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Pagano D, Khouzam S, Magro B, Barbara M, Cintorino D, di Francesco F, Li Petri S, Bonsignore P, Calamia S, Deiro G, Cammà C, Canzonieri M, Gruttadauria S. How important is the role of iterative liver direct surgery in patients with hepatocellular carcinoma for a transplant center located in an area with a low rate of deceased donation? Front Oncol 2022; 12:929607. [PMID: 35965558 PMCID: PMC9372920 DOI: 10.3389/fonc.2022.929607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/28/2022] [Indexed: 12/24/2022] Open
Abstract
IntroductionHepatocellular carcinoma (HCC) accounts for nearly 90% of primary liver cancers, with estimates of over 1 million people affected by 2025. We aimed to explore the impacting role of an iterative surgical treatment approach in a cohort of HCC patients within the Milan criteria, associated with clinical risk factors for tumor recurrence (RHCC) after liver transplant (LT) and loco-regional therapies (LRT), as well as liver resection (LR) and/or microwave thermal ablation (MWTA).MethodsWe retrospectively analyzed our experience performed during an 8-year period between January 2013 and December 2021 in patients treated for HCC, focusing on describing the impact on preoperative end-stage liver disease severity, oncologic staging, tumor characteristics, and surgical treatments. The Cox model was used to evaluate variables that could predict relapse risks. Relapse risk curves were calculated according to the Kaplan–Meier method, and the log-rank test was used to compare them.ResultsThere were 557 HCC patients treated with a first-line approach of LR and/or LRTs (n = 335) or LT (n = 222). The median age at initial transplantation was 59 versus 68 for those whose first surgical approach was LR and/or LRT. In univariate analysis with the Cox model, nodule size was the single predictor of recurrence of HCC in the posttreatment setting (HR: 1.61, 95% CI: 1.05–2.47, p = 0.030). For the LRT group, we have enlightened the following clinical characteristics as significantly associated with RHCC: hepatitis B virus infection (which has a protective role with HR: 0.34, 95% CI: 0.13–0.94, p = 0.038), number of HCC nodules (HR: 1.54, 95% CI: 1.22–1.94, p < 0.001), size of the largest nodule (HR: 1.06, 95% CI: 1.01–1.12, p = 0.023), serum bilirubin (HR: 1.57, 95% CI: 1.03–2.40, p = 0.038), and international normalized ratio (HR: 16.40, 95% CI: 2.30–118.0, p = 0.006). Among the overall 111 patients with RHCC in the LRT group, 33 were iteratively treated with further curative treatment (12 were treated with LR, two with MWTA, three with a combined LR-MWTA treatment, and 16 underwent LT). Only one of 18 recurrent patients previously treated with LT underwent LR. For these RHCC patients, multivariable analysis showed the protective roles of LT for primary RHCC after IDLS (HR: 0.06, 95% CI: 0.01–0.36, p = 0.002), of the time relapsed between the first and second IDLS treatments (HR: 0.97, 95% CI: 0.94–0.99, p = 0.044), and the impact of previous minimally invasive treatment (HR: 0.28, 95% CI: 0.08–1.00, p = 0.051).ConclusionThe coexistence of RHCC with underlying cirrhosis increases the complexity of assessing the net health benefit of ILDS before LT. Minimally invasive surgical therapies and time to HCC relapse should be considered an outcome in randomized clinical trials because they have a relevant impact on tumor-free survival.
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Affiliation(s)
- Duilio Pagano
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Simone Khouzam
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Bianca Magro
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Marco Barbara
- Research Department, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico - Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Davide Cintorino
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Fabrizio di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Sergio Li Petri
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Pasquale Bonsignore
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Sergio Calamia
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Giacomo Deiro
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Calogero Cammà
- Section of Gastroenterology & Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy
| | - Marco Canzonieri
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
- *Correspondence: Salvatore Gruttadauria,
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Kitamura M, Hidaka M, Muta K, Miuma S, Miyaaki H, Takatsuki M, Nakao K, Eguchi S, Mukae H, Nishino T. Prediction of Liver Prognosis from Pre-Transplant Renal Function Adjusted by Diuretics and Urinary Abnormalities in Adult-to-Adult Living Donor Liver Transplantation. Ann Transplant 2020; 25:e924805. [PMID: 32895363 PMCID: PMC7501738 DOI: 10.12659/aot.924805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/13/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Renal function is strongly associated with patient survival after liver transplantation. However, the estimated glomerular filtration rate (eGFR) after liver transplantation changes, especially in patients who receive diuretics or have urinary abnormalities. We aimed to elucidate how adjusting for these factors affecting eGFR predicted liver graft prognosis. MATERIAL AND METHODS This retrospective study included patients who underwent adult-to-adult living donor liver transplantation (LDLT) between 2000 and 2017. The factors affecting eGFR were assessed, and the association between eGFR and prognosis was investigated using Cox regression models after adjusting for factors affecting renal function. RESULTS We enrolled 244 patients. The median observation period was 4.6 years, and 88 patients reached graft loss or death with a functioning graft. One year after transplantation, 193 patients were living, and one-third of these showed improved eGFR; most of the patients with improved eGFR had taken diuretics before transplantation. A Cox regression model adjusted for the classical risk factors showed that donor age (P<0.001) and lower eGFR (P=0.02) were the independent risk factors associated with poor prognosis. After adjusting for diuretics and urinary abnormalities, eGFR was more strongly associated with liver graft prognosis (P=0.003). CONCLUSIONS Pre-transplant eGFR was associated with prognosis following LDLT and had a stronger effect on prognosis after adjusting for factors affecting eGFR.
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Affiliation(s)
- Mineaki Kitamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki City, Nagasaki, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki City, Nagasaki, Japan
| | - Kumiko Muta
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki City, Nagasaki, Japan
| | - Satoshi Miuma
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki City, Nagasaki, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki City, Nagasaki, Japan
| | - Mitsuhisa Takatsuki
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki City, Nagasaki, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki City, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki City, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki City, Nagasaki, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki City, Nagasaki, Japan
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Xu X, Pu X, Jiang L, Huang Y, Yan L, Yang J, Wen T, Li B, Wu H, Wang W. Living donor liver transplantation or hepatic resection combined with intraoperative radiofrequency ablation for Child-Pugh A hepatocellular carcinoma patient with Multifocal Tumours Meeting the University of California San Francisco (UCSF) criteria. J Cancer Res Clin Oncol 2020; 147:607-618. [PMID: 32852635 DOI: 10.1007/s00432-020-03364-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND How much difference there is between hepatic resection (HR) combined with intraoperative radiofrequency ablation (RFA) and living donor liver transplantation (LDLT) in treatment of multifocal hepatocellular carcinomas (HCCs) remains unclear. This study compared outcomes for patients with multifocal HCCs meeting the University of California San Francisco (UCSF) criteria treated by LDLT or HR + RFA. METHODS A total of 126 consecutive Child-Pugh A patients with multifocal HCCs meeting the UCSF criteria, who underwent LDLT (n = 51) or HR + RFA (n = 75), were included. Propensity score (PS) matching was performed to adjust for baseline differences. Overall survival (OS) and recurrence-free survival (RFS) were calculated, and subgroup, multivariate and nomogram analyses were performed. RESULTS LDLT provided significantly better OS and RFS than did HR + RFA before and after PS matching and reduced the dropout rate on waiting list, but HR + RFA was more convenient, less invasive and less cost. Patients with all lesions located in the same lobe had better OS and RFS than those located in the different lobes after HR + RFA. Multivariate and nomogram analyses revealed that HR + RFA, alpha-fetoprotein ≥ 400 ng/mL, the major tumour size > 3 cm and microvascular invasion were independent predictors of poor prognosis. CONCLUSION For Child-Pugh A patients with multiple HCCs meeting the UCSF criteria, LDLT may offer significantly better long-term results than did HR + RFA, and HR + RFA may still be considered as an acceptable curative therapy for those without considering transplantation or as a bridge treatment for a patient, with a plan for transplantation in the future.
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Affiliation(s)
- Xi Xu
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Xingyu Pu
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Li Jiang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
| | - Yang Huang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Lunan Yan
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jiayin Yang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Tianfu Wen
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Bo Li
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Hong Wu
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Wentao Wang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
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Pagano D, Ricotta C, Barbàra M, Cintorino D, di Francesco F, Tropea A, Calamia S, Lomaglio L, Terzo D, Gruttadauria S. ERAS Protocol for Perioperative Care of Patients Treated with Laparoscopic Nonanatomic Liver Resection for Hepatocellular Carcinoma: The ISMETT Experience. J Laparoendosc Adv Surg Tech A 2020; 30:1066-1071. [PMID: 32716674 DOI: 10.1089/lap.2020.0445] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Liver resection (LR) remains the best therapeutic option for patients with early-stage hepatocellular carcinoma (HCC) with preserved hepatic function and who are not eligible for liver transplantation. After its inception, the enhanced recovery after surgery (ERAS) protocol was widely used for treating patients with liver cancer, although there are still no clear indications for improving upon it in both open and laparoscopic surgery. Objective: This study aims to describe our institute's experience in the application of the ERAS protocol in a cohort of HCC patients, and to explore possible factors that could have an impact on postoperative outcomes. Materials and Methods: We retrospectively analyzed our experience with LR performed from September 2017 to January 2020 in patients treated with ERAS protocol, focusing on describing impact on postoperative nutrition, analgesic requirements, and length of hospitalization. Demographics, operative factors, and postoperative complications of patients were reviewed. Results: During the study period, 89 HCC patients were eligible for LR, and 75% of patients presented with liver cirrhosis. The most prevalent among etiologic factors was hepatitis C virus infection (53 patients out of 89, 60%), followed by nonalcoholic steatohepatitis (18 patients, 20%). The median age was 70 years. Liver cirrhosis did not have an impact on postoperative course of patients. Patients who underwent laparoscopic surgery and nonanatomic LR experienced low complication rates, shorter length of stay, and shorter time of intravenous analgesic requirements. Conclusions: Continual refinement with ERAS protocol for treating HCC patients based on perioperative counseling and surgical decision-making is crucial to guarantee low complication rates, and reduce patient morbidity and time for recovery.
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Affiliation(s)
- Duilio Pagano
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, and IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Calogero Ricotta
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, and IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Marco Barbàra
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, and IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Davide Cintorino
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, and IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Fabrizio di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, and IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Alessandro Tropea
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, and IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Sergio Calamia
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, and IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Laura Lomaglio
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, and IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Danilo Terzo
- Rehabilitation Service, IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, and IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy.,Department of Surgery and Surgical and Medical Specialties, University of Catania, Catania, Italy
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Hammad A, Kaido T, Ogawa K, Fujimoto Y, Uemura T, Mori A, Hatano E, Okajima H, Uemoto S. Liver transplantation for advanced hepatocellular carcinoma in patients with Child-Pugh A and B. Surg Today 2015; 46:248-54. [PMID: 25721174 DOI: 10.1007/s00595-015-1142-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 02/09/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE To investigate the outcomes of living donor liver transplantation for advanced hepatocellular carcinoma in Child-Pugh A/B patients and the usefulness of our expanded selection criteria, the Kyoto criteria. METHODS A total of 82 recipients with a Child-Pugh class A (n = 27) or B (n = 55) status having either multiple hepatic nodules or solitary tumors ≥5 cm in size treated between February 1999 and August 2012 were enrolled in this study. RESULTS The overall recurrence rate was significantly less for the Child-Pugh B patients than for the Child-Pugh A patients (P = 0.042), while the survival rates did not differ. In the Child-Pugh A and B patients, the survival rate was significantly greater, while the recurrence rate was lower among the patients meeting the Kyoto criteria than those exceeding these criteria (P = 0.006, P = 0.001, P = 0.032 and P < 0.001, respectively). In the Child-Pugh B patients, the overall survival and recurrence rates did not differ between the patients treated with and without pretreatment for hepatocellular carcinoma. In the Child-Pugh B patients treated with pretreatment, the overall survival rate was significantly greater, while the recurrence rate was lower among the patients meeting the Kyoto criteria than those exceeding these criteria (P < 0.001, P < 0.001, respectively). CONCLUSIONS Living donor liver transplantation performed within the Kyoto criteria achieves excellent overall survival and recurrence rates, especially for Child-Pugh B patients, even those with advanced hepatocellular carcinoma.
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Affiliation(s)
- Ahmed Hammad
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.,Department of Surgery, Mansoura University, Mansoura, Egypt
| | - Toshimi Kaido
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Kohei Ogawa
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yasuhiro Fujimoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tadahiro Uemura
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akira Mori
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Etsuro Hatano
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hideaki Okajima
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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6
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Lim KC, Wang VW, Siddiqui FJ, Shi L, Chan ESY, Oh HC, Tan SB, Chow PKH. Cost-effectiveness analysis of liver resection versus transplantation for early hepatocellular carcinoma within the Milan criteria. Hepatology 2015; 61:227-37. [PMID: 24638991 DOI: 10.1002/hep.27135] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 03/13/2014] [Indexed: 12/13/2022]
Abstract
UNLABELLED Both liver resection (LR) and cadaveric liver transplantation (CLT) are potentially curative treatments for patients with hepatocellular carcinoma (HCC) within the Milan criteria and with adequate liver function. Adopting either as a first-line therapy carries major cost and resource implications. The objective of this study was to estimate the relative cost-effectiveness of LR against CLT for patients with HCC within the Milan criteria using a decision analytic model. A Markov cohort model was developed to simulate a cohort of patients aged 55 years with HCC within the Milan criteria and Child-Pugh A/B cirrhosis, undergoing LR or CLT, and followed up over their remaining life expectancy. Analysis was performed in different geographical cost settings: the USA, Switzerland and Singapore. Transition probabilities were obtained from systematic literature reviews, supplemented by databases from Singapore and the Organ Procurement and Transplantation Network (USA). Utility and cost data were obtained from open sources. LR produced 3.9 quality-adjusted life years (QALYs) while CLT had an additional 1.4 QALYs. The incremental cost-effectiveness ratio (ICER) of CLT versus LR ranged from $111,821/QALY in Singapore to $156,300/QALY in Switzerland, and was above thresholds for cost-effectiveness in all three countries. Sensitivity analysis revealed that CLT-related 5-year cumulative survival, one-time cost of CLT, and post-LR 5-year cumulative recurrence rates were the most sensitive parameters in all cost scenarios. ICERs were reduced below threshold when CLT-related 5-year cumulative survival exceeded 84.9% and 87.6% in Singapore and the USA, respectively. For Switzerland, the ICER remained above the cost-effectiveness threshold regardless of the variations. CONCLUSION In patients with HCC within the Milan criteria and Child-Pugh A/B cirrhosis, LR is more cost-effective than CLT across three different costing scenarios: the USA, Switzerland, Singapore.
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Affiliation(s)
- Kheng Choon Lim
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore; Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
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7
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Sourianarayanane A, El-Gazzaz G, Sanabria JR, Menon KVN, Quintini C, Hashimoto K, Kelly D, Eghtesad B, Miller C, Fung J, Aucejo F. Loco-regional therapy in patients with Milan Criteria-compliant hepatocellular carcinoma and short waitlist time to transplant: an outcome analysis. HPB (Oxford) 2012; 14:325-32. [PMID: 22487070 PMCID: PMC3384852 DOI: 10.1111/j.1477-2574.2012.00453.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Liver transplantation (LT) in Milan Criteria (MC) hepatocellular carcinoma (HCC) has excellent outcomes. Pre-transplant loco-regional therapy (LRT) has been used to downstage HCC to meet the MC. However, its benefit in patients with a brief waiting time to transplant remains unclear. This study evaluated outcomes in patients with short waitlist times to LT for MC-compliant HCC. METHODS Patients undergoing LT for MC HCC at either of two transplant centres between 2002 and 2009 were retrospectively evaluated for outcome. Patients for whom post-transplant follow-up amounted to <12 months were excluded. RESULTS A total of 225 patients were included, 93 (41.3%) of whom received neoadjuvant LRT. The median waiting time to transplant was 48 days. Mean post-transplant follow-up was 32.2 months. Overall and disease-free survival at 1 year, 3 years and 5 years were 93.1%, 82.4% and 72.6%, and 91.3%, 79.3% and 70.6%, respectively. There was no difference in overall (P= 0.94) and disease-free survival (P= 0.94) between groups who received and did not receive pre-LT LRT. There were also no disparities in survival or tumour recurrence among categories of patients (with single tumours measuring <3 cm, with single tumours measuring 3-5 cm, with multiple tumours). CONCLUSIONS Loco-regional therapy followed by rapid transplantation in MC HCC appears not to have an impact on post-transplant outcome.
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Affiliation(s)
| | - Galal El-Gazzaz
- Department of Transplant Surgery, Cleveland ClinicCleveland, OH, USA
| | - Juan R Sanabria
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, Case Western Reserve University School of Medicine and University Hospitals, Case Medical CenterCleveland, OH, USA
| | - K V Narayanan Menon
- Department of Gastroenterology and Hepatology, Cleveland ClinicCleveland, OH, USA
| | | | - Koji Hashimoto
- Department of Transplant Surgery, Cleveland ClinicCleveland, OH, USA
| | - Dympna Kelly
- Department of Transplant Surgery, Cleveland ClinicCleveland, OH, USA
| | - Bijan Eghtesad
- Department of Transplant Surgery, Cleveland ClinicCleveland, OH, USA
| | - Charles Miller
- Department of Transplant Surgery, Cleveland ClinicCleveland, OH, USA
| | - John Fung
- Department of Transplant Surgery, Cleveland ClinicCleveland, OH, USA
| | - Federico Aucejo
- Department of Transplant Surgery, Cleveland ClinicCleveland, OH, USA
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Milan Criteria and UCSF Criteria: A Preliminary Comparative Study of Liver Transplantation Outcomes in the United States. Int J Hepatol 2012; 2012:253517. [PMID: 22957260 PMCID: PMC3432361 DOI: 10.1155/2012/253517] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 07/15/2012] [Indexed: 02/07/2023] Open
Abstract
The application of orthotopic liver transplantation (OLT) for patients with hepatocellular cancer (HCC) necessitates highly selective criteria to maximize survival and to optimize allocation of a scarce resource. The objective of this study was to compare the outcomes of OLT for HCC in patients transplanted under Milan and UCSF criteria. The United Network of Organ Sharing (UNOS) database was queried for patients who had undergone OLT for HCC from 2002 to 2007, and 1,972 patients (Milan criteria, n = 1, 913; UCSF criteria, n = 59) were identified. Patients were stratified by pretransplant criteria (Milan versus UCSF), and clinical and pathologic factors and overall survival were compared. There were no differences in age, gender, diabetes mellitus, body mass index, and hepatitis B, or C status between the two groups. Overall survival was similar between the Milan and UCSF cohorts (1-, 2-, 3-, and 4-year survival rates: 88%, 81%, 76%, and 72% versus 91%, 80%, 68% and 51%, respectively, P = 0.21). Although the number of patients within UCSF criteria was small, our results nevertheless suggest that patients with HCC may have equivalent survival when transplanted under Milan and UCSF criteria. Long-term followup may better determine whether UCSF criteria should be widely adopted.
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Hoffmann K, Hinz U, Hillebrand N, Radeleff BA, Ganten TM, Schirmacher P, Schmidt J, Büchler MW, Schemmer P. Risk factors of survival after liver transplantation for HCC: a multivariate single-center analysis. Clin Transplant 2011; 25:E541-51. [PMID: 21518002 DOI: 10.1111/j.1399-0012.2011.01465.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The selection criteria for liver transplantation (LT) in patients with hepatocellular cancer (HCC) are well defined. Increasing evidence suggests that the effectiveness of pre-transplant bridging influences the individual course after LT significantly. Thus, the aim of this study was to determine its impact on tumor progression during waiting time and identify patient subgroups with favorable oncological long-term outcome. METHODS Prospectively collected data of 78 consecutive patients undergoing LT for HCC between 2001 and 2007 were analyzed retrospectively. Survival rates were assessed using the Kaplan-Meier estimate. Clinicopathologic prognostic factors were identified by Cox regression analysis. RESULTS After 48.9 months of median follow-up, the five-yr overall survival rate is 57% with a five-yr recurrence-free survival rate of 74%. Progressive disease (PD) during bridging was developed in 32% of patients, and a trend toward impaired overall survival in patients with PD before LT was detected in multivariate analysis (p = 0.073). HCC ≥3 cm was associated with a three times increased risk of recurrent disease. Neither fulfillment of MILAN criteria nor bridging with transarterial chemoembolization had an impact on the outcome. CONCLUSION PD during waiting time influences the oncological course after LT. However, even with an increasing organ shortage, further studies are warranted to define clear selection criteria based on the biological tumor behavior and allow a more personalized treatment.
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Affiliation(s)
- Katrin Hoffmann
- Department of General and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Merchant N, David CS, Cunningham SC. Early Hepatocellular Carcinoma: Transplantation versus Resection: The Case for Liver Resection. Int J Hepatol 2011; 2011:142085. [PMID: 21994848 PMCID: PMC3170737 DOI: 10.4061/2011/142085] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 02/27/2011] [Indexed: 12/11/2022] Open
Abstract
The optimal surgical treatment of hepatocellular carcinoma on well-compensated cirrhosis is controversial. Advocates of liver transplantation cite better long-term survival, lower risk of recurrence, and the ability of transplantation to treat both the HCC and the underlying liver cirrhosis. Transplantation, however, is not universally available to all appropriate-risk candidates because of a lack of sufficient organ donors and in addition suffers from the disadvantages of requiring a more complex pre- and postoperative management associated with risks of inaccessibility, noncompliance, and late complications. Resection, by contrast, is much more easily and widely available, avoids many of those risks, is by many accounts as effective at achieving similar long-term survival, and still allows for safe, subsequent liver transplantation in cases of recurrence. Here, arguments are made in favor of resection being easier, safer, simpler, and comparably effective in the treatment of HCC relative to transplantation, and therefore being the optimal initial treatment in cases of hepatocellular carcinoma on well-compensated cirrhosis.
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Affiliation(s)
- Nishant Merchant
- Department of Surgery, Saint Agnes Hospital, 900 Caton Avenue, Mailbox #207, Baltimore, MD 21229, USA
| | - Calvin S. David
- Department of Surgery, Saint Agnes Hospital, 900 Caton Avenue, Mailbox #207, Baltimore, MD 21229, USA
| | - Steven C. Cunningham
- Department of Surgery, Saint Agnes Hospital, 900 Caton Avenue, Mailbox #207, Baltimore, MD 21229, USA,*Steven C. Cunningham:
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11
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Polacco M, Vitale A, Valmasoni M, D'Amico F, Gringeri E, Brolese A, Zanus G, Neri D, Carraro A, Pauletto A, Romanelli E, Lo Bello S, Cillo U. Liver resection associated with mini porto-caval shunt as salvage treatment in patients with progression of hepatocellular carcinoma before liver transplantation: a case report. Transplant Proc 2010; 42:1378-80. [PMID: 20534307 DOI: 10.1016/j.transproceed.2010.03.090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Tumor progression before orthotopic liver transplantation (OLT) is the main cause of dropouts from waiting lists among patients with hepatocellular carcinoma (HCC). Performing a porto-caval shunt (PCS) before parenchymal liver transection has the potential to allow an extended hepatectomy in patients with decompensated liver cirrhosis, reducing portal hyperflow and therefore the sinusoidal shear-stress on the remnant liver. We report the case of a 59-year-old man affected by hepatitis C virus (HCV)-related decompensated liver cirrhosis (Child Pugh score presentation, C-10; Model for End Stage Liver Disease score, 18) and HCC (2 lesions of 2 and 2.8 cm). The patient began the evaluation to join the OLT waiting list, but, in the 3 months required to complete the evaluation, he developed tumor progression: 3 HCC lesions, the largest 1 with a diameter of about 4.4 cm. These findings excluded transplantation criteria and the patient was referred to our center. After appropriate preoperative studies, the patient underwent a major liver resection (trisegmentectomy) after side-to-side PCS by interposition of an iliac vein graft from a cadaveric donor. The patient overcame the worsened severity of cirrhosis. After 6 months of follow-up, he developed 2 other HCC nodules. He was then included on the waiting list at our center, undergoing OLT from a cadaveric donor at 8 months after salvage treatment. At 36 months after OLT, he is alive and free from HCC recurrence. Associating a partial side-to-side PCS with hepatic resection may represent a potential salvage therapy for patients with decompensated cirrhosis and HCC progression beyond listing criteria for OLT.
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Affiliation(s)
- M Polacco
- Unità di Chirurgia Epatobiliare e Trapianto Epatico, Dipartimento assistenziale di Chirurgia Generale e Trapianti d'Organo, Università degli Studi di Padova, Padova, Italy.
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12
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Hoffe SE, Finkelstein SE, Russell MS, Shridhar R. Nonsurgical options for hepatocellular carcinoma: evolving role of external beam radiotherapy. Cancer Control 2010; 17:100-10. [PMID: 20404793 DOI: 10.1177/107327481001700205] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and thus poses a global concern. Its incidence is expected to increase in North America secondary to the increasing incidence of patients who develop hepatitis C. Patients who ultimately develop cirrhosis have an increased risk of developing hepatocellular carcinoma. METHODS The authors focus on nonsurgical therapies for this disease with an exploration of how external beam radiotherapy can be used alone or with other modalities. The development of partial liver strategies secondary to an explosion in radiation treatment planning and delivery advances is reviewed. Integration of advanced technology has evolved from three-dimensional conformal treatment to intensity-modulated radiation therapy and image-guided radiation therapy, along with stereotactic body radiation therapy, tomotherapy, and proton beam therapy. RESULTS Current data show a promising future for treatment strategies incorporating radiation with high rates of infield tumor control and low rates of radiation-induced liver disease. Radiation can be delivered in conjunction with transarterial catheter embolization for advanced-stage patients. External beam radiotherapy also has a role in the setting of patients with macrovascular tumor thrombus. CONCLUSIONS Future directions include how to best synergize the effects of radiation strategies with novel agents, given the hypervascularity of HCC. Downstaging of larger lesions with these therapies to resectable or transplantable disease may lead to better outcomes for patients deemed inoperable at diagnosis, and definitive radiotherapy may offer cure to patients with smaller lesions.
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Affiliation(s)
- Sarah E Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA.
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Dutkowski P, De Rougemont O, Müllhaupt B, Clavien PA. Current and future trends in liver transplantation in Europe. Gastroenterology 2010; 138:802-9.e1-4. [PMID: 20096694 DOI: 10.1053/j.gastro.2010.01.030] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Philipp Dutkowski
- Department of Surgery, Swiss Hepato-Pancreatico-Biliary and Transplant Center, University Hospital Zurich, 8091 Zurich, Switzerland
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