1
|
Mehta N, Kelley RK, Yao FY. Refining the approach to down-staging of HCC prior to liver transplantation: Patient selection, loco-regional treatments, and systemic therapies. Hepatology 2024; 80:238-253. [PMID: 37183865 DOI: 10.1097/hep.0000000000000452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - R Katie Kelley
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California, USA
| | - Francis Y Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, California, USA
| |
Collapse
|
2
|
Akabane M, McVey JC, Firl DJ, Kwong AJ, Melcher ML, Kim WR, Sasaki K. Continuous Risk Score Predicts Waitlist and Post-transplant Outcomes in Hepatocellular Carcinoma Despite Exception Changes. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00584-6. [PMID: 38908731 DOI: 10.1016/j.cgh.2024.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 05/27/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND & AIMS Continuous risk-stratification of candidates and urgency-based prioritization have been utilized for liver transplantation (LT) in patients with non-hepatocellular carcinoma (HCC) in the United States. Instead, for patients with HCC, a dichotomous criterion with exception points is still used. This study evaluated the utility of the hazard associated with LT for HCC (HALT-HCC), an oncological continuous risk score, to stratify waitlist dropout and post-LT outcomes. METHODS A competing risk model was developed and validated using the UNOS database (2012-2021) through multiple policy changes. The primary outcome was to assess the discrimination ability of waitlist dropouts and LT outcomes. The study focused on the HALT-HCC score, compared with other HCC risk scores. RESULTS Among 23,858 candidates, 14,646 (59.9%) underwent LT and 5196 (21.8%) dropped out of the waitlist. Higher HALT-HCC scores correlated with increased dropout incidence and lower predicted 5-year overall survival after LT. HALT-HCC demonstrated the highest area under the curve (AUC) values for predicting dropout at various intervals post-listing (0.68 at 6 months, 0.66 at 1 year), with excellent calibration (R2 = 0.95 at 6 months, 0.88 at 1 year). Its accuracy remained stable across policy periods and locoregional therapy applications. CONCLUSIONS This study highlights the predictive capability of the continuous oncological risk score to forecast waitlist dropout and post-LT outcomes in patients with HCC, independent of policy changes. The study advocates integrating continuous scoring systems like HALT-HCC in liver allocation decisions, balancing urgency, organ utility, and survival benefit.
Collapse
Affiliation(s)
- Miho Akabane
- Division of Abdominal Transplant, Department of Surgery, Stanford University Medical Center, Stanford, California
| | - John C McVey
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel J Firl
- Department of Surgery, Duke University Hospital, Durham, North Carolina
| | - Allison J Kwong
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California
| | - Marc L Melcher
- Division of Abdominal Transplant, Department of Surgery, Stanford University Medical Center, Stanford, California
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California
| | - Kazunari Sasaki
- Division of Abdominal Transplant, Department of Surgery, Stanford University Medical Center, Stanford, California.
| |
Collapse
|
3
|
Arvind A, Seif El Dahan K, Malhotra R, Daher D, Rich NE, Patel MS, VanWagner LB, Lieber SR, Cotter TG, Louissaint J, Mufti AR, Kulik L, Pillai A, Parikh ND, Singal AG. Association between bridging therapy and posttransplant outcomes in patients with HCC within Milan criteria: A systematic review and meta-analysis. Liver Transpl 2024; 30:595-606. [PMID: 38466889 DOI: 10.1097/lvt.0000000000000357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/15/2024] [Indexed: 03/13/2024]
Abstract
Liver transplantation is the curative therapy of choice for patients with early-stage HCC. Locoregional therapies are often employed as a bridge to reduce the risk of waitlist dropout; however, their association with posttransplant outcomes is unclear. We conducted a systematic review using Ovid MEDLINE and EMBASE to identify studies published between database inception and August 2, 2023, which reported posttransplant recurrence-free survival and overall survival among patients transplanted for HCC within Milan criteria, stratified by receipt of bridging therapy. Pooled HRs were calculated for each outcome using the DerSimonian and Laird method for a random-effects model. We identified 38 studies, including 19,671 patients who received and 20,148 patients who did not receive bridging therapy. Bridging therapy was not associated with significant differences in recurrence-free survival (pooled HR: 0.91, 95% CI: 0.77-1.08; I2 =39%) or overall survival (pooled HR: 1.09, 95% CI: 0.95-1.24; I2 =47%). Results were relatively consistent across subgroups, including geographic location and study period. Studies were discordant regarding the differential strength of association by pretreatment tumor burden and pathologic response, but potential benefits of locoregional therapy were mitigated in those who received 3 or more treatments. Adverse events were reported in a minority of studies, but when reported occurred in 6%-15% of the patients. Few studies reported loss to follow-up and most had a risk of residual confounding. Bridging therapy is not associated with improvements in posttransplant recurrence-free or overall survival among patients with HCC within Milan criteria. The risk-benefit ratio of bridging therapy likely differs based on the risk of waitlist dropout.
Collapse
Affiliation(s)
- Ashwini Arvind
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Karim Seif El Dahan
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Riya Malhotra
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Darine Daher
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole E Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Madhukar S Patel
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Lisa B VanWagner
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah R Lieber
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Thomas G Cotter
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jeremy Louissaint
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Arjmand R Mufti
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Laura Kulik
- Department of Internal Medicine, Northwestern Medicine, Chicago, Illinois, USA
| | - Anjana Pillai
- Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Neehar D Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
4
|
Al-Hasan M, Mehta N, Yang JD, Singal AG. Role of biomarkers in the diagnosis and management of HCC. Liver Transpl 2024:01445473-990000000-00379. [PMID: 38738964 DOI: 10.1097/lvt.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/06/2024] [Indexed: 05/14/2024]
Abstract
For many cancers, biomarkers have served as an important tool across the cancer care continuum from risk stratification and early detection to diagnosis and treatment. Alpha-fetoprotein (AFP) remains one of the few validated biomarkers for patients with HCC. Although AFP has shown potential for each of these steps, its performance, when used alone, has often been suboptimal. There continue to be discordant recommendations about AFP's value when combined with ultrasound for surveillance, as well as its role in diagnostic algorithms. Conversely, high AFP levels are associated with aggressive tumor biology and survival, so it remains a key factor for the selection of candidates for liver transplant. There have been immense efforts to identify and validate additional biomarkers for each of these steps in the HCC care continuum. Indeed, biomarker panels have shown promising data for HCC risk stratification and surveillance among patients with cirrhosis, as well as prognostication and detection of minimal residual disease in patients undergoing HCC treatment. Several large prospective studies are currently ongoing to evaluate the role of these emerging biomarkers in clinical practice.
Collapse
Affiliation(s)
- Mohammed Al-Hasan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Neil Mehta
- Department of Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Ju Dong Yang
- Department of Internal Medicine, Cedars Sinai, Los Angeles, California, USA
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
5
|
Di Sandro S, Centonze L, Catellani B, Odorizzi R, Caracciolo D, Guidetti C, Magistri P, Esposito G, Guerrini GP, Di Benedetto F. Current role and perspectives of living donor liver transplantation for hepatocellular carcinoma: systematic review of the past 20 years. Updates Surg 2024:10.1007/s13304-024-01862-y. [PMID: 38704462 DOI: 10.1007/s13304-024-01862-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024]
Abstract
Hepatocellular carcinoma (HCC) poses a significant global health challenge, and liver transplantation (LT) remains the best curative option. Living donor liver transplantation (LDLT) emerged as a potential solution to organ scarcity, reducing waitlist times. This comprehensive review explores LDLT practices, focusing on patient selection criteria and oncologic outcomes. A systematic review following PRISMA guidelines included 50 studies (2004-2023) with 8062 patients. Data encompassed baseline characteristics, HCC features, and oncologic outcomes. Further analysis categorized results by geography and publication year. Heterogeneity in patient demographics, tumor burden, and transplant characteristics was observed. Recent LDLT series demonstrated a shift towards refined selection criteria, increased neoadjuvant treatment, and improved oncologic outcomes. Geographic disparities revealed unique challenges in Eastern and Western practices. LDLT proves effective for HCC, addressing donor shortages. Evolving practices highlight the importance of refining inclusion criteria and optimizing tumor management. While geographic differences exist, LDLT, when judiciously applied, offers promising outcomes.
Collapse
Affiliation(s)
- Stefano Di Sandro
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy.
| | - Leonardo Centonze
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Barbara Catellani
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberta Odorizzi
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Daniela Caracciolo
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Cristiano Guidetti
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Paolo Magistri
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Giuseppe Esposito
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Gian Piero Guerrini
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Fabrizio Di Benedetto
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| |
Collapse
|
6
|
Bajaj JS, Choudhury A, Kumaran V, Wong F, Seto WK, Alvares-Da-Silva MR, Desalgn H, Hayes PC, Idilman R, Topazian M, Torre A, Xie Q, George J, Kamath PS. Geographic disparities in access to liver transplant for advanced cirrhosis: Time to ring the alarm! Am J Transplant 2024; 24:733-742. [PMID: 38387623 DOI: 10.1016/j.ajt.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024]
Abstract
Decompensated cirrhosis and hepatocellular cancer are major risk factors for mortality worldwide. Liver transplantation (LT), both live-donor LT or deceased-donor LT, are lifesaving, but there are several barriers toward equitable access. These barriers are exacerbated in the setting of critical illness or acute-on-chronic liver failure. Rates of LT vary widely worldwide but are lowest in lower-income countries owing to lack of resources, infrastructure, late disease presentation, and limited donor awareness. A recent experience by the Chronic Liver Disease Evolution and Registry for Events and Decompensation consortium defined these barriers toward LT as critical in determining overall survival in hospitalized cirrhosis patients. A major focus should be on appropriate, affordable, and early cirrhosis and hepatocellular cancer care to prevent the need for LT. Live-donor LT is predominant across Asian countries, whereas deceased-donor LT is more common in Western countries; both approaches have unique challenges that add to the access disparities. There are many challenges toward equitable access but uniform definitions of acute-on-chronic liver failure, improving transplant expertise, enhancing availability of resources and encouraging knowledge between centers, and preventing disease progression are critical to reduce LT disparities.
Collapse
Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA.
| | - Ashok Choudhury
- Department of Hepatology, Institute for Liver and Biliary Sciences, New Delhi, India
| | - Vinay Kumaran
- Division of Transplant Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Florence Wong
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wai Kay Seto
- Department of Medicine, School of Clinical Medicine, the University of Hong Kong, Hong Kong, China
| | - Mario Reis Alvares-Da-Silva
- Department of Hepatology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Hailemichael Desalgn
- Gastroenterology and Hepatology Unit, St Paul's Hospital, Millennium Medical College, Addis Ababa, Ethiopia
| | - Peter C Hayes
- Hepatology, Division of Health Sciences, Deanery of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Ramazan Idilman
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Mark Topazian
- Gastroenterology and Hepatology Unit, St Paul's Hospital, Millennium Medical College, Addis Ababa, Ethiopia
| | - Aldo Torre
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Qing Xie
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jacob George
- Storr Liver Centre, Westmead Millennium Institute, Westmead Hospital and University of Sydney, New South Wales, Australia
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| |
Collapse
|
7
|
Liu H, Sethi V, Li X, Xiao Y, Humar A. Liver Transplantation for Hepatocellular Carcinoma: A Narrative Review and A Glimpse into The Future. Semin Liver Dis 2024; 44:79-98. [PMID: 38211621 DOI: 10.1055/a-2242-7543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Liver transplantation (LT) is a highly effective treatment for carefully selected patients with hepatocellular carcinoma (HCC). In this review, we explored the development of LT selection criteria and organ allocation policies, comparing original data to underscore their historical progression into the intricate task of quantitatively estimating pre- and post-LT survivals. We emphasized the role of biomarkers such as serum alpha-fetoprotein, Des-gamma-carboxy-prothrombin, circulating tumor cells, and circulating tumor DNA in predicting patient outcomes. Additionally, we examined the transplant-associated survival benefits and the difficulties in accurately calculating these benefits. We also reviewed recent advancements in targeted therapy and checkpoint inhibitors for advanced, inoperable HCC and projected their integration into LT for HCC. We further discussed the growing use of living donor liver transplants in the United States and compared its outcomes with those of deceased donor liver transplants. Furthermore, we examined the progress in machine perfusion techniques, which have shown potential in improving patient outcomes and enlarging the donor pool. These advancements present opportunities to enhance LT patient survivals, refine selection criteria, establish new priority metrics, develop innovative bridging and downstaging strategies, and formulate redesigned LT strategies for HCC treatments.
Collapse
Affiliation(s)
- Hao Liu
- Department of Surgery, Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vrishketan Sethi
- Department of Surgery, Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Xingjie Li
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Yao Xiao
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Abhinav Humar
- Department of Surgery, Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
8
|
Mehta N. Updates in liver transplantation policy for patients with hepatocellular carcinoma (HCC). Clin Liver Dis (Hoboken) 2024; 23:e0157. [PMID: 38681512 PMCID: PMC11049753 DOI: 10.1097/cld.0000000000000157] [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: 12/11/2023] [Accepted: 02/13/2024] [Indexed: 05/01/2024] Open
|
9
|
Goudsmit BF, Ilaria Prosepe, Tushuizen ME, Mazzaferro V, Alwayn IP, van Hoek B, Braat AE, Putter H. Survival benefit from liver transplantation for patients with and without hepatocellular carcinoma. JHEP Rep 2023; 5:100907. [PMID: 38034881 PMCID: PMC10685016 DOI: 10.1016/j.jhepr.2023.100907] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/11/2023] [Accepted: 08/31/2023] [Indexed: 12/02/2023] Open
Abstract
Background & Aims In the USA, inequal liver transplantation (LT) access exists between patients with and without hepatocellular carcinoma (HCC). Survival benefit considers survival without and with LT and could equalise LT access. We calculated bias-corrected LT survival benefit for patients with(out) HCC who underwent a transplant, based on longitudinal data in a recent United States cohort. Methods Adult LT candidates with(out) HCC between 2010 and 2019 were included. Waitlist survival over time was contrasted to post-transplant survival, to estimate 5-year survival benefit from the moment of LT. Waitlist survival was modelled with a bias-corrected Cox regression, and post-transplant survival was estimated through Cox proportional hazards regression. Results Mean HCC survival without LT was always lower than non-HCC waitlist survival. Below model for end-stage liver disease (sodium) (MELD(-Na)) 30, patients with HCC gained more life-years from LT than patients without HCC at the same MELD(-Na) score. Only patients without HCC below MELD(-Na) 9 had negative benefit. Most patients with HCC underwent a transplant below MELD(-Na) 14, and most patients without HCC underwent a transplant above MELD(-Na) 26. Liver function [MELD(-Na), albumin] was the main predictor of 5-year benefit. Therefore, during 5 years, most patients with HCC gained 0.12 to 1.96 years from LT, whereas most patients without HCC gained 2.48 to 3.45 years. Conclusions On an individual level, performing a transplant in patients with HCC resulted in survival benefit. However, on a population level, benefit was indirectly decreased, as patients without HCC were likely to gain more survival owing to decreased liver function. For patients who underwent a transplant, a constructed online calculator estimates 5-year survival benefit given specific patient characteristics. Survival benefit scores could serve to equalise LT access. Impact and implications Benefit is a comparison of the survival with and without liver transplantation, and it is important when deciding who should undergo a transplant. Liver function is most important when predicting possible benefit from transplantation. Patients with liver cancer die sooner on the waiting list than similar patients without liver cancer. However, patients with liver cancer more often have better liver function. Most patients without liver cancer derive more benefit from transplantation than patients with liver cancer.
Collapse
Affiliation(s)
- Ben F.J. Goudsmit
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ilaria Prosepe
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten E. Tushuizen
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincenzo Mazzaferro
- Department of Oncology, University of Milan, Milan, Italy
- Hepatology and Liver Transplantation Unit, Department of Surgery, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Tumori, Milan, Italy
| | - Ian P.J. Alwayn
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Andries E. Braat
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
10
|
Ferrarese A, Bucci M, Zanetto A, Senzolo M, Germani G, Gambato M, Russo FP, Burra P. Prognostic models in end stage liver disease. Best Pract Res Clin Gastroenterol 2023; 67:101866. [PMID: 38103926 DOI: 10.1016/j.bpg.2023.101866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/13/2023] [Accepted: 08/18/2023] [Indexed: 12/19/2023]
Abstract
Cirrhosis is a major cause of death worldwide, and is associated with significant health care costs. Even if milestones have been recently reached in understanding and managing end-stage liver disease (ESLD), the disease course remains somewhat difficult to prognosticate. These difficulties have already been acknowledged already in the past, when scores instead of single parameters have been proposed as valuable tools for short-term prognosis. These standard scores, like Child Turcotte Pugh (CTP) and model for end-stage liver disease (MELD) score, relying on biochemical and clinical parameters, are still widely used in clinical practice to predict short- and medium-term prognosis. The MELD score, which remains an accurate, easy-to-use, objective predictive score, has received significant modifications over time, in order to improve its performance especially in the liver transplant (LT) setting, where it is widely used as prioritization tool. Although many attempts to improve prognostic accuracy have failed because of lack of replicability or poor benefit with the comparator (often the MELD score or its variants), few scores have been recently proposed and validated especially for subgroups of patients with ESLD, as those with acute-on-chronic liver failure. Artificial intelligence will probably help hepatologists in the near future to fill the current gaps in predicting disease course and long-term prognosis of such patients.
Collapse
Affiliation(s)
- A Ferrarese
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Bucci
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - A Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - G Germani
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Gambato
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - F P Russo
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - P Burra
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy.
| |
Collapse
|
11
|
Natarajan B, Tabrizian P, Hoteit M, Frenette C, Parikh N, Ghaziani T, Dhanasekaran R, Guy J, Shui A, Florman S, Yao FY, Mehta N. Downstaging hepatocellular carcinoma before liver transplantation: A multicenter analysis of the "all-comers" protocol in the Multicenter Evaluation of Reduction in Tumor Size before Liver Transplantation (MERITS-LT) consortium. Am J Transplant 2023; 23:1771-1780. [PMID: 37532179 PMCID: PMC10998692 DOI: 10.1016/j.ajt.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/27/2023] [Accepted: 07/27/2023] [Indexed: 08/04/2023]
Abstract
Patients with hepatocellular carcinoma meeting united network for organ sharing (UNOS)-downstaging (DS) criteria have excellent liver transplantation (LT) outcomes after DS. However, outcomes for "all-comers" (AC) patients with tumors initially exceeding UNOS-DS are poorly understood. Patients meeting AC (n = 82) or UNOS-DS (n = 229) at 7 LT centers in 4 UNOS regions were prospectively followed from 2015-2020. AC patients had a lower probability of successful DS (67% vs 83% within 12 months; P < .001). The 3-year survival was 69% for UNOS-DS vs 58% for AC (P = .05) and reduced to 30% in patients with Child-Pugh B/C cirrhosis or alpha-fetoprotein (AFP) ≥ 500. Five-year LT probability was 42% for AC vs 74% in UNOS-DS (P = .10). Thirty-eight percent were understaged on explant, with the increasing sum of the largest tumor diameter plus the number of lesions before LT (odds ratio 1.3; P = .01) and AFP ≥ 20 (odds ratio 5.9; P = .005) associated with understaging. Post-LT 3-year survival was 91% for AC vs 81% for UNOS-DS (P = .67). In this first prospective multiregional study of AC patients from the multicenter evaluation of reduction in tumor size before liver transplantation (MERITS-LT) consortium, we observed a 65% probability of successful DS. Three-year survival in AC was nearly 60%, though AC with Child-Pugh B/C or AFP ≥ 500 had poor survival. Explant pathology and 3-year post-LT outcomes were similar between cohorts, suggesting that LT is a reasonable goal in selected AC patients.
Collapse
Affiliation(s)
- Brahma Natarajan
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - Parissa Tabrizian
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maarouf Hoteit
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine Frenette
- Center for Organ and Cell Transplantation, Scripps Green Hospital, La Jolla, California, USA
| | - Neehar Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Tara Ghaziani
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California, USA
| | - Renu Dhanasekaran
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California, USA
| | - Jennifer Guy
- Department of Transplantation, California Pacific Medical Center, San Francisco, California, USA
| | - Amy Shui
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - Sander Florman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Francis Y Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA.
| |
Collapse
|
12
|
Mehta N, Kotwani P, Norman J, Shui A, Saxena V, Chan W, Yao FY. AFP-L3 and DCP are superior to AFP in predicting waitlist dropout in HCC patients: Results of a prospective study. Liver Transpl 2023; 29:1041-1049. [PMID: 37159217 PMCID: PMC10523909 DOI: 10.1097/lvt.0000000000000149] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/28/2023] [Indexed: 05/10/2023]
Abstract
In patients with HCC awaiting liver transplantation (LT), there is a need to identify biomarkers that are superior to AFP in predicting prognosis. AFP-L3 and des-gamma-carboxyprothrombin (DCP) play a role in HCC detection, but their ability to predict waitlist dropout is unknown. In this prospective single-center study commenced in July 2017, 267 HCC patients had all 3 biomarkers obtained at LT listing. Among them, 96.2% received local-regional therapy, and 18.8% had an initial tumor stage beyond Milan criteria requiring tumor downstaging. At listing, median AFP was 7.0 ng/mL (IQR 3.4-21.5), median AFP-L3 was 7.1% (IQR 0.5-12.5), and median DCP was 1.0 ng/mL (IQR 0.2-3.8). After a median follow-up of 19.3 months, 63 (23.6%) experienced waitlist dropout, while 145 (54.3%) received LT, and 59 (22.1%) were still awaiting LT. Using Cox proportional hazards analysis, AFP-L3≥35% and DCP≥7.5 ng/mL were associated with increased waitlist dropout, whereas AFP at all tested cutoffs, including ≥20,≥ 100, and≥250 ng/mL was not. In a multivariable model, AFP-L3≥35% (HR 2.25, p =0.04) and DCP≥7.5 ng/mL (HR 2.20, p =0.02) remained associated with waitlist dropout as did time from HCC diagnosis to listing ≥ 1 year and increasing MELD-Na score. Kaplan-Meier probability of waitlist dropout within 2 years was 21.8% in those with AFP-L3<35% and DCP<7.5 ng/mL, 59.9% with either AFP-L3 or DCP elevated, and 100% for those with both elevated ( p <0.001). In this prospective study, listing AFP-L3% and DCP were superior to AFP in predicting waitlist dropout with the combination of AFP-L3≥35% and DCP≥7.5 ng/mL associated with a 100% risk of waitlist dropout, thus clearly adding prognostic value to AFP alone.
Collapse
Affiliation(s)
- Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
| | - Prashant Kotwani
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
| | - Joshua Norman
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
| | - Amy Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Varun Saxena
- Department of Gastroenterology and Transplant Hepatology, Kaiser Permanente South San Francisco
| | - Wesley Chan
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
| | - Francis Y. Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
| |
Collapse
|
13
|
Norman J, Mehta N, Kwong A. Optimizing liver transplant prioritization for hepatocellular carcinoma through risk stratification. Curr Opin Organ Transplant 2023; 28:265-270. [PMID: 37339511 DOI: 10.1097/mot.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
PURPOSE OF REVIEW In the United States, candidates with hepatocellular carcinoma (HCC) meeting standardized qualifying criteria receive similar priority on the liver transplant waiting list through Model for End-Stage Liver Disease exception points, without consideration of the dropout risk or relative expected benefit from liver transplantation. A more nuanced allocation scheme for HCC is needed to better represent the individual urgency for liver transplant and optimize organ utility. In this review, we discuss the development of HCC risk prediction models for practical use in liver allocation. RECENT FINDINGS HCC is a heterogenous disease that requires improved risk stratification for patients who fall within current transplant eligibility criteria. Several models have been proposed, though none have been adopted in clinical practice or liver allocation to date, due to various limitations. SUMMARY Improved HCC risk stratification for liver transplant candidates is needed to more accurately represent their urgency for transplant, with continued attention to the potential impact on post-liver transplant outcomes. Plans to implement a continuous distribution model for liver allocation in the United States may provide an opportunity to re-consider a more equitable allocation scheme for patients with HCC.
Collapse
Affiliation(s)
- Joshua Norman
- Department of Medicine, Stanford University, Stanford
| | - Neil Mehta
- Division of Gastroenterology, University of California, San Francisco, San Francisco
| | - Allison Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, USA
| |
Collapse
|
14
|
Wu X, Heller M, Kwong A, Fidelman N, Mehta N. Cost-Effectiveness Analysis of Interventional Liver-Directed Therapies for a Single, Small Hepatocellular Carcinoma in Liver Transplant Candidates. J Vasc Interv Radiol 2023:S1051-0443(23)00170-7. [PMID: 36804296 DOI: 10.1016/j.jvir.2023.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/01/2023] [Accepted: 02/12/2023] [Indexed: 02/18/2023] Open
Abstract
PURPOSE To assess the cost effectiveness of 3 main locoregional therapies (LRTs) (transarterial chemoembolization [TACE], transarterial radioembolization [TARE], and percutaneous ablation) as bridging therapy. MATERIALS AND METHODS A cost-effectiveness analysis was performed comparing the 3 LRTs for patients with a single hepatocellular carcinoma (HCC) with a diameter of 3 cm or less over a 5-year time horizon from a payer's perspective. The clinical courses, including transplantation, decompensation resulting in delisting, and the need for a second LRT, were based on data from the United Network for Organ Sharing (2016-2019). Costs and effectiveness were measured in U.S. dollars and quality-adjusted life-years, respectively. Probabilistic and deterministic sensitivity analyses were performed. RESULTS A total of 2,594, 1,576, and 903 patients underwent TACE, ablation, and TARE, respectively. Ablation was the dominant strategy, with the lowest expected cost and highest effectiveness. The probabilistic sensitivity analysis demonstrated that ablation was the most cost-effective strategy in 93.9% of simulations. A subgroup analysis was performed for different wait times, with ablation remaining the most cost-effective strategy. The sensitivity analysis showed that ablation was most effective if the risk of waitlist dropout was less than 2.00% and the rate of transplantation was more than 15.1% quarterly. TARE was most effective if the risk of dropout was less than 1.19% and the rate of transplantation was more than 24.0%. TACE was most effective if the risk of dropout was less than 1.01% and the rate of transplantation was more than 45.7%. Ablation remained the most cost-effective modality until its procedural cost was more than $34,843. CONCLUSIONS Ablation is the most cost-effective bridging strategy for patients with a single, small (≤3 cm) HCC prior to liver transplantation. The conclusion remained robust in multiple sensitivity analyses.
Collapse
Affiliation(s)
- Xiao Wu
- Department of Radiology and Biomedical Imaging, Stanford University, San Francisco, California
| | - Michael Heller
- Department of Radiology and Biomedical Imaging, Stanford University, San Francisco, California
| | - Allison Kwong
- Department of Gastroenterology & Hepatology, Stanford University, San Francisco, California
| | - Nicholas Fidelman
- Department of Radiology and Biomedical Imaging, Stanford University, San Francisco, California
| | - Neil Mehta
- Department of General Hepatology and Liver Transplantation, University of California, Stanford University, San Francisco, California.
| |
Collapse
|
15
|
Lazzarotto-da-Silva G, Grezzana-Filho TJM, Scaffaro LA, Farenzena M, Silva RK, de Araujo A, Arruda S, Feier FH, Prediger L, Lazzaretti GS, Alvares-da-Silva MR, Chedid AD, Kruel CRP, Chedid MF. Percutaneous ethanol injection is an acceptable bridging therapy to hepatocellular carcinoma prior to liver transplantation. Langenbecks Arch Surg 2023; 408:26. [PMID: 36639606 DOI: 10.1007/s00423-022-02750-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 10/20/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Locoregional therapies (LRT) are employed for bridging patients with hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT). Although the main LRT options include transarterial chemoembolization (TACE) and radiofrequency ablation (RFA), percutaneous ethanol injection (PEI) is an alternative with considerably lower costs. This study is a pioneering evaluation of the natural history of PEI bridging to OLT as compared to TACE. METHODS All consecutive cirrhotic patients with HCC enlisted for OLT (2011-2020) at a single center were analyzed. Patients were divided into three LRT modality groups: PEI, TACE, and PEI+TACE. The primary study outcome was waitlist dropout due to tumor progression beyond Milan criteria. A comparison of post-transplant outcomes of patients as stratified by LRT modality also was performed. RESULTS One hundred twenty-nine patients were included (PEI=56, TACE=43, PEI+TACE=30). The dropout rate due to tumor progression was not different among the three groups: PEI=8.9%, TACE=14%, PEI+TACE=16.7% (p=0.54). Thirteen (76.4%) patients underwent OLT after successful downstaging (3 [75%] in the PEI group, 5 [83.3%] in the TACE group, and 5 [71.4%] in the PEI+TACE group). For the 96 patients undergoing OLT, 5-year post-transplant recurrence-free survival was PEI=55.6% vs. TACE=55.1% vs. PEI+TACE=71.4% (p=0.42). Complete/near-complete pathological response rate was similar among groups (p=0.82). CONCLUSION Dropout rates and post-transplant recurrence-free survivals related to PEI were comparable to those of TACE. This study supports the use of PEI alone or in combination with TACE for HCC patients awaiting OLT whenever RFA is not an option.
Collapse
Affiliation(s)
- Gabriel Lazzarotto-da-Silva
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Tomaz J M Grezzana-Filho
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Leandro A Scaffaro
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Mauricio Farenzena
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Rafaela K Silva
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Alexandre de Araujo
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Soraia Arruda
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Flavia H Feier
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Lucas Prediger
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Glória S Lazzaretti
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Mario R Alvares-da-Silva
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Aljamir D Chedid
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Cleber R P Kruel
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil
| | - Marcio F Chedid
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 91340-400, Brazil.
| |
Collapse
|
16
|
Kwong AJ, Mehta N. Liver allocation policies for hepatocellular carcinoma have leveled the playing field-But who should be playing? Liver Transpl 2022; 28:1821-1822. [PMID: 35959967 DOI: 10.1002/lt.26555] [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: 08/03/2022] [Accepted: 08/03/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Allison J Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, USA
| | - Neil Mehta
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
17
|
Minoux K, Lassailly G, Ningarhari M, Lubret H, El Amrani M, Canva V, Truant S, Mathurin P, Louvet A, Lebuffe G, Goria O, Nguyen-Khac E, Boleslawski E, Dharancy S. Neo-Adjuvant Use of Sorafenib for Hepatocellular Carcinoma Awaiting Liver Transplantation. Transpl Int 2022; 35:10569. [PMID: 36438781 PMCID: PMC9681796 DOI: 10.3389/ti.2022.10569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 10/21/2022] [Indexed: 12/01/2023]
Abstract
Data on efficacy and safety of sorafenib in a neoadjuvant setting for HCC awaiting liver transplantation (LT) are heterogeneous and scarce. We aimed to investigate the trajectory of patients treated with sorafenib while awaiting LT. All patients listed for HCC and treated with sorafenib were included in a monocentric observational study. A clinical and biological evaluation was performed every month. Radiological tumor response evaluation was realized every 3 months on the waiting list and every 6 months after LT. Among 327 patients listed for HCC, 62 (19%) were treated with Sorafenib. Sorafenib was initiated for HCC progression after loco-regional therapy (LRT) in 50% of cases and for impossibility of LRT in 50% of cases. The mean duration of treatment was 6 months. Thirty six patients (58%) dropped-out for tumor progression and 26 (42%) patients were transplanted. The 5-year overall and recurrent-free survival after LT was 77% and 48% respectively. Patients treated for impossibility of LRT had acceptable 5-year intention-to-treat overall and post-LT survivals. Conversely, patients treated for HCC progression presented high dropout rate and low intention-to-treat survival. Our results suggest that it is very questionable in terms of utility that patients treated for HCC progression should even be kept listed once the tumor progression has been observed.
Collapse
Affiliation(s)
- Kate Minoux
- CHU Lille, Department of Hepatogastroenterology, Lille, France
- INSERM U995, University of Lille, Lille, France
| | - Guillaume Lassailly
- CHU Lille, Department of Hepatogastroenterology, Lille, France
- INSERM U995, University of Lille, Lille, France
| | - Massih Ningarhari
- CHU Lille, Department of Hepatogastroenterology, Lille, France
- INSERM U995, University of Lille, Lille, France
| | - Henri Lubret
- CHU Lille, Department of Hepatogastroenterology, Lille, France
- INSERM U995, University of Lille, Lille, France
| | - Medhi El Amrani
- CHU Lille, Department of Digestive Surgery and Transplantation, University of Lille, Lille, France
| | - Valérie Canva
- CHU Lille, Department of Hepatogastroenterology, Lille, France
- INSERM U995, University of Lille, Lille, France
| | - Stéphanie Truant
- CHU Lille, Department of Digestive Surgery and Transplantation, University of Lille, Lille, France
| | - Philippe Mathurin
- CHU Lille, Department of Hepatogastroenterology, Lille, France
- INSERM U995, University of Lille, Lille, France
| | - Alexandre Louvet
- CHU Lille, Department of Hepatogastroenterology, Lille, France
- INSERM U995, University of Lille, Lille, France
| | - Gilles Lebuffe
- CHU Lille, Department of Anesthesiology, Resuscitation, and Critical Care Anesthesiology, University of Lille, Lille, France
| | - Odile Goria
- CHU Rouen, Department of Hepatogastroenterology, Hôpital Charles Nicolle, Rouen, France
| | - Eric Nguyen-Khac
- CHU Amiens-Picardie, Hôpital Sud, Department of Hepatogastroenterology, Amiens, France
- CHU Amiens, Centre Universitaire de Recherche en Santé (CURS), Université de Picardie-Jules-Verne (UPJV), Groupe de Recherche sur l’alcool et les Pharmacodépendances (GRAP), Inserm U1247, Amiens, France
| | - Emmanuel Boleslawski
- CHU Lille, Department of Digestive Surgery and Transplantation, University of Lille, Lille, France
| | - Sebastien Dharancy
- CHU Lille, Department of Hepatogastroenterology, Lille, France
- INSERM U995, University of Lille, Lille, France
| |
Collapse
|
18
|
Magnetic Resonance Imaging Predictors of Hepatocellular Carcinoma Progression and Dropout in Patients in Liver Transplantation Waiting List. Transplant Direct 2022; 8:e1365. [PMID: 36284930 PMCID: PMC9584197 DOI: 10.1097/txd.0000000000001365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022] Open
Abstract
UNLABELLED With the rising incidence of hepatocellular carcinoma (HCC), more patients are now eligible for liver transplantation. Consequently, HCC progression and dropout from the waiting list are also anticipated to rise. We developed a predictive model based on radiographic features and alpha-fetoprotein to identify high-risk patients. METHODS This is a case-cohort retrospective study of 76 patients with HCC who were listed for liver transplantation with subsequent liver transplantation or delisting due to HCC progression. We analyzed imaging-based predictive variables including tumor margin (well- versus ill-defined), capsule bulging lesions, volumetric analysis and distance to portal vein, tumor numbers, and tumor diameter. Volumetric analysis of the index lesions was used to quantify index tumor total volume and volumetric enhancement, whereas logistic regression and receiver operating characteristic curve (ROC) analyses were used to predict the main outcome of disease progression. RESULTS In univariate analyses, the following baseline variables were significantly associated with disease progression: size and number of lesions, sum of lesion diameters, lesions bulging the capsule, and total and venous-enhancing (viable) tumor volumes. Based on multivariable analyses, a risk model including lesion numbers and diameter, capsule bulging, tumor margin (infiltrative versus well-defined), and alpha-fetoprotein was developed to predict HCC progression and dropout. The model has an area under the ROC of 82%, which was significantly higher than Milan criteria that has an area under the ROC of 67%. CONCLUSIONS Our model has a high predictive test for patient dropout due to HCC progression. This model can identify high-risk patients who may benefit from more aggressive HCC treatment early after diagnosis to prevent dropout due to such disease progression.
Collapse
|
19
|
Hepatocellular Carcinoma, Alpha Fetoprotein, and Liver Allocation for Transplantation: Past, Present and Future. Curr Oncol 2022; 29:7537-7551. [PMID: 36290870 PMCID: PMC9600271 DOI: 10.3390/curroncol29100593] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/01/2022] [Accepted: 10/02/2022] [Indexed: 11/05/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the leading indications for liver transplantation and has been the treatment of choice due to the oncologic benefit for patients with advanced chronic liver disease (AdvCLD) and small tumors for the last 25 years. For HCC patients undergoing liver transplantation, alpha fetoprotein (AFP) has increasingly been applied as an independent predictor for overall survival, disease free recurrence, and waitlist drop out. In addition to static AFP, newer studies evaluating the AFP dynamic response to downstaging therapy show enhanced prognostication compared to static AFP alone. While AFP has been utilized to select HCC patients for transplant, despite years of allocation policy changes, the US allocation system continues to take a uniform approach to HCC patients, without discriminating between those with favorable or unfavorable tumor biology. We aim to review the history of liver allocation for HCC in the US, the utility of AFP in liver transplantation, the implications of weaving AFP as a biomarker into policy. Based on this review, we encourage the US transplant community to revisit its HCC organ allocation model, to incorporate more precise oncologic principles for patient selection, and to adopt AFP dynamics to better stratify waitlist dropout risk.
Collapse
|
20
|
Su K, Guo L, Ma W, Wang J, Xie Y, Rao M, Zhang J, Li X, Wen L, Li B, Yang X, Song Y, Huang W, Chi H, Gu T, Xu K, Liu Y, Chen J, Wu Z, Jiang Y, Li H, Zeng H, Wang P, Feng X, Chen S, Yang B, Jin H, He K, Han Y. PD-1 inhibitors plus anti-angiogenic therapy with or without intensity-modulated radiotherapy for advanced hepatocellular carcinoma: A propensity score matching study. Front Immunol 2022; 13:972503. [PMID: 36211350 PMCID: PMC9539675 DOI: 10.3389/fimmu.2022.972503] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundWhether intensity-modulated radiotherapy (IMRT) can enhance the efficacy of the programmed death (PD)-1 inhibitors combined with anti-angiogenic therapy for hepatocellular carcinoma (HCC) is unclear. Therefore, we conducted this multicenter retrospective study to investigate the efficacy of the combination of PD-1 inhibitors with anti-angiogenic therapy and IMRT.MethodsFrom April 2019 to March 2022, a total of 197 patients with HCC [combination of PD-1 inhibitors with anti-angiogenic therapy and IMRT (triple therapy group), 54; PD-1 inhibitors plus anti-angiogenic therapy (control group), 143] were included in our study. Propensity score matching (PSM) was applied to identify two groups with similar baselines. The objective response rate (ORR), overall survival (OS), and progression-free survival (PFS) of the two groups were compared before and after matching.ResultsPrior to PSM, the triple therapy group had higher ORR (42.6% vs 24.5%, P = 0.013) and more superior median OS (mOS) (20.1 vs 13.3 months, P = 0.009) and median PFS (mPFS) (8.7 vs 5.4 months, P = 0.001) than the control group. Following PSM, the triple therapy group still exhibited better mPFS (8.7 vs 5.4 months, P = 0.013) and mOS (18.5 vs 12.6 months, P = 0.043) than the control group. However, the ORR of the two groups was similar (40% vs 25%, P = 0.152). No significant difference was observed in the treatment-related adverse events between the two groups (P < 0.05 for all). ConclusionsThe combination of PD-1 inhibitors with anti-angiogenic therapy and IMRT for HCC is a promising regimen.
Collapse
Affiliation(s)
- Ke Su
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Lu Guo
- Department of Ophthalmology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wenqiong Ma
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jing Wang
- Clinical Research Institute, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yunchuan Xie
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Mingyue Rao
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jianwen Zhang
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xueting Li
- Department of Oncology, 363 Hospital, Chengdu, China
| | - Lianbin Wen
- Department of Geriatric Cardiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
| | - Bo Li
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
- Academician (Expert) Workstation of Sichuan Province, Luzhou, China
| | - Xiaoli Yang
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
- Academician (Expert) Workstation of Sichuan Province, Luzhou, China
| | - Yanqiong Song
- Department of Radiotherapy, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Weihong Huang
- Clinical Medical College, Southwest Medical University, Luzhou, China
| | - Hao Chi
- Clinical Medical College, Southwest Medical University, Luzhou, China
| | - Tao Gu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ke Xu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yanlin Liu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiali Chen
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zhenying Wu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yi Jiang
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Han Li
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hao Zeng
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Pan Wang
- Clinical Skills Center, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xunjie Feng
- Clinical Medical College, Southwest Medical University, Luzhou, China
| | - Siyu Chen
- Clinical Medical College, Southwest Medical University, Luzhou, China
| | - Binbin Yang
- Clinical Medical College, Southwest Medical University, Luzhou, China
| | - Hongping Jin
- Clinical Medical College, Southwest Medical University, Luzhou, China
| | - Kun He
- Clinical Research Institute, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- *Correspondence: Yunwei Han, ; Kun He,
| | - Yunwei Han
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
- Academician (Expert) Workstation of Sichuan Province, Luzhou, China
- *Correspondence: Yunwei Han, ; Kun He,
| |
Collapse
|
21
|
Huang AC, Dodge JL, Yao FY, Mehta N. National Experience on Waitlist Outcomes for Down-Staging of Hepatocellular Carcinoma: High Dropout Rate in All-Comers. Clin Gastroenterol Hepatol 2022; 21:1581-1589. [PMID: 36038129 DOI: 10.1016/j.cgh.2022.08.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/26/2022] [Accepted: 08/16/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The United Network for Organ Sharing (UNOS) grants priority listing for liver transplant for patients with hepatocellular carcinoma after successful down-staging to Milan criteria. We evaluated the national experience on down-staging by comparing 2 down-staging groups: tumor burden meeting UNOS down-staging (UNOS-DS) inclusion criteria, and all-comers (AC)-DS with initial tumor burden beyond UNOS-DS criteria vs patients always within Milan criteria. METHODS We performed a retrospective analysis of the UNOS database of 23,398 patients listed for liver transplant who had submitted a hepatocellular carcinoma Model for End-Stage Liver Disease exception application from 2010 to 2019, classified as always within Milan (n = 20,579), UNOS-DS (n = 2151), and AC-DS (n = 668). RESULTS The 2-year cumulative probabilities of dropout were 19% for Milan, 25% for UNOS-DS (P < .001), and 30% for AC-DS (P < .001). In multivariate analysis of the down-staging groups, factors predicting dropout included Model for End-Stage Liver Disease at listing (hazard ratio [HR], 1.06; P < .001) and initial total tumor diameter (HR, 1.04; P = .002). Compared with α-fetoprotein (AFP) level ≤20 ng/mL, AFP levels of 21 to 100, 101 to 1000, and greater than 1000 ng/mL were associated with a higher risk of dropout (HRs, 1.63, 2.06, and 4.58, respectively; P < .001). A subset of all-comers with AFP levels greater than 100 ng/mL had a 2-year probability of dropout of 52% vs 26% for all others beyond Milan criteria (P < .001). CONCLUSIONS All-comers had a significantly higher risk for waitlist dropout compared with the UNOS-DS and Milan groups after initial successful down-staging to Milan criteria. In particular, the subgroup of AC-DS with an AFP level greater than 100 ng/mL had a greater than 50% probability of dropout in the next 2 years. These observations suggest a high likelihood of failure when expanding the indications for down-staging.
Collapse
Affiliation(s)
- Annsa C Huang
- Division of Gastroenterology/Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jennifer L Dodge
- Division of Gastroenterology, Department of Medicine, University of Southern California, Los Angeles, California; Department of Preventive Medicine, University of Southern California, Los Angeles, California
| | - Francis Y Yao
- Division of Gastroenterology/Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California; Department of Surgery, University of California San Francisco, San Francisco, California
| | - Neil Mehta
- Division of Gastroenterology/Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California.
| |
Collapse
|
22
|
Piñero F, Thompson M, Boin I, Chagas A, Quiñonez E, Bermúdez C, Vilatobá M, Santos L, Anders M, Hoyos Duque S, Soares Lima A, Menendez J, Padilla M, Poniachik J, Zapata R, Maraschio M, Chong Menéndez R, Muñoz L, Arufe D, Figueroa R, Perales SR, Maccali C, Vergara Sandoval R, McCormack L, Varón A, Marciano S, Mattera J, Carrilho F, Silva M. Performance of pre-transplant criteria in prediction of hepatocellular carcinoma progression and waitlist dropout. Liver Int 2022; 42:1879-1890. [PMID: 35304813 DOI: 10.1111/liv.15223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/08/2022] [Accepted: 02/25/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIM Liver transplantation (LT) selection models for hepatocellular carcinoma (HCC) have not been proposed to predict waitlist dropout because of tumour progression. The aim of this study was to compare the alpha-foetoprotein (AFP) model and other pre-LT models in their prediction of HCC dropout. METHODS A multicentre cohort study was conducted in 20 Latin American transplant centres, including 994 listed patients for LT with HCC from 2012 to 2018. Longitudinal tumour characteristics, and patterns of progression were recorded at time of listing, after treatments and at last follow-up over the waitlist period. Competing risk regression models were performed, and model's discrimination was compared estimating Harrell's adapted c-statistics. RESULTS HCC dropout rate was significantly higher in patients beyond (24% [95% CI 16-28]) compared to those within Milan criteria (8% [95% IC 5%-12%]; p < .0001), with a SHR of 3.01 [95% CI 2.03-4.47]), adjusted for waiting list time and bridging therapies (c-index 0.63 [95% CI 0.57; 0.69). HCC dropout rates were higher in patients with AFP scores >2 (adjusted SHR of 3.17 [CI 2.13-4.71]), c-index of 0.71 (95% CI 0.65-0.77; p = .09 vs Milan). Similar discrimination power for HCC dropout was observed between the AFP score and the Metroticket 2.0 model. In patients within Milan, an AFP score >2 points discriminated two populations with a higher risk of HCC dropout (SHR 1.68 [95% CI 1.08-2.61]). CONCLUSIONS Pre-transplant selection models similarly predicted HCC dropout. However, the AFP model can discriminate a higher risk of dropout among patients within Milan criteria.
Collapse
Affiliation(s)
- Federico Piñero
- Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires, Argentina.,Hospital Universitario Austral, University, School of Medicine, Buenos Aires, Argentina
| | - Marcos Thompson
- Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires, Argentina
| | - Ilka Boin
- Hospital das Clínicas UNICAMP Campinas, Sao Paulo, Brazil
| | - Aline Chagas
- Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas Department of Gastroenterology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Carla Bermúdez
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mario Vilatobá
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | | | | | - Sergio Hoyos Duque
- Hospital Pablo Tobón Uribe & Gastroenterology group from the University of Antioquia, Medellín, Colombia
| | - Agnaldo Soares Lima
- Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Martín Padilla
- Universidad Nacional de San Marcos, Hospital Guillermo Almenara, Lima, Peru
| | | | - Rodrigo Zapata
- Clínica Alemana, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | | | | | - Linda Muñoz
- Hospital Universitario "Dr. José E. González", Monterrey, Mexico
| | - Diego Arufe
- Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | | | | | - Claudia Maccali
- Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas Department of Gastroenterology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | | | | | | | | | - Flair Carrilho
- Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas Department of Gastroenterology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Marcelo Silva
- Latin American Liver Research Educational and Awareness Network (LALREAN), Buenos Aires, Argentina.,Hospital Universitario Austral, University, School of Medicine, Buenos Aires, Argentina
| |
Collapse
|
23
|
Kwong AJ, Ghaziani TT, Mehta N. Decreased Urgency Among Liver Transplantation Candidates With Hepatocellular Carcinoma in the United States. Liver Transpl 2022; 28:725-727. [PMID: 34806834 DOI: 10.1002/lt.26373] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Allison J Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - T Tara Ghaziani
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Neil Mehta
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA
| |
Collapse
|
24
|
Bernards S, Hirose R, Yao FY, Jin C, Dodge JL, Huang CY, Mehta N. The Impact of Median Model for End-Stage Liver Disease at Transplant Minus 3 National Policy on Waitlist Outcomes in Patients With and Without Hepatocellular Carcinoma. Liver Transpl 2022; 28:376-385. [PMID: 34761847 PMCID: PMC8857020 DOI: 10.1002/lt.26368] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/20/2021] [Accepted: 10/21/2021] [Indexed: 01/13/2023]
Abstract
As a result of ongoing regional disparities, the United Network for Organ Sharing (UNOS) implemented policy in May 2019 limiting exception points for waitlisted patients with hepatocellular carcinoma (HCC) to median Model for End-Stage Liver Disease at transplant in the area surrounding a transplant center minus 3 points (MMAT-3). The impact of this policy change remains unknown. We included adult patients with HCC (n = 4567) and without HCC (n = 19,773) in the UNOS database added to the waiting list before this policy change (May 7, 2017-May 18, 2019) and after (May 19, 2019-March 7, 2020). Cumulative incidence analysis estimated the probability of dropout within 1 year of listing decreased from 12.9% before the policy to 11.1% after the policy in candidates without HCC and from 14% to 10.7% in candidates with HCC. Incidence rates of liver transplantation (LT) and waitlist dropout varied significantly before the policy in patients with HCC and without HCC but nearly equalized in the postpolicy era. These effects were observed in both shorter and longer wait regions. With policy change being modeled as a time-dependent covariate, competing risk regression analyses estimated a decreased risk of dropout after policy change in the non-HCC group (cause-specific hazard ratio, 0.91; P = 0.02) after adjusting for demographic variables. These results suggest that the MMAT-3 policy has successfully reduced disparities in access to LT including across UNOS wait regions, although certain patients with HCC are now disadvantaged.
Collapse
Affiliation(s)
- Sarah Bernards
- Department of Medicine, University of California, San Francisco; San Francisco, CA
| | - Ryutaro Hirose
- Department of Surgery, University of California, San Francisco; San Francisco, CA
| | - Francis Y. Yao
- Department of Medicine, University of California, San Francisco; San Francisco, CA,Department of Surgery, University of California, San Francisco; San Francisco, CA
| | - Chengshi Jin
- Department of Surgery, University of California, San Francisco; San Francisco, CA
| | - Jennifer L. Dodge
- Department of Medicine, University of Southern California; Los Angeles, CA
| | - Chiung-Yu Huang
- Department of Surgery, University of California, San Francisco; San Francisco, CA
| | - Neil Mehta
- Department of Medicine, University of California, San Francisco; San Francisco, CA
| |
Collapse
|
25
|
Kwong A, Hameed B, Syed S, Ho R, Mard H, Arshad S, Ho I, Suleman T, Yao F, Mehta N. Machine learning to predict waitlist dropout among liver transplant candidates with hepatocellular carcinoma. Cancer Med 2022; 11:1535-1541. [PMID: 35029055 PMCID: PMC8921896 DOI: 10.1002/cam4.4538] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/30/2021] [Accepted: 12/04/2021] [Indexed: 12/18/2022] Open
Abstract
Background Accurate prediction of outcome among liver transplant candidates with hepatocellular carcinoma (HCC) remains challenging. We developed a prediction model for waitlist dropout among liver transplant candidates with HCC. Methods The study included 18,920 adult liver transplant candidates in the United States listed with a diagnosis of HCC, with data provided by the Organ Procurement and Transplantation Network. The primary outcomes were 3‐, 6‐, and 12‐month waitlist dropout, defined as removal from the liver transplant waitlist due to death or clinical deterioration. Results Using 1,181 unique variables, the random forest model and Spearman's correlation analyses converged on 12 predictive features involving 5 variables, including AFP (maximum and average), largest tumor size (minimum, average, and most recent), bilirubin (minimum and average), INR (minimum and average), and ascites (maximum, average, and most recent). The final Cox proportional hazards model had a concordance statistic of 0.74 in the validation set. An online calculator was created for clinical use and can be found at: http://hcclivercalc.cloudmedxhealth.com/. Conclusion In summary, a simple, interpretable 5‐variable model predicted 3‐, 6‐, and 12‐month waitlist dropout among patients with HCC. This prediction can be used to appropriately prioritize patients with HCC and their imminent need for transplant.
Collapse
Affiliation(s)
- Allison Kwong
- Division of Gastroenterology and Hepatology Stanford University Stanford USA
| | - Bilal Hameed
- Division of Gastroenterology University of California San Francisco California USA
| | - Shareef Syed
- Division of Transplant Surgery University of California San Francisco California USA
| | - Ryan Ho
- CloudMedx, Inc Palo Alto California USA
| | | | | | - Isaac Ho
- CloudMedx, Inc Palo Alto California USA
| | | | - Francis Yao
- Division of Gastroenterology University of California San Francisco California USA
| | - Neil Mehta
- Division of Gastroenterology University of California San Francisco California USA
| |
Collapse
|
26
|
Biolato M, Galasso T, Marrone G, Miele L, Grieco A. Upper Limits of Downstaging for Hepatocellular Carcinoma in Liver Transplantation. Cancers (Basel) 2021; 13:cancers13246337. [PMID: 34944957 PMCID: PMC8699392 DOI: 10.3390/cancers13246337] [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: 11/08/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Currently, most transplant centres worldwide accept patients with hepatocellular carcinoma who underwent successful downstaging. Concurrently, the effectiveness of radiological and systemic therapies used for the downstaging of hepatocellular carcinoma are increasing. It is now more frequently observed that candidates for liver transplantation have an excellent response to downstaging, even if the baseline stage was well beyond the transplantable tumour. Downstaged patients have a higher risk of dropout from the waiting list and post-transplant recurrence if not transplanted in a short time. Since an increasing number of downstaged patients affects the waitlist dynamics, the definition of upper limits of downstaging is becoming a crucial issue. In this narrative review, we summarise current evidence on the downstaging of hepatocellular carcinoma for liver transplantation, including downstaging of patients with macrovascular invasion or extrahepatic metastasis at presentation and employment of the new systemic treatments for hepatocellular carcinoma. Abstract In Europe and the United States, approximately 1100 and 1800 liver transplantations, respectively, are performed every year for hepatocellular carcinoma (HCC), compared with an annual incidence of 65,000 and 39,000 new cases, respectively. Because of organ shortages, proper patient selection is crucial, especially for those exceeding the Milan criteria. Downstaging is the reduction of the HCC burden to meet the eligibility criteria for liver transplantation. Many techniques can be used in downstaging, including ablation, chemoembolisation, radioembolisation and systemic treatments, with a reported success rate of 60–70%. In recent years, an increasing number of patient responders to downstaging procedures has been included in the waitlist, generally with a comparable five-year post-transplant survival but with a higher probability of dropout than HCC patients within the Milan criteria. While the Milan criteria are generally accepted as the endpoint of downstaging, the upper limits of tumour burden for downstaging HCC for liver transplantation are controversial. Very challenging situations involve HCC patients with large nodules, macrovascular invasion or even extrahepatic metastasis at baseline who respond to increasingly more effective downstaging procedures and who aspire to be placed on the waitlist for transplantation. This narrative review analyses the most important evidence available on cohorts subjected to “extended” downstaging, including HCC patients over the up-to-seven criteria and over the University of California San Francisco downstaging criteria. We also address surrogate markers of biological aggressiveness, such as alpha-fetoprotein and the response stability to locoregional treatments, which are very useful in selecting responders to downstaging procedures for waitlisting inclusion.
Collapse
Affiliation(s)
- Marco Biolato
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (M.B.); (G.M.); (L.M.)
- Institute of Internal Medicine, Catholic University of Sacred Hearth, 00168 Rome, Italy;
| | - Tiziano Galasso
- Institute of Internal Medicine, Catholic University of Sacred Hearth, 00168 Rome, Italy;
| | - Giuseppe Marrone
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (M.B.); (G.M.); (L.M.)
- Institute of Internal Medicine, Catholic University of Sacred Hearth, 00168 Rome, Italy;
| | - Luca Miele
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (M.B.); (G.M.); (L.M.)
- Institute of Internal Medicine, Catholic University of Sacred Hearth, 00168 Rome, Italy;
| | - Antonio Grieco
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (M.B.); (G.M.); (L.M.)
- Institute of Internal Medicine, Catholic University of Sacred Hearth, 00168 Rome, Italy;
- Correspondence:
| |
Collapse
|
27
|
Tapper EB, Mirabella R, Walicki JJ, Banales JM. Optimizing the use of twitter for research dissemination: The "Three Facts and a Story" randomized-controlled trial. J Hepatol 2021; 75:271-274. [PMID: 34062178 DOI: 10.1016/j.jhep.2021.05.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND & AIMS Published research promoted on twitter reaches more readers. Tweets with graphics are more engaging than those without. However, data are limited regarding how to optimize multimedia tweets for engagement. METHODS The "Three facts and a Story" trial is a randomized-controlled trial comparing a tweet featuring a graphical abstract to paired tweets featuring the personal motivations behind the research and a summary of the findings. Fifty-four studies published by the Journal of Hepatology were randomized at the time of online publication. The primary endpoint was assessed at 28-days from online publication with a primary outcome of full-text downloads from the website. Secondary outcomes included page views and twitter engagement including impressions, likes, and retweets. RESULTS Overall, 31 studies received standard tweets and 23 received story tweets. Five studies were randomized to story tweets but crossed over to standard tweets for lack of author participation. Most papers tweeted were original articles (94% standard, 91% story) and clinical topics (55% standard, 61% story). Story tweets were associated with a significant increase in the number of full text downloads, 51 (34-71) vs. 25 (13-41), p = 0.002. There was also a non-significant increase in the number of page views. Story tweets generated an average of >1,000 more impressions than standard tweets (5,388 vs. 4,280, p = 0.002). Story tweets were associated with a similar number of retweets, and a non-significant increase in the number of likes. CONCLUSION Tweets featuring the authors and their motivations may increase engagement with published research.
Collapse
Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, USA.
| | - Rossana Mirabella
- Editorial Office, Journal of Hepatology, 7 Rue Daubin, 1203 Geneva, Switzerland
| | - Joël J Walicki
- Editorial Office, Journal of Hepatology, 7 Rue Daubin, 1203 Geneva, Switzerland
| | - Jesus M Banales
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute - Donostia University Hospital -, University of the Basque Country (UPV/EHU), CIBERehd, Ikerbasque, San Sebastian, Spain
| |
Collapse
|
28
|
Brusset B, Dumortier J, Cherqui D, Pageaux GP, Boleslawski E, Chapron L, Quesada JL, Radenne S, Samuel D, Navarro F, Dharancy S, Decaens T. Liver Transplantation for Hepatocellular Carcinoma: A Real-Life Comparison of Milan Criteria and AFP Model. Cancers (Basel) 2021; 13:cancers13102480. [PMID: 34069594 PMCID: PMC8160826 DOI: 10.3390/cancers13102480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary The α-fetoprotein (AFP) model officially replaced the Milan criteria in France for liver transplantation (LT) for hepatocellular carcinoma (HCC) in January 2013. The aim of our retrospective study was to analyze the agreement of the criteria and the results of LT with an intention-to-treat design since the adoption of the AFP model and to compare them to the practice and results of LT before the adoption of the AFP model. We did not observe significant changes in practices in 523 consecutively listed patients, with a good agreement (88%) to AFP criteria on the explants before and after the adoption of the AFP model. However, the prognosis of patients listed in the most recent period was worse, maybe because of a significant increase in bridging treatments and in the waiting time. This observational study provides an insight into the real-life course of LT for HCC. Abstract Purpose: To compare the agreement for the criteria on the explant and the results of liver transplantation (LT) before and after adoption of the AFP (α-fetoprotein) model. Methods: 523 patients consecutively listed in five French centers were reviewed to compare results of the Milan criteria period (MilanCP, n = 199) (before 2013) and the AFP score period (AFPscP, n = 324) (after 2013). (NCT03156582). Results: During AFPscP, there was a significantly longer waiting time on the list (12.3 vs. 7.7 months, p < 0.001) and higher rate of bridging therapies (84 vs. 75%, p = 0.012) compared to the MilanCP. Dropout rate was slightly higher in the AFPscP (31 vs. 24%, p = 0.073). No difference was found in the histological AFP score between groups (p = 0.838) with a global agreement in 88% of patients. Post-LT recurrence was 9.2% in MilanCP vs. 13.2% in AFPscP (p = 0.239) and predictive factors were AFP > 2 on the last imaging, downstaging policy and salvage transplantation. Post-LT survival was similar (83 vs. 87% after 2 years, p = 0.100), but after propensity score analysis, the post-listing overall survival (OS) was worse in the AFPscP (HR 1.45, p = 0.045). Conclusions: Agreement for the AFP model on explant analysis (≤2) did not significantly change. AFP score > 2 was the major prognostic factor for recurrence. Graft allocation policy has a major impact on prognosis, with a post-listing OS significantly decreased, probably due to the increase in waiting time, increase in bridging therapies, downstaging policy and salvage transplantation.
Collapse
Affiliation(s)
- Bleuenn Brusset
- Faculty of Medicine, University Grenoble-Alpes, 38000 Grenoble, France;
- CHU Grenoble-Alpes, 38000 Grenoble, France; (L.C.); (J.-L.Q.)
| | - Jerome Dumortier
- Hospices Civiles de Lyon, Hôpital Edouard Herriot, 69003 Lyon, France;
| | - Daniel Cherqui
- Assistance Publique des Hôpitaux de Paris, Hôpital Paul Brousse, Centre Hépato-Biliaire, 94800 Villejuif, France; (D.C.); (D.S.)
| | | | | | | | | | - Sylvie Radenne
- Hospices Civiles de Lyon, Hôpital de la Croix Rousse, 69004 Lyon, France;
| | - Didier Samuel
- Assistance Publique des Hôpitaux de Paris, Hôpital Paul Brousse, Centre Hépato-Biliaire, 94800 Villejuif, France; (D.C.); (D.S.)
| | - Francis Navarro
- CHU de Montpellier, 34295 Montpellier, France; (G.-P.P.); (F.N.)
| | | | - Thomas Decaens
- Faculty of Medicine, University Grenoble-Alpes, 38000 Grenoble, France;
- CHU Grenoble-Alpes, 38000 Grenoble, France; (L.C.); (J.-L.Q.)
- Institute for Advanced Biosciences, Research Center UGA/Inserm U 1209/CNRS 5309, 38000 Grenoble, France
- Correspondence: ; Tel.: +33-4-7676-5441
| |
Collapse
|
29
|
The Relationship between Hepatic Myeloid-Derived Suppressor Cells and Clinicopathological Parameters in Patients with Chronic Liver Disease. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6612477. [PMID: 33860040 PMCID: PMC8024072 DOI: 10.1155/2021/6612477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/08/2021] [Accepted: 03/16/2021] [Indexed: 12/14/2022]
Abstract
Myeloid-derived suppressor cells (MDSCs) have attracted attention due to their important role in inflammation. Several studies have investigated the involvement of MDSCs in chronic liver disease. However, due to the difference of MDSC phenotypes, patient types, and sample sources among the studies, the results are inconsistent and controversial. We took advantage of a large well-defined cohort of 98 (24 patients with CHB, 18 with NAFLD, 13 with HCC, 16 with PBC, and 27 with AIH) patients with liver inflammation and 12 healthy controls to investigate the expression of MDSCs, and the relationships between the expression of hepatic MDSCs and the clinical characteristics were analyzed. We found that the expression of CD11b+CD33+ MDSCs is closely related to chronic liver disease and positively correlated with clinical parameters such as ALT, AST, and globulin. Ultimately, the present study suggests that hepatic CD11b+CD33+ MDSCs are increased in HCC and AIH and positively correlate with the liver stages of hepatitis activity and liver fibrosis stage.
Collapse
|
30
|
Gundlach JP, Schmidt S, Bernsmeier A, Günther R, Kataev V, Trentmann J, Schäfer JP, Röcken C, Becker T, Braun F. Indication of Liver Transplantation for Hepatocellular Carcinoma Should Be Reconsidered in Case of Microvascular Invasion and Multilocular Tumor Occurrence. J Clin Med 2021; 10:jcm10061155. [PMID: 33801887 PMCID: PMC7998779 DOI: 10.3390/jcm10061155] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/21/2021] [Accepted: 03/03/2021] [Indexed: 02/07/2023] Open
Abstract
Liver transplantation (LT) is routinely performed for hepatocellular carcinoma (HCC) in cirrhosis without major vascular invasion. Although the adverse influence of microvascular invasion is recognized, its occurrence does not contraindicate LT. We retrospectively analyzed in our LT cohort the significance of microvascular invasion on survival and demonstrate bridging procedures. At our hospital, 346 patients were diagnosed with HCC, 171 patients were evaluated for LT, and 153 were listed at Eurotransplant during a period of 11 years. Among these, 112 patients received LT and were included in this study. Overall survival after 1, 3 and 5 years was 86.3%, 73.9%, and 67.9%, respectively. Microvascular invasion led to significantly reduced overall (p = 0.030) and disease-free survival (p = 0.002). Five-year disease-free survival with microvascular invasion was 10.5%. Multilocular tumor occurrence with simultaneous microvascular invasion revealed the worst prognosis. In our LT cohort, predominant bridging treatment was transarterial chemoembolization (TACE) and the number of TACE significantly correlated with poorer overall survival after LT (p = 0.028), which was confirmed in multiple Cox regression analysis for overall and disease-free survival (p = 0.015 and p = 0.011). Microvascular tumor invasion is significantly associated with reduced prognosis after LT, which is aggravated by simultaneous occurrence of multiple lesions. Therefore, indication strategies for LT should be reconsidered.
Collapse
Affiliation(s)
- Jan-Paul Gundlach
- Department of General, Visceral-, Thoracic-, Transplantation- and Pediatric Surgery, Campus Kiel, University Medical Center Schleswig-Holstein (UKSH), Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (S.S.); (A.B.); (T.B.); (F.B.)
- Correspondence: ; Tel.: +49-431-500-33421
| | - Stephan Schmidt
- Department of General, Visceral-, Thoracic-, Transplantation- and Pediatric Surgery, Campus Kiel, University Medical Center Schleswig-Holstein (UKSH), Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (S.S.); (A.B.); (T.B.); (F.B.)
| | - Alexander Bernsmeier
- Department of General, Visceral-, Thoracic-, Transplantation- and Pediatric Surgery, Campus Kiel, University Medical Center Schleswig-Holstein (UKSH), Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (S.S.); (A.B.); (T.B.); (F.B.)
| | - Rainer Günther
- Department of Internal Medicine I, UKSH, Campus Kiel, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (R.G.); (V.K.)
| | - Victor Kataev
- Department of Internal Medicine I, UKSH, Campus Kiel, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (R.G.); (V.K.)
| | - Jens Trentmann
- Institute of Radiology and Neuroradiology, UKSH, Campus Kiel, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (J.T.); (J.P.S.)
| | - Jost Philipp Schäfer
- Institute of Radiology and Neuroradiology, UKSH, Campus Kiel, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (J.T.); (J.P.S.)
| | - Christoph Röcken
- Department of Pathology, UKSH, Campus Kiel, Arnold-Heller-Strasse 3, 24105 Kiel, Germany;
| | - Thomas Becker
- Department of General, Visceral-, Thoracic-, Transplantation- and Pediatric Surgery, Campus Kiel, University Medical Center Schleswig-Holstein (UKSH), Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (S.S.); (A.B.); (T.B.); (F.B.)
| | - Felix Braun
- Department of General, Visceral-, Thoracic-, Transplantation- and Pediatric Surgery, Campus Kiel, University Medical Center Schleswig-Holstein (UKSH), Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (S.S.); (A.B.); (T.B.); (F.B.)
| |
Collapse
|