Is hepatocellular carcinoma in cirrhosis an actual indication for liver transplantation?

Liver transplantation versus liver resection for hepatocellular carcinoma: a meta-analysis

BACKGROUND

Liver transplantation (LT) and liver resection (LR) are currently considered the standard treatment of patients with hepatocellular carcinoma (HCC). However, the outcomes of LT and LR are still inconclusive.

DATA SOURCES

MEDLINE, EMBASE, and Cochrane Library were searched for relevant studies. Surgical safety indices such as treatment-related morbidity and mortality, and efficacy indices such as overall and tumor-free survival outcomes were evaluated. Weighted mean differences and odds ratios (ORs) were calculated using a random-effects model.

RESULTS

Seventeen studies were included in this meta-analysis. LT achieved significantly higher rates of surgery-related morbidity (OR=1.47; 95% CI: 1.02-2.13) and mortality (OR=2.12; 95% CI: 1.11-4.05). Likewise, the 1-year survival rate was lower in LT (OR=0.86; 95% CI: 0.61-1.20). However, the 3- and 5-year survival rates were significantly higher in LT than in LR and the ORs were 1.12 (95% CI: 0.96-1.30) in 3 years and 1.84 (95% CI: 1.49-2.28) in 5 years. Furthermore, the tumor-free survival rate in LT was significantly higher than that in LR in 1, 3, 5 years after surgery, with the ORs of 1.72 (95% CI: 1.24-2.41), 3.75 (95% CI: 2.94-4.78) and 5.64 (95% CI: 4.35-7.31), respectively.

CONCLUSIONS

One-year morbidity and mortality are higher in LT than in LR for patients with HCC. However, long-term survival and tumor-free survival rates are higher in patients treated with LT than those treated with LR.

Systematic review: the role of liver transplantation in the management of hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a major cause of morbidity and mortality worldwide. Liver transplantation offers a potential cure for this otherwise devastating disease. The selection of the most appropriate candidates is paramount in an era of graft shortage.

AIM

To review systematically the role of liver transplantation in the management of HCC in current clinical practice.

METHODS

An electronic literature search using PUBMED (1980-2010) was performed. Search terms included HCC, hepatoma, liver cancer, and liver transplantation.

RESULTS

Liver transplantation is a highly successful treatment for HCC, in patients within Milan criteria (MC), defined as a solitary tumour ≤50 mm in diameter or ≤3 tumours ≤30 mm in diameter in the absence of extra-hepatic or vascular spread. Other eligibility criteria for liver transplantation are also used in clinical practice, such as the University of California, San Francisco criteria, with outcomes comparable to MC. Loco-regional therapies have a role in the bridging treatment of HCC by minimising wait-list drop-out secondary to tumour progression. Beyond MC, encouraging results have been demonstrated for patients with down-staged tumours. Post-liver transplantation, there is no evidence to support a specific immunosuppressive regimen. In the context of an insufficient cadaveric donor pool to meet demand, the role of adult living donation may be increasingly important.

CONCLUSIONS

Liver transplantation offers a curative therapy for selected patients with HCC. The optimisation of eligibility criteria is paramount to ensure that maximum benefit is accrued. Although wait-list therapies have been incorporated into clinical practice, additional high quality data are required to support this strategy.

Early Hepatocellular Carcinoma: Transplantation versus Resection: The Case for Liver Resection

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.

Alpha-fetoprotein and tumour size are associated with microvascular invasion in explanted livers of patients undergoing transplantation with hepatocellular carcinoma

BACKGROUND

To determine factors associated with outcomes and microvascular invasion (MVI) in patients undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC).

METHODS

Between July 1996 and August 2008 at the Universities of Kentucky or Tennessee, LT recipients were retrospectively analysed.

RESULTS

One hundred and one patients had HCC in the explanted liver; one patient was excluded because of fibrolamellar histology. Seventy-nine (79%) were male and 81 (81%) were older than 50. HCC was incidental in 32 patients (32%). Median follow-up was 31 months. Ten patients (10%) developed recurrence, which was associated with poor survival (P= 0.006). Overall 1-, 3-, and 5-year survival rates were 87%, 69% and 62%, respectively. Excluding patients with lymph node metastasis (LNM) or MVI yielded 91%, 81% and 75% survival at the same time points. MVI was independently associated with recurrence (OR 28.40, 95% CI 1.77-456.48, P= 0.018) and decreased survival (OR 4.70, 95% CI 1.24-17.80, P= 0.023), and LNM with decreased survival (OR 6.05, 95% CI 1.23-29.71, P= 0.027). Tumour size (OR 4.1, 95% CI 1.2-13.5, P= 0.013) and alpha-fetoprotein (AFP) > 100 (OR 5.0, 95% CI 1.4-18.1, P= 0.006) were associated with MVI.

CONCLUSIONS

MVI greatly increases the risk of recurrence and death after LT for HCC, and is strongly associated with tumour size and AFP > 100.

Adjuvant adenovirus-mediated delivery of herpes simplex virus thymidine kinase administration improves outcome of liver transplantation in patients with advanced hepatocellular carcinoma

PURPOSE

Previous poor results of liver transplantation (LT) have been confirmed in patients with advanced hepatocellular carcinoma (HCC). Adenovirus-mediated delivery of herpes simplex virus thymidine kinase (ADV-TK) therapy is an established adjuvant treatment in cancer, and we evaluated its potential as an adjuvant treatment for HCC patients who underwent LT.

EXPERIMENTAL DESIGN

Forty-five HCC patients with tumors >5 cm in diameter participated in the study over a follow-up period of 50 months. Among these patients, 22 received LT only, and 23 received LT combined with ADV-TK therapy. All HCC patients enrolled in this study had tumors >5 cm in diameter and no metastasis in lungs or bones was detected by computed tomography or magnetic resonance imaging scans.

RESULTS

The recurrence-free survival and the overall survival in the LT plus ADV-TK therapy group were 43.5% and 69.6%, respectively, at 3 years; both values were significantly higher than those in the LT-only group (9.1% and 19.9%, respectively). In the nonvascular invasion subgroup, overall survival was 100% and recurrence-free survival was 83.3% in the patients receiving LT plus ADV-TK, significantly higher than the patients receiving LT only.

CONCLUSIONS

HCC patients with no vascular invasion could be selected for LT followed by adjuvant ADV-TK therapy, regardless of intrahepatic huge or diffuse tumor. We propose that the current criteria for LT based on tumor size may be expanded if accompanied by ADV-TK therapy due to improved prognosis.

The predictors of microvascular invasion in candidates for liver transplantation with hepatocellular carcinoma-with special reference to the serum levels of des-gamma-carboxy prothrombin

The microvascular invasion of cancer cells (mvi) is a good prognostic factor after orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC). The aim of this study is to predict mvi in patients with HCC who were candidates for OLT. We studied 218 patients with HCC resections who had HCC without any extrahepatic metastases and vascular invasion detected during preoperative evaluation. We analyzed the clinico-pathological data of these patients to predict the mvi presence. The mvi prediction scoring system was made and the accuracy of this system was examined using independent clinico-pathologic factors. The size and histological grade of the tumor were significantly correlated with the mvi. The des-gamma-carboxy prothrombin (DCP) is a mvi predictor. The sensitivity of our mvi prediction system was 75% and the specificity was 85% in 32 patients who underwent living-donor liver transplantations for HCC. Our study shows that besides the tumor size and histological grade, a measurement of the serum DCP levels could be a good predictor for mvi. A tumor biopsy and a preoperative measurement of DCP could improve the selection of patients with HCC for OLT. Our scoring system for mvi provides us a precise prediction of the presence of mvi.

Liver transplantation for hepatocellular carcinoma

In patients with cirrhosis and hepatocellular carcinoma (HCC), orthotopic liver transplantation (OLT) offers hope for cure of both the complicating HCC and the underlying chronic liver disease. Excellent 5 year survival has been reported when the restrictive Milan criteria are used to select transplant candidates. Alternative recommendations have recently been proposed by groups at University of California San Francisco, University of Pittsburgh and Mount Sinai. We review current and evolving concepts regarding selection criteria for OLT in patients with HCC, along with strategies to reduce waiting times, such as the impact of the implementation of the model for end-stage liver disease (MELD) scoring system on organ distribution and the role of living donor OLT for this indication. The possible efficacy of adjuvant anti-tumour therapies in limiting HCC growth while waiting for OLT, along with factors influencing the risk of HCC recurrence post-OLT, the major cause of death in this setting, are also discussed.

Advances in the surgical management of liver malignancies

Primary malignancies of the liver include tumors arising from the hepatocytes (hepatocellular carcinoma and the fibrolamellar variant) and the intrahepatic bile ducts (intrahepatic cholangiocarcinoma). Hepatocellular carcinoma is the most common primary cancer of the liver and is a leading cause of death from cancer worldwide. Although it is uncommon in the United States, the incidence of hepatocellular carcinoma is rising. Hepatitis, ethanol use, and cirrhosis often dominate the clinical picture and may dictate prognosis. New clinical and pathological staging systems have allowed for the more accurate stratification of patients to more appropriately identify patients for resection, transplantation, and percutaneous ablation therapies. A correlation between liver volume and surgical outcome has recently been demonstrated, with small liver remnant size being associated with increased morbidity. Portal vein embolization has therefore been proposed as one way to induce hypertrophy of the anticipated liver remnant before resection. Initial reports have shown that portal vein embolization decreases the incidence of postoperative complications. More recently, systemic chemotherapy and chemoembolization have been investigated as both primary and neoadjuvant therapy. Chemoimmunotherapy with 5-fluorouracil and interferon may be associated with a superior response rate in the fibrolamellar variant of hepatocellular carcinoma. Two recent randomized studies have also indicated improved survival after hepatic artery embolization in selected patients.

Hepatoma—resection or transplantation

The most frequent tumors of the liver originate from the hepatocytes, bile duct epithelium, and endothelial cells. Hepatocellular carcinoma accounts for 80% to 90% of primary liver cancer. Cholangiocarcinoma, a neoplasm that arises from the biliary tree, is the second most common primary hepatic malignancy. This article deals with the epidemiology and clinical presentation and the diagnostic confirmation and classification of both conditions, and with the use of liver resection and transplanation treatment for both.

Resection prior to liver transplantation for hepatocellular carcinoma

OBJECTIVE

To evaluate the feasibility and postoperative course of liver transplantation (LT) in cirrhotic patients who underwent liver resection prior to LT for HCC.

SUMMARY BACKGROUND DATA

Although LT provides longer survival than liver resection for treatment of small HCCs, donor shortage and long LT wait time may argue against LT. The feasibility and survival following LT after hepatic resection have not been previously examined.

METHODS

Between 1991 and 2001, among 107 patients who underwent LT for HCC, 88 met Mazzafero's criteria upon pathologic analysis of the explant. Of these, 70 underwent primary liver transplantation (PLT) and 18 liver resection prior to secondary liver transplantation (SLT) for recurrence (n = 11), deterioration of liver function (n = 4), or high risk for recurrence (n = 3). Perioperative and postoperative factors and long-term survival were compared.

RESULTS

Comparison of PLT and SLT groups at the time of LT revealed similar median age (53 vs. 55 years), sex, and etiology of liver disease (alcohol/viral B/C/other). In the SLT group, the mean time between liver resection and listing for LT was 20 months (range 1-84 months). Overall time on LT waiting list of the two groups was similar (3 vs. 5 months). Pathologic analysis after LT revealed similar tumor size (2.2 vs. 2.3 cm) and number (1.6 vs. 1.7). Perioperative and postoperative courses were not different in terms of operative time (551 vs. 530 minutes), blood loss (1191 vs. 1282 mL), transfusion (3 vs. 2 units), ICU (9 vs. 10 days) or hospital stay (32 vs. 31 days), morbidity (51% vs. 56%) or 30-day mortality (5.7% vs. 5.6%). During a median follow-up of 32 months (3 to 158 months), 3 patients recurred after PLT and one after SLT. After transplantation, 3- and 5-year overall survivals were not different between groups (82 vs. 82% and 59 vs. 61%).

CONCLUSIONS

In selected patients, liver resection prior to transplantation does not increase the morbidity or impair long-term survival following LT. Therefore, liver resection prior to transplantation can be integrated in the treatment strategy for HCC.

Surgical treatment of hepatocellular cancer in the era of hepatic transplantation

BACKGROUND

This study compares liver resection (LR) or transplantation (LTx) in an attempt to reevaluate the indications for treatment.

STUDY DESIGN

One hundred fifty-four LRs and 121 LTxs performed from 1985 to 1999 were considered. Survival and recurrence rate, together with age, gender, liver disease, Child-Pugh classification, alpha-fetoprotein (AFP), tumor capsule, vascular invasion, size, number of nodules, histologic grade, and pTNM were considered. Followup was completed in all cases (mean +/- SD = 3.2 +/- 2.9 years).

RESULTS

The 5- and 10-year actuarial survival rates were 61.7% and 59.8% in LTx and 46.9% and 28.0% in LR (p = 0.08). Recurrence-free survival was 85.9% and 85.9%, respectively, in LTx and 42.8% and 30.7% in LR (p < 0.0001). In both groups, size, capsule, AFP, vascular invasion, grade, pTNM, Child-Pugh classification, and age were all significantly related to survival and cancer recurrence. pTNM, AFP, Child-Pugh classification, and age, in LR, and capsule, AFP, and viral cirrhosis, in LTx, were significant independent variables in Cox's regression model for survival. Only AFP, vascular invasion, and grade were significant in both groups for recurrence.

CONCLUSIONS

LTx offers better recurrence freedom than LR, but longterm survival is not significantly different in the two series. A strict selection should be made to optimize graft allocation. Size and multifocality should not be considered absolute contraindications for LTx. AFP, vascular invasion, and grade are more likely to reflect the risk of recurrence of the disease. LR should be considered in patients who do not fulfill transplant criteria and also in some categories of patients with certain tumor characteristics (small resectable tumors in well-compensated cirrhosis).

Prognostic significance of vascular endothelial growth factor, basic fibroblast growth factor, and angiogenin in patients with resectable hepatocellular carcinoma after surgery

BACKGROUND

Hepatocellular carcinoma (HCC) is a hypervascular malignancy. Vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and angiogenin (ANG) are important angiogenic factors of neoangiogenesis. This study investigated the predictive value of serum VEGF, bFGF, and ANG in tumor recurrence, disease-free survival (DFS), and overall survival (OS) in HCC patients.

METHODS

Preoperative serum VEGF, bFGF, and ANG were measured in 98 patients with resectable HCC and in 15 healthy controls. The median follow-up time was 43 months.

RESULTS

Preoperative serum VEGF was increased in patients with resectable HCC compared with healthy controls (P <.05). Increased serum VEGF was correlated with tumor recurrence (P =.001). Univariate analysis showed that serum VEGF, tumor-node-metastasis stage, tumor size and number, macroscopic portal vein invasion, and microscopic vascular invasion were correlated with OS and DFS. Serum bFGF and ANG were not associated with survival. Multivariate analysis showed that serum VEGF was the most significant predictor of DFS (relative risk, 2.35; 95% confidence interval, 1.26-4.39; P =.007) and OS (relative risk, 3.44; 95% confidence interval, 1.81-6.57; P <.001) in HCC patients after surgical resection.

CONCLUSIONS

Preoperative serum VEGF is a significant independent predictor of tumor recurrence, DFS, and OS in patients with resectable HCC.

Liver transplantation for hepatocellular cancer: should the current indication criteria be changed?

Liver transplantation (LTx) is the best treatment for hepatocellular carcinoma (HCC), but should be offered only to selected patients. The usual procedure is to transplant only for small and unilobular tumors. The aim of this paper is to verify whether the actual indication criteria are still justified. The details of 121 patients with HCC who were submitted to LTx from 1985 to 2000 were analyzed. Age, gender, liver disease, Child class, alpha-fetoprotein (AFP) level, presence of tumor capsule, vascular invasion, size and number of nodules, histological grade, and pTNM were considered. The 5- and 10-year actuarial survival rates were 61.7% and 53.1%. Freedom from recurrence was 85.9% and 85.9%, respectively. At univariate analysis, size, presence of capsule, AFP levels, vascular invasion, grade, pTNM, transarterial chemoembolization (TACE), Child class, and age were all significantly related to survival and/or cancer recurrence. Presence of capsule, AFP levels, and viral cirrhosis were independent variables in Cox's analysis for survival, whereas histological grade, AFP levels, and vascular invasion were significant independent variables for recurrence. In conclusion, a strict selection should be made to optimize graft allocation while size and multifocality should probably no longer be considered a contraindication for LTx. Histological grade, AFP levels, and vascular invasion, as indicator of tumor behavior, more likely reflect the risk of recurrence.

Hepatic artery embolization for hepatocellular carcinoma: technique, patient selection, and outcomes

Most patients with HCC do not qualify for surgical interventions. In carefully selected patients, TACE may improve survival, reduce the rate of tumor growth, and decrease the incidence of portal vein occlusion. Since the introduction of TACE in the 1980s, the technical aspects of the procedure have significantly improved. Sophisticated angiographic equipment and techniques have made superselective arterial catheterization possible for more focused drug delivery. The use of ethiodized oil allows for more effective targeting of HCC and provides dual embolization of the hepatic artery and the portal venules supplying the tumor. Many important technical questions about TACE remain unanswered at this time: there are no reliable, standardized patient selection criteria, ideal cytotoxic agents have not yet been identified, the optimal dose of ethiodized oil has not been confirmed, and the optimal frequency and timing of repeat treatment sessions remain unknown. One major limitation of TACE--the need for repeated treatments, which can result in deterioration of liver function--may be avoided by use of a combination of interventional therapies. The combination of limited TACE with PEI or RFA may lead to improved survival and decreased risk of liver failure. More recently, two excellent randomized clinical trials have demonstrated significant survival benefit for patients treated with TACE when compared with those treated symptomatically.

Indications and limitations of liver transplantation for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common cause of cancer-related death worldwide, yet remains difficult to treat, with dismal overall long-term survival rates. Recent strategies using liver transplantation for carefully selected patients with stage I and II HCC and cirrhosis have shown promising results, with 5-year survival rates comparable to survival rates for transplantation patients without malignancy. Currently, however, limited resources and a severe organ shortage make liver transplantation an option for only a limited number of patients with HCC in the United States. Future studies must document the long-term success of this therapy and improve methods for disease control before and after transplantation.

Surgical management of hepatocellular carcinoma: resection and ablation

In this article, the author reviews the recent advances in the surgical management of hepatocellular carcinoma (HCC). Partial hepatic resection or, in some instances, liver transplantation provides the best chance for cure. Risk of perioperative mortality after partial hepatectomy is less than 5% in most experienced centers. Careful preoperative assessment of hepatic function is important to reduce the risk of postoperative liver failure after liver resection. Long-term outcomes after resection are comparable to those with liver transplantation, with reported 5-year survival rates of 25%-50%. Although limited controlled comparative studies exist, surgical and nonsurgical local ablative therapies, including ethanol and radiofrequency ablation, may result in survival benefit.

Long-term survival and pattern of recurrence after resection of small hepatocellular carcinoma in patients with preserved liver function: implications for a strategy of salvage transplantation

OBJECTIVE

To evaluate the survival results and pattern of recurrence after resection of potentially transplantable small hepatocellular carcinomas (HCC) in patients with preserved liver function, with special reference to the implications for a strategy of salvage transplantation.

SUMMARY BACKGROUND DATA

Primary resection followed by transplantation for recurrence or deterioration of liver function has been recently suggested as a rational strategy for patients with HCC 5 cm or smaller and preserved liver function. However, there are no published data on transplantability after HCC recurrence or long-term deterioration of liver function after resection of small HCC in Child-Pugh class A patients. Such data are critical in determining the feasibility of salvage transplantation.

METHODS

From a prospective database of 473 patients with resection of HCC between 1989 and 1999, 135 patients age 65 years or younger had Child-Pugh class A chronic liver disease (chronic hepatitis or cirrhosis) and transplantable small HCC (solitary < or =5 cm or two or three tumors < or = 3 cm). Survival results were analyzed and the pattern of recurrence was examined for eligibility for salvage transplantation based on the same criteria as those of primary transplantation for HCC.

RESULTS

Overall survival rates at 1, 3, 5, and 10 years were 90%, 76%, 70%, and 35%, respectively, and the corresponding disease-free survival rates were 74%, 50%, 36%, and 22%. Cirrhosis and oligonodular tumors were predictive of worse disease-free survival. Patients with concomitant oligonodular tumors and cirrhosis had a 5-year overall survival rate of 48% and a disease-free survival rate of 0%, which were significantly worse compared with other subgroups. At a median follow-up of 48 months, 67 patients had recurrence and 53 (79%) of them were considered eligible for salvage transplantation. Decompensation from Child-Pugh class A to B or C without recurrence occurred in only six patients.

CONCLUSIONS

For Child-Pugh class A patients with small HCC, hepatic resection is a reasonable first-line treatment associated with a favorable 5-year overall survival rate. A considerable proportion of patients may survive without recurrence for 5 or even 10 years; among those with recurrence, the majority may be eligible for salvage transplantation. These data suggest that primary resection and salvage transplantation may be a feasible and rational strategy for patients with small HCC and preserved liver function. Primary transplantation may be a preferable option for the subset of patients with oligonodular tumors in cirrhotic liver in view of the poor survival results after resection.

Current status of liver transplantation for hepatocellular cancer

The incidence of hepatocellular cancer is increasing in the United States and is one of the most common cancers worldwide. Traditionally, the gold standard treatment for hepatocellular cancer has been surgical resection, but most patients were not suitable candidates due to advanced disease. Other treatments include locally ablative techniques (cryosurgery, radiofrequency ablation and various injection therapies), chemotherapeutic options and rarely, radiation therapies. In the 1980s, liver transplant emerged as the treatment of choice for end-stage liver disease and also became an option for patients with hepatocellular cancer. When comparing liver transplant with resection in retrospective studies, liver transplant patients had better survival and reduced recurrence. However, not all patients with hepatocellular cancer will be candidates for liver transplant. Size, stage, and histological grade of tumor all affect prognosis after transplant. Use of chemotherapeutic treatments and locally ablative techniques may be beneficial prior to liver transplant, but larger controlled studies are needed. Liver transplant is the most effective treatment for hepatocellular cancer in the subgroup of smaller tumors, but ultimately we are limited by the number of available donors. Future goals in this area include increasing the donor pool and determining optimal management to allow patients to wait for an appropriate donor.

Liver transplantation for hepatocellular carcinoma

The surgical management for hepatocellular carcinoma (HCC) is multiplicity. In Japan, liver resection has generally been considered to be the only curative treatment for HCC. The resectability of a tumor in cirrhotic patients, however, is limited by the diminished functional reserve of the cirrhotic liver and the attendant risk for intraoperative bleeding and postoperative liver failure. In cirrhotic patients, liver transplantation has been considered as the indication for HCC in many countries except Japan. Although the survival rate of patients with HCC who received liver transplants was poor in the early period, it later moved to the same level as for patients with other liver diseases. In 1993, living donor adult liver transplantation was started in Japan and it became an additional option for the treatment of HCC. A shortage of liver donors means that new methods of liver procurement must be explored. Domino liver transplantation using the livers of patients with familial amyloid polyneuropathy was also another option for advanced HCC. For the prevention of a recurrence of HCC, pre-, intra-, and postoperative chemotherapy have been performed after both liver resection and liver transplantation. We should also try to minimize intraoperative dissemination by surgical manipulation. Recently, potential gene therapies for HCC have been studied. Electroporation-mediated IL-12 gene therapy for HCC was found to be effective for both mIL-12-transferred HCC and for distant HCC. For patients with HCC accompanied by liver cirrhosis, liver transplantation remains the ultimate curative therapy. Immunologic and oncologic approaches to HCC can help prevent tumor recurrence and also help us to obtain better results after liver transplantation.

Serum vascular endothelial growth factor predicts venous invasion in hepatocellular carcinoma: a prospective study

OBJECTIVE

To evaluate the correlation between serum vascular endothelial growth factor (VEGF) level and the clinicopathologic features in patients with hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

VEGF is an important angiogenic factor regulating tumor angiogenesis. A high serum VEGF level has been shown to be associated with tumor progression and metastasis in several human cancers, but its significance in HCC is unclear. The correlation between serum VEGF level and tumor pathologic features in patients with HCC has not been studied before.

METHODS

Preoperative serum samples and tumor specimens were prospectively collected in 100 patients undergoing resection of HCC. Serum VEGF level was measured by enzyme-linked immunosorbent assay, and tumor VEGF expression was assessed by immunohistochemical study. Histopathologic examination was performed by a pathologist without prior knowledge of the serum VEGF level or tumor VEGF expression.

RESULTS

Preoperative serum VEGF levels ranged from 15 to 1,789 pg/mL (median 269). When serum VEGF levels were compared between groups categorized by different clinicopathologic variables, significant correlation was found between a high serum VEGF level and absence of tumor capsule, presence of intrahepatic metastasis, presence of microscopic venous invasion, and advanced stage. There was a positive correlation between the serum VEGF level and tumor expression of VEGF as well as platelet count. When the 75th percentile serum VEGF level (500 pg/mL) was used as a cutoff level, the frequency of venous invasion in patients with a high serum VEGF level was significantly greater compared with patients with a low serum VEGF level. By multivariate analysis, a serum VEGF level of more than 500 pg/mL and tumor size more than 5 cm were independent preoperative factors predictive of microscopic venous invasion. During a median follow-up of 11.6 months, 48% of patients with a serum VEGF level of more than 500 pg/mL and 27% of those with a serum VEGF level of 500 pg/mL or less developed postoperative recurrence.

CONCLUSIONS

These results show that a high preoperative serum VEGF level is a predictor of microscopic venous invasion in HCC, suggesting that the serum VEGF level may be useful as a biologic marker of tumor invasiveness and a prognostic factor in HCC.

Localized Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) most commonly affects patients with underlying cirrhosis. Screening of cirrhotic patients can result in early detection of HCC. If the tumor is localized to the liver, the patient can be offered therapy. It is our belief that those patients with good liver function (Child-Pugh A/B or better) should be considered for surgical resection of one or two surgical segments of the liver. Otherwise, ablative measures, including radiofrequency ablation (RFA), cryotherapy, or angiographic embolization should be offered to the patient. Alternatively, direct injection of alcohol or acetic acid can result in effective ablation of the lesion, with unclear effects on long-term outcome. Chemotherapy does not appear to impact survival, but it is our belief that combined protocols may offer superior outcomes to single therapeutic interventions. Orthotopic liver transplantation (OLT) can have excellent efficacy in a very select group of patients.

Localized hepatocellular carcinoma: therapeutic options

Hepatocellular carcinoma (HCC) is among the most common malignancies worldwide. Recent surveillance programs have allowed early detection and diagnosis, but overall survival of patients with HCC remains poor. This article provides a definition for localized HCC and summarizes the array of treatments that have emerged and the salient literature and findings for each. Among the treatments reviewed here are surgical resection, orthotopic liver transplantation, and local ablative therapies such as cryosurgery, percutaneous ethanol injection therapy, and transarterial chemoembolization.

Hepatocellular carcinoma: comparison between liver transplantation, resective surgery, ethanol injection, and chemoembolization

Between January 1989 and June 1997, 533 patients (423 male, 110 female, mean age 61 years, range 22-89 years) with hepatocellular carcinoma (HCC) were observed at our center. We report on 419 patients retrospectively compared for different treatments: liver transplantation (LT; 55 patients), resective surgery (RS; 41 patients), transarterial chemoembolization (TACE; 171 patients) and percutaneous ethanol injection (PEI; 152 patients). The 3- and 5-year actuarial survival rates were, respectively, 72% and 68% for LT, 64 and 44% for RS, 54 and 36% for PEI, and 32 and 22% for TACE. Survival curves were compared for sex, age, tumor characteristics, alphafetoprotein level, Child class, and etiology of cirrhosis. All patient-related characteristics examined (sex, age) are not significantly related to patient survival. Tumor-related variables and associated liver disease variables significantly conditioned survival in relation to different treatments. LT seems to be the treatment of choice for monofocal HCC less then 5 cm in diameter and in selected cases of plurifocal HCC.