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Gómez-Gavara C, Lim C, Adam R, Zieniewicz K, Karam V, Mirza D, Heneghan M, Pirenne J, Cherqui D, Oniscu G, Watson C, Schneeberger S, Boudjema K, Fondevila C, Pratschke J, Salloum C, Esposito F, Esono D, Lahat E, Feray C, Azoulay D. The impact of advanced patient age in liver transplantation: a European Liver Transplant Registry propensity-score matching study. HPB (Oxford) 2022; 24:974-985. [PMID: 34872865 DOI: 10.1016/j.hpb.2021.11.007] [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: 08/23/2021] [Revised: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The futility of liver transplantation in elderly recipients remains under debate in the HCV eradication era. METHODS The aim was to assess the effect of older age on outcome after liver transplantation. We used the ELTR to study the relationship between recipient age and post-transplant outcome. Young and elderly recipients were compared using a PSM method. RESULTS A total of 10,172 cases were analysed. Recipient age >65 years was identified as an independent risk factor associated with reduced patient survival (HR:1.42 95%CI:1.23-1.65,p < 0.001). After PSM, 2124 patients were matched, and the same association was found between elderly recipients and patient survival and graft survival (p < 0.001). As hepatocellular carcinoma and alcoholic cirrhosis were independent prognostic factors for patient and graft survival a propensity score-matching was performed for each. Patient and graft survival were significantly worse (p < 0.05) in the alcoholic cirrhosis elderly group. However, patient and graft survival in the hepatocellular carcinoma cohort were similar (p > 0.05) between groups. CONCLUSION Liver transplantation is an acceptable and safe curative option for elderly transplant candidates, with worse long-term outcomes compare to young candidates. The underlying liver disease for liver transplantation has a significant impact on the selection of elderly patients.
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Affiliation(s)
- Concepción Gómez-Gavara
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Vall D´Hebrón Hospital, Barcelona, Spain
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Paris, France
| | - René Adam
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Krzysztof Zieniewicz
- Department of General and Liver Surgery, Medical University of Warsaw, Banacha, Poland
| | - Vincent Karam
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Darius Mirza
- HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | | | - Jacques Pirenne
- Abdominal Transplant Surgery, Transplantation Research Group, KU, Leuven, Belgium
| | - Daniel Cherqui
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Gabriel Oniscu
- Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Edinburgh, United Kingdom
| | - Christopher Watson
- Department of Surgery, Addenbrooke´s Hospital, Cambridge, United Kingdom
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Karim Boudjema
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, 2 Rue Henri le Guilloux, 35000, Rennes, France
| | - Constantino Fondevila
- General & Digestive Surgery, Institut Clínic de Malalties Digestives I Metabòliques, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Johann Pratschke
- Department of Surgery, Campus Mitte/Campus Virchow, Charité University Hospital, Berlin, Germany
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Francesco Esposito
- Department of Digestive Surgery, Grand Hôpital de L'Est Francilien, Meaux, France
| | - Daniel Esono
- Department of Information and Communications Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel
| | - Cyrille Feray
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel; Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France.
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Nidoni R, Kandagaddala R, Agarwal S, Dey R, Chikkala BR, Gupta S. Living Donor Liver Transplant in Patients Aged 60 Years or Older: Experience from a Large Volume Centre in India. J Clin Exp Hepatol 2021; 11:3-8. [PMID: 33679042 PMCID: PMC7897854 DOI: 10.1016/j.jceh.2020.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/12/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND With ageing population and higher prevalence of nonalcoholic steatohepatitis (NASH) and hepatocellular carcinoma (HCC) in older patients, more and more living donor liver transplants (LDLTs) are being considered in this group of patients as eligibility for deceased donor liver transplant is restricted to those aged 65 years and younger. However, the short- and long-term outcomes of this group have not been reported from India, which does not have a robust national health scheme. The aim of this study was to provide guidelines for transplant in this group. METHODS All patients aged 60 years and older (group 1) who underwent LDLT in our centre between January 2006 and December 2017 were studied. A propensity score-matched group in 1:2 ratio was created with comparable sex and Model for End-Stage Liver Disease score (group 2). The 2 groups were compared for duration of hospital stay, surgical complications, hospital mortality and 1-, 3- and 5-year survival. RESULTS Group 1 consisted of 207 patients, and group 2 had 414 patients. The number of patients in group 1 gradually increased with time from 4 in 2006 to 33 in 2017 accounting for 15% of total cases. Group 1 had more patients with viral hepatitis, NASH and HCC, and they had a higher 30-day mortality due to cardiorespiratory complications. Although 1- and 3-year survival was similar, the 5-year survival was significantly lower in group 1. CONCLUSION Five-year survival was lower in the elderly group due to cardiorespiratory complications and recurrence of HCC. Outcomes in the elderly group can be improved with better patient selection and preventing HCC recurrence.
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Key Words
- BMI, Body Mass Index
- CIT, Cold Ischaemia Time
- CLD, Chronic Liver Disease
- GRWR, Graft Recipient Weight Ratio
- HAT, Hepatic Artery Thrombosis
- HCC, Hepatocellular Carcinoma
- LDLT, Living Donor Liver Transplant
- MELD, Model of End-Stage Liver Disease
- NASH, Nonalcoholic Steatohepatitis
- PVT, Portal Vein Thrombosis
- WIT, Warm Ischaemia Time
- elderly liver recipients
- liver transplant in India
- liver transplant in old patients
- liver transplant outcomes
- living donor liver transplantation
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Shapey IM, Malik HZ, de Liguori Carino N. Data driven decision-making for older patients with hepatocellular carcinoma. Eur J Surg Oncol 2020; 47:576-582. [PMID: 32600896 DOI: 10.1016/j.ejso.2020.05.023] [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: 05/22/2020] [Accepted: 05/28/2020] [Indexed: 10/24/2022] Open
Abstract
Older age is a risk factor for the development of HCC. However, the treatment options available for older patients with HCC, their safety, efficacy and utility, are poorly understood resulting in challenging decision-making. In this review, we aim to report the best available evidence to facilitate optimal decision making for older patients with HCC. We report that surgical resection for HCC is equally safe (90-day mortality ~3%) and effective (five-year disease free survival ~40%) for older patients as it is for younger patients. Five-year survival after ablation therapy for HCC is in excess of 50% in older patients, whilst morbidity rates are in the region of 3%. Survival rates of 30% after chemoembolisation reflects its role as a non-curative treatment. Transplantation is an option that may be helpful for a minority of patients, but the high risks of in-hospital mortality and lower likelihood of receiving a transplant should be duly considered before committing to this approach. We therefore advocate an individualised assessment for older patients based on these risk profiles and probabilities of optimal outcomes. In patients with a projected life-span ≥ 3 years, and who have sufficient physiological and functional reserve, surgical resection should be the treatment of choice. Patients with a projected life-span < 3 years are better served with loco-regional therapies, and tumour size, at a threshold of 3 cm, should guide the choice between ablation and chemoembolisation therapies.
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Affiliation(s)
- Iestyn M Shapey
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University, NHS Foundation Trust, Manchester, M13 9WL, UK; Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - Hassan Z Malik
- Hepatobiliary Unit, University Hospital Aintree, Liverpool, UK
| | - Nicola de Liguori Carino
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University, NHS Foundation Trust, Manchester, M13 9WL, UK.
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Gómez-Gavara C, Charco R, Tapiolas I, Ridaura N, Campos-Varela I, Dopazo C, Pando E, Caralt M, Hidalgo E, Castells L, Bilbao I. Recipient Age for Liver Transplantation: Should It Be Limited? A Propensity Score Matching Analysis of a Large European Series. Transplant Proc 2020; 52:1442-1449. [PMID: 32387080 DOI: 10.1016/j.transproceed.2020.02.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 02/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS The demand for older patients not to be denied access to liver transplantation (LT) has intensified as the European population continues to live longer and maintains better health. AIM This study aims to ascertain the impact of recipient age on the post-LT survival in 2 well-balanced populations at Vall d'Hebron University Hospital. METHODS From January 1990 to December 2016, LT recipients (young group: 50-65 years of age; elderly group: >65 years of age) were compared by means of a propensity score matching (PSM) method. RESULTS Prior to PSM, graft survival and patient survival were worse for the elderly group (P < .001). In 1126 LT recipients, a caliper width of 0.01 was used based on the donor (age, sex, cause of donor death, and donor intensive care unit stay) and recipient covariates (sex, body mass index, indication for LT, intraoperative blood transfusion, cardiovascular risk factors, and Model for End-Stage Liver Disease [MELD]-Era). After PSM, 206 patients were matched; 1-, 5-, and 10-year patient survival rates were 77%, 63%, and 52% vs 80%, 64%, and 45% (P = .50) for young vs elderly recipients, respectively. Similar graft survival rates were observed in both groups (P = .42). CONCLUSIONS Advanced age alone should not exclude patients from LT.
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Affiliation(s)
- Concepción Gómez-Gavara
- Department of HPB Surgery and Transplantation, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Ramón Charco
- Department of HPB Surgery and Transplantation, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ingrid Tapiolas
- Department of HPB Surgery and Transplantation, Vall d'Hebron University Hospital, Barcelona, Spain; Autonoma University Barcelona, Barcelona, Spain
| | - Núria Ridaura
- Department of HPB Surgery and Transplantation, Vall d'Hebron University Hospital, Barcelona, Spain; Autonoma University Barcelona, Barcelona, Spain
| | - Isabel Campos-Varela
- Liver Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Cristina Dopazo
- Department of HPB Surgery and Transplantation, Vall d'Hebron University Hospital, Barcelona, Spain; Autonoma University Barcelona, Barcelona, Spain
| | - Elizabeth Pando
- Department of HPB Surgery and Transplantation, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mireia Caralt
- Department of HPB Surgery and Transplantation, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ernest Hidalgo
- Department of HPB Surgery and Transplantation, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Lluís Castells
- Liver Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Itxarone Bilbao
- Department of HPB Surgery and Transplantation, Vall d'Hebron University Hospital, Barcelona, Spain; Autonoma University Barcelona, Barcelona, Spain
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Gómez Gavara C, Esposito F, Gurusamy K, Salloum C, Lahat E, Feray C, Lim C, Azoulay D. Liver transplantation in elderly patients: a systematic review and first meta-analysis. HPB (Oxford) 2019; 21:14-25. [PMID: 30146227 DOI: 10.1016/j.hpb.2018.07.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/13/2018] [Accepted: 07/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Elderly recipients are frequently discussed by the scientific community but objective indication for this parameter has been provided. The aim of this study was to synthesize the available evidence on liver transplantation for elderly patients to assess graft and patient survival. METHODS A literature search of the Medline, EMBASE, and Scopus databases was carried out from January 2000 to August 2018. Clinical studies comparing the outcomes of liver transplantation in adult younger (<65 years) and elderly (>65 years) populations were analyzed. The primary outcomes were patient mortality and graft loss rates. This review was registered (Number CRD42017058261) as required in the international prospective register for systematic review protocols (PROSPERO). RESULTS Twenty-two studies were included involving a total of 242,487 patients (elderly: 23,660 and young: 218,827) were included in this study. In the meta-analysis, the elderly group had patient mortality (hazard ratio [HR]: 1.26; 95% confidence interval [CI]: 0.97-1.63; P = 0.09; I2 = 48%) and graft (HR: 1.09; 95% CI: 0.81-1.47; P = 0.59; I2 = 12%) loss rates comparable to those in the young group. CONCLUSIONS Elderly patients have similar long-term survival and graft loss rates as young patients. Liver transplantation is an acceptable and safe curative option for elderly transplant candidates.
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Affiliation(s)
- Concepción Gómez Gavara
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France; Department of Surgery, Royal Free Campus, UCL Medical School, Pond Street, London, NW3 2QG, UK
| | - Francesco Esposito
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Kurinchi Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, Pond Street, London, NW3 2QG, UK
| | - Chady Salloum
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Eylon Lahat
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Cyrille Feray
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France; Unité INSERM 955, Créteil, France
| | - Chetana Lim
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Daniel Azoulay
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France; Unité INSERM 955, Créteil, France.
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Tissue miRNA 483-3p expression predicts tumor recurrence after surgical resection in histologically advanced hepatocellular carcinomas. Oncotarget 2018; 9:17895-17905. [PMID: 29707155 PMCID: PMC5915163 DOI: 10.18632/oncotarget.24860] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 02/27/2018] [Indexed: 02/07/2023] Open
Abstract
The choice of surgical treatment for hepatocellular carcinoma (HCC) depends on several prognostic variables, among which histological features, like microvascular invasion and tumor grade, are well established. This study aims to identify the tissue miRNAs predictive of recurrence after liver resection in "histologically advanced" HCC. We selected 54 patients: 15 retrospective resected patients without recurrence (group A), 19 retrospective resected patients with HCC recurrence (group B), and 20 prospective patients (group C), with 4 recurrence cases. All selected HCC were "histologically advanced" (high Edmondson grade and/or presence of microvascular invasion). A wide spectrum of miRNAs was studied with TaqMan Human microRNA Arrays; qRT-PCR assays were used to validate results on selected miRNAs; immunohistochemistry for IGF2 was applied to study the mechanism of miR-483-3p. As a result, a significant differential expression between group A and B was found for 255 miRNAs. Among them we selected miR-483-3p and miR-548e (P<0.001). As a single variable (group C), HCC with miR-483-3p downregulation (mean fold increase 0.21) had 44.4% of recurrence cases; HCC with miR-483-3p upregulation (mean fold increase 5.94) showed no recurrence cases (P=0.011). At immunohistochemistry (group C), the HCC with loss of cytoplasmic IGF2 expression showed a down-regulation of miR-483-3p (fold increase 0.57). In conclusion, in patients with "histologically advanced" HCC, the analysis of specific tissue miRNAs (particularly miR-483-3p) could help identify the recurrence risk and choose which treatment algorithm to implement (follow-up, resection or transplantation). This could have an important impact on patient survival and transplantation outcome, improving organ allocation.
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Li HY, Wei YG, Yan LN, Li B. Outcomes Between Elderly and Young Hepatocellular Carcinoma Living Donor Liver Transplantation Recipients: A Single-Center Experience. Medicine (Baltimore) 2016; 95:e2499. [PMID: 26844458 PMCID: PMC4748875 DOI: 10.1097/md.0000000000002499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Although older age theoretically might be a negative risk factor for liver transplantation (LT) outcomes, age alone should not exclude a patient from waiting list. This study is to investigate the outcomes of elderly hepatocellular carcinoma (HCC) living donor liver transplantation (LDLT) recipients which meet Milan criteria.A retrospective study was performed in a single liver transplantation center. Demographic and clinical data of 110 HCC LDLT recipients from January 2004 to December 2012 were collected and analyzed, including 31 elderly recipients in group E (≥ 60 years) and 79 younger recipients in group Y (<60 years).Recipients' age between 2 groups were significantly different (65.4 ± 4.8 vs 49.9 ± 5.9, P = 0.000). There was no significant difference in preoperative demographic data as well as postoperative liver function. Complication rates, length of ICU and hospital stay, graft loss, and mortality were similar in both groups, as well as the 1-, and 3-year overall and disease-free survival rates (77.4%, and 64.5% vs 82.8%, and 44.6%, P = 0.458; 94.7%, and 80.7% vs 98.6%, and 85.9%, P = 0.661). When recipients were further stratified into group E1, E2, Y1, and Y2, no significant difference was found in 1-, and 3-year overall and disease-free survival rates. In multivariate analysis, recipients' age was not a predictor for long-term survival.Following rigorous listing criteria, if overall clinical conditions and comorbidities allowed, elderly HCC recipients achieved similar LDLT outcomes and survival rates with the younger HCC recipients.
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Affiliation(s)
- Hong Yu Li
- From the Department of pancreatic Surgery (HYL), Department of Liver Surgery, Center of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, China (YW, LY)
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Pinato DJ, Karamanakos G, Ishizuka M, Smirne C, Pirisi M, Kubota K, Sharma R. The Kings Score refines prognostic prediction in hepatocellular carcinoma: a novel application. Liver Int 2015; 35:2458-65. [PMID: 25845291 DOI: 10.1111/liv.12841] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 03/20/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS There are a number of prognostic scores in hepatocellular carcinoma (HCC), none of which is optimal in predicting overall survival (OS) in the individual patient, particularly in intermediate stage disease, where patients are not surgically treatable but may qualify for a wide range of palliative interventions. We evaluated the prognostic role of a biochemical algorithm, the Kings Score (KS), in the palliative setting of care. METHODS We used the algorithm [age x AST x INR]/platelet count to derive the KS. Full clinical data including Barcelona Clinic Liver Cancer (BCLC) stage were studied in a training set of 97 patients from the UK. Independent predictors of survival identified in multivariate analysis were validated in an independent cohort of 766 patients from Japan and Italy. RESULTS In both training and validation sets, KS was confirmed as an independent predictor of OS (P < 0.01). Ad-hoc subgroup analysis revealed the KS to be prognostic in the palliative setting, being able to subclassify patients presenting with intermediate and advanced disease according to BCLC criteria (P < 0.001). CONCLUSION The KS integrates into the BCLC system to improve prognostic substratification in the palliative setting of care. The KS may help reducing disease heterogeneity and refine treatment allocation in intermediate-advanced HCC.
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Affiliation(s)
- David J Pinato
- Division of Experimental Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Georgios Karamanakos
- Division of Experimental Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Mitsuru Ishizuka
- Department of Gastroenterological Surgery, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Carlo Smirne
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale "A. Avogadro", Novara, Italy
| | - Mario Pirisi
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale "A. Avogadro", Novara, Italy.,Interdisciplinary Research Center of Autoimmune Diseases, Università degli Studi del Piemonte Orientale "A. Avogadro", Novara, Italy
| | - Keiichi Kubota
- Department of Gastroenterological Surgery, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Rohini Sharma
- Division of Experimental Medicine, Imperial College London, Hammersmith Hospital, London, UK
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