameters, tumor progression significantly increases the risk of recurrence and patient death not only for MC-OUT patients but also for MC-IN patients. The monitoring of both parameters in combination with the initial radiological MC status is an essential element for further refining the selection criteria for potential liver recipients with HCC.
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Affiliation(s)
- Quirino Lai
- Starzl Unit of Abdominal Transplantation, St. Luc University Hospital, Catholic University of Louvain, Brussels, Belgium; Department of General Surgery and Organ Transplantation, Umberto I Hospital, Sapienza University, Rome, Italy
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Bolondi L, Cillo U, Colombo M, Craxì A, Farinati F, Giannini EG, Golfieri R, Levrero M, Pinna AD, Piscaglia F, Raimondo G, Trevisani F, Bruno R, Caraceni P, Ciancio A, Coco B, Fraquelli M, Rendina M, Squadrito G, Toniutto P. Position paper of the Italian Association for the Study of the Liver (AISF): the multidisciplinary clinical approach to hepatocellular carcinoma. Dig Liver Dis 2013; 45:712-23. [PMID: 23769756 DOI: 10.1016/j.dld.2013.01.012] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/16/2013] [Indexed: 12/11/2022]
Abstract
Patients with hepatocellular carcinoma should be managed with a multidisciplinary approach framed in a network where all the diagnostic techniques and therapeutic resources are available in order to provide the optimal level of care. Given this assumption, the Coordinating Committee of the Italian Association for the Study of the Liver nominated a panel of experts to elaborate practical recommendations for the multidisciplinary management of hepatocellular carcinoma aiming to provide: (1) homogeneous and efficacious diagnostic and staging work-up, and (2) the best treatment choice tailored to patient status and tumour stage at diagnosis. The 2010 updated American Association for the Study of Liver Disease Guidelines for hepatocellular carcinoma were selected as the reference document. For each management issue, the American Association for the Study of Liver Disease recommendations were briefly summarised and discussed, according to both the scientific evidence published after their release and the clinical expertise of the Italian centres taking care of these patients. The Italian Association for the Study of the Liver expert panel recommendations are finally reported.
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Zhang Q, Chen X, Zang Y, Zhang L, Chen H, Wang L, Niu Y, Ren X, Shen Z, Shang L. The survival benefit of liver transplantation for hepatocellular carcinoma patients with hepatitis B virus infection and cirrhosis. PLoS One 2012; 7:e50919. [PMID: 23236406 PMCID: PMC3517605 DOI: 10.1371/journal.pone.0050919] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 10/25/2012] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND A precise predictive survival model of liver transplantation (LT) with antiviral prophylaxis for hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) and cirrhosis has not been established. The aim of our study was to identify predictors of outcome after LT in these patients based on tumor staging systems, antitumor therapy pre-LT, and antiviral prophylaxis in patients considered to be unfit by Milan or UCSF criteria. METHODS From 2002 to 2008, 917 LTs with antiviral prophylaxis were performed on patients with HBV-cirrhosis, and 313 had concurrent HCC. RESULTS Stratified univariate and multivariate analyses demonstrated that independent predictors for poor survival were tumor size >7.5 cm (P = 0.001), tumor number >1 (P = 0.005), vascular invasion (P = 0.001), pre-LT serum alpha-fetoprotein (AFP) level ≥1000 ng/ml (P = 0.009), and pre-LT aspartate aminotransferase (AST) level ≥120 IU/L (P = 0.044). Pre-LT therapy for HCC was an independent predictor of better survival (P = 0.028). Based on CLIP and TNM tumor staging systems, HCC patients with HBV-cirrhosis who met the following criteria: solitary tumor ≤7.5 cm, or ≤4 multifocal nodules, the largest lesion ≤5 cm and total tumor diameter ≤10 cm, or more nodules with the largest lesion ≤3 cm, and pre-LT serum AFP level <1000 µg/L and AST level <120 IU/L without vascular invasion and lymph node metastasis who were unfit for UCSF, had survival rates of 89% at 5 years. There was a 47% 5-year survival rate for patients with HCC exceeding the revised criteria. CONCLUSIONS The current criteria for LT based on tumor size, number and levels of AFP and AST may be modestly expanded while still preserving excellent survival after LT. The expanded criteria combined with antiviral prophylaxis and pre-LT adjuvant therapy for HCC may be a rational strategy to prolong survival after LT for HCC patients with HBV-associated cirrhosis.
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Affiliation(s)
- Qing Zhang
- Institute of Liver Transplantation, General Hospital of Chinese People's Armed Police Force, Beijing, China
| | - Xinguo Chen
- Institute of Liver Transplantation, General Hospital of Chinese People's Armed Police Force, Beijing, China
| | - Yunjin Zang
- Institute of Liver Transplantation, General Hospital of Chinese People's Armed Police Force, Beijing, China
| | - Li Zhang
- First Department of Surgery, Shaanxi Provincial Corps Hospital of Chinese People's Armed Police Force, Xi'an, China
| | - Hong Chen
- Institute of Liver Transplantation, General Hospital of Chinese People's Armed Police Force, Beijing, China
| | - Letian Wang
- Institute of Liver Transplantation, General Hospital of Chinese People's Armed Police Force, Beijing, China
| | - Yujian Niu
- Institute of Liver Transplantation, General Hospital of Chinese People's Armed Police Force, Beijing, China
| | - Xiuyun Ren
- Institute of Liver Transplantation, General Hospital of Chinese People's Armed Police Force, Beijing, China
| | - Zhongyang Shen
- Institute of Liver Transplantation, General Hospital of Chinese People's Armed Police Force, Beijing, China
- * E-mail: (ZS); (LS)
| | - Lei Shang
- Department of Health Statistics, Faculty of Preventive Medicine, Fourth Military Medical University, Xi'an, China
- * E-mail: (ZS); (LS)
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Cucchetti A, Piscaglia F, Cescon M, Ercolani G, Terzi E, Bolondi L, Zanello M, Pinna AD. Conditional survival after hepatic resection for hepatocellular carcinoma in cirrhotic patients. Clin Cancer Res 2012; 18:4397-405. [PMID: 22745107 DOI: 10.1158/1078-0432.ccr-11-2663] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE Survival estimates are commonly reported as actuarial survival after the first observation, but future survival probabilities can change over time. Conditional survival is a measure of prognosis for patients who have sometimes already survived several years since diagnosis; however, data on conditional survival for cirrhotic patients, resected for hepatocellular carcinoma (HCC), are lacking. EXPERIMENTAL DESIGN Clinical data from 300 consecutive cirrhotic patients who underwent HCC resection were reviewed and the actuarial survival estimated. The 5-year conditional survival was calculated as CS = S(x + 5)/S(x) and represents the probability of surviving an additional 5 years, given that the patient has already survived x years. RESULTS The 3-, 5-, and 10-year survival rates were, respectively, 69.0%, 57.7%, and 25.3% and were lower in cases of portal hypertension, Model for End-stage Liver Disease (MELD) score ≥9, United Network for Organ-Sharing T3 tumor, GIII-GIV tumors, and microscopic vascular invasion. However, the 5-year conditional survival calculation showed that patients resected for more advanced (T3) tumors or with adverse histologic features will experience the same survival probabilities as patients with less advanced tumors or favorable histology from the third year after surgery onward, as they had probably escaped recurrence from intrahepatic metastases. Patients who underwent repeated hepatectomy for recurrence presented higher conditional survival. CONCLUSIONS Conditional survival showed that the impact of different variables influencing survival is not linear over time after hepatic resection. Information derived from conditional survival can be used to better manage patients with HCCs, including the potential future setting of adjuvant therapies and the choice of listing, or not, for transplantation resected patients not recurring within 2 years.
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What is the probability of being too old for salvage transplantation after hepatocellular carcinoma resection? Dig Liver Dis 2012; 44:523-9. [PMID: 22387286 DOI: 10.1016/j.dld.2012.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 12/21/2011] [Accepted: 01/30/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND The strategy of salvage transplantation for patients with hepatocellular carcinoma is based on the premise that tumour recurrence will be still transplantable at the time of recurrence. However, patients can not only present non-transplantable recurrence but can also be over the age limit accepted for transplantation. AIMS To measure the risk of being too old for salvage transplantation of patients resected for hepatocellular carcinoma within Milan criteria. METHODS A Markov simulation model was developed on the basis of published literature. RESULTS The risk of being too old for salvage transplantation depends on the time-span between age at hepatic resection and age limit, and the expected median waiting-time. Patients resected at an age 2 or 3 years below the age limit carry a risk of being too old that overcomes the probability of receiving transplantation. Salvage strategy can cause harm that depends on the tumour characteristics and degree of portal hypertension, becoming maximal for patients with multiple tumours, clinical signs of portal hypertension and increased bilirubin levels. CONCLUSIONS The best strategy to adopt should be balanced between the risk of being too old and the expected transplant benefit, but salvage strategy could be pursued if it did not turn into significant harm in comparison to primary transplantation.
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Avolio AW, Agnes S, Cillo U, Lirosi MC, Romagnoli R, Baccarani U, Zamboni F, Nicolini D, Donataccio M, Perrella A, Ettorre GM, Romano M, Morelli N, Vennarecci G, de Waure C, Fagiuoli S, Burra P, Cucchetti A. http://www.D-MELD.com, the Italian survival calculator to optimize donor to recipient matching and to identify the unsustainable matches in liver transplantation. Transpl Int 2012; 25:294-301. [PMID: 22268763 DOI: 10.1111/j.1432-2277.2011.01423.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Alfonso W Avolio
- Department of Surgery, General Surgery and Transplantation Unit, A. Gemelli Hospital, Catholic University, Rome, Italy.
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Avolio AW, Cillo U, Salizzoni M, De Carlis L, Colledan M, Gerunda GE, Mazzaferro V, Tisone G, Romagnoli R, Caccamo L, Rossi M, Vitale A, Cucchetti A, Lupo L, Gruttadauria S, Nicolotti N, Burra P, Gasbarrini A, Agnes S. Balancing donor and recipient risk factors in liver transplantation: the value of D-MELD with particular reference to HCV recipients. Am J Transplant 2011; 11:2724-36. [PMID: 21920017 DOI: 10.1111/j.1600-6143.2011.03732.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Donor-recipient match is a matter of debate in liver transplantation. D-MELD (donor age × recipient biochemical model for end-stage liver disease [MELD]) and other factors were analyzed on a national Italian database recording 5946 liver transplants. Primary endpoint was to determine factors predictive of 3-year patient survival. D-MELD cutoff predictive of 5-year patient survival <50% (5yrsPS<50%) was investigated. A prognosis calculator was implemented (http://www.D-MELD.com). Differences among D-MELD deciles allowed their regrouping into three D-MELD classes (A < 338, B 338-1628, C >1628). At 3 years, the odds ratio (OR) for death was 2.03 (95% confidence interval [CI], 1.44-2.85) in D-MELD class C versus B. The OR was 0.40 (95% CI, 0.24-0.66) in class A versus class B. Other predictors were hepatitis C virus (HCV; OR = 1.42; 95% CI, 1.11-1.81), hepatitis B virus (HBV; OR = 0.69; 95% CI, 0.51-0.93), retransplant (OR = 1.82; 95% CI, 1.16-2.87) and low-volume center (OR = 1.48; 95% CI, 1.11-1.99). Cox regressions up to 90 months confirmed results. The hazard ratio was 1.97 (95% CI, 1.59-2.43) for D-MELD class C versus class B and 0.42 (95% CI, 0.29-0.60) for D-MELD class A versus class B. Recipient age, HCV, HBV and retransplant were also significant. The 5yrsPS<50% cutoff was identified only in HCV patients (D-MELD ≥ 1750). The innovative approach offered by D-MELD and covariates is helpful in predicting outcome after liver transplantation, especially in HCV recipients.
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Affiliation(s)
- A W Avolio
- General Surgery and Transplantation Unit, Department of Surgery, A. Gemelli Hospital, Catholic University, Rome, Italy.
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Vitale A, Morales RR, Zanus G, Farinati F, Burra P, Angeli P, Frigo AC, Del Poggio P, Rapaccini G, Di Nolfo MA, Benvegnù L, Zoli M, Borzio F, Giannini EG, Caturelli E, Chiaramonte M, Trevisani F, Cillo U. Barcelona Clinic Liver Cancer staging and transplant survival benefit for patients with hepatocellular carcinoma: a multicentre, cohort study. Lancet Oncol 2011; 12:654-62. [PMID: 21684210 DOI: 10.1016/s1470-2045(11)70144-9] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Allocation of deceased-donor livers to patients with chronic liver failure is improved by prioritising patients by 5-year liver transplantation survival benefit. The Barcelona Clinic Liver Cancer (BCLC) staging has been proposed as the standard means to assess for prognosis of patients with hepatocellular carcinoma. We aimed to create a prediction model linking the BCLC stage of patients with hepatocellular carcinoma to their 5-year liver transplant benefit. METHODS A large cohort of consecutive patients with hepatocellular carcinoma (n=1328) from the ITA.LI.CA database (n=2951) were judged as potentially eligible for liver transplantation according to the following criteria: absence of macroscopic vascular invasion or metastases, age 70 years or younger, and absence of relevant extra-hepatic comorbidities. To assess the correlation between BCLC staging and non-liver transplantation survival, we did Cox univariate and multivariate analyses including the following covariates: BCLC stage, year of diagnosis, age, sex, cause of cirrhosis, model for end-stage liver disease score, α-fetoprotein concentrations, and treatment. Liver-transplantation survival benefit for patients was calculated, using Monte Carlo simulation analysis, as the patient's 5-year life expectancy with liver transplantation (estimated by the Metroticket model) minus the 5-year life expectancy without liver transplantation according to BCLC stage. FINDINGS 83 (6%) of 1328 patients had BCLC 0 stage disease, 614 (46%) had BCLC A, 500 (38%) had BCLC B-C, and 131 (10%) had BCLC D. In the Cox non-liver transplantation survival multivariate model, hazard ratios associated with increasing BCLC stages were 1.530 (95% CI 1.107-2.116) for BCLC A versus BCLC 0, 1.572 (1.350-1.830) for BCLC B-C versus BCLC A, and 1.470 (1.164-1.856) for BCLC D versus BCLC B-C. Results of the Monte Carlo simulation analysis confirmed the significant effect of BCLC classification on transplant benefit; in the adjusted model, a median 5-year transplant benefit of 11.19 months (IQR 10.73-11.67) for BCLC 0, 13.49 months (11.51-15.57) for BCLC A, 17.36 months (15.06-19.28) for BCLC B-C, and 28.46 months (26.38-30.34) for BCLC D. INTERPRETATION Liver transplantation could result in survival benefit for patients with hepatocellular carcinoma and advanced liver cirrhosis (BCLC stage D) and in those with intermediate tumours (BCLC stages B-C), regardless of the nodule number-size criteria (ie, Milan criteria), provided that macroscopic vascular invasion and extra-hepatic disease are absent. FUNDING None.
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Affiliation(s)
- Alessandro Vitale
- Unità di Chirurgia Epatobiliare e Trapianto Epatico, Azienda Ospedaliera, Università di Padova, Padova, Italy.
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Cucchetti A, Cescon M, Ercolani G, Morelli MC, Del Gaudio M, Zanello M, Pinna AD. Comparison between observed survival after resection of transplantable hepatocellular carcinoma and predicted survival after listing through a Markov model simulation. Transpl Int 2011; 24:787-96. [PMID: 21615549 DOI: 10.1111/j.1432-2277.2011.01276.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
There is still some debate on whether hepatic resection or liver transplantation should be the initial treatment for hepatocellular carcinoma (HCC) in compensated cirrhosis. Clinical data and observed survivals of 150 transplantable patients (within Milan criteria) resected for HCC were reviewed and their predicted survival after listing for liver transplantation was calculated using a Markov model simulation. Differences between observed and predicted survival estimates were explored by standardized differences (d). The mean observed survival within 5 years after surgery was 45.35 months, and the predicted survival after listing was 49.18 months (d = 0.265). The largest gain in life-expectancy with liver transplantation would be obtained in patients with Model for End-stage Liver Disease (MELD) score >9 (d = 0.403); conversely, observed and predicted survivals were similar in HCV+ patients (d = -0.002) and in patients with MELD ≤9 (d = -0.057). For T1 tumors, the observed mean estimate of survival after hepatic resection was higher than that predicted by the simulation (d = -0.606). In conclusion, in HCV patients and in those with very well compensated cirrhosis, hepatic resection could lead to results similar to those of transplantation strategy for HCC within Milan criteria; HCC T1 patients are probably best served by resection as first-line therapy rather than listing for transplantation.
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Affiliation(s)
- Alessandro Cucchetti
- Liver and Multiorgan Transplant Unit, Department of General Surgery of the S.Orsola Hospital, University of Bologna, Bologna, Italy.
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Piscaglia F, Cucchetti A, Bolondi L. "Survival benefit": the final destination, with still a long way to go. Dig Liver Dis 2010; 42:608-10. [PMID: 20678743 DOI: 10.1016/j.dld.2010.07.001] [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] [Received: 07/10/2010] [Accepted: 07/12/2010] [Indexed: 02/07/2023]
Affiliation(s)
- Fabio Piscaglia
- Division of Internal Medicine, Department of Digestive Disease and Internal Medicine, Bologna, Italy.
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