Liver transplantation and incidental primary liver tumors

Outcomes of Liver Transplantation with Incidental Intrahepatic Cholangiocarcinoma-Own Experience and a Systematic Review

Background: Cholangiocarcinoma, the second most common primary liver cancer, is still a contraindication for performing liver transplantation in most patients. Despite various trials being performed in large clinical centers, the results are still not satisfactory. The aim of this study was to present cases from our own cohort and perform a systematic review of the results of liver transplantation in patients with incidental intrahepatic cholangiocarcinoma. Materials and methods: We retrospectively reviewed the records of all patients who underwent liver transplantation and identified two patients with incidental intrahepatic cholangiocarcinoma via histopathological examination of the explanted liver. The results of radiological and biochemical screening performed during liver transplantation, standardized histopathological examination and follow-up data are presented. Additionally, a systematic review of PubMed and Cochrane Reviews based on the PRISMA protocol was performed, yielding 413 similar cases. Results: We present two cases of incidental intrahepatic cholangiocarcinoma found after liver transplantation. The patients were managed according to a standard protocol with no consecutive modification of immunosuppression or chemotherapy. There was no recurrence or mortality. In this systematic review, the mean reported number of lesions ranged between 1 and 2 per patient. A total of 42 recurrences were reported. The percentage of recurrences ranged between 28.6% and 80%. Conclusions: Despite not being a frequent finding, follow-up and further treatment of patients with incidental iCCA should be reported and analyzed. Extra carefulness in screening is advised in patients who are already diagnosed with oncological disease of the liver. In long-term follow-up, recurrence of the disease is rather probable.

Comparison of Milan and UCSF criteria for liver transplantation to treat hepatocellular carcinoma

AIM: To assess the validity of the Milan and University of California San Francisco (UCSF) criteria and examine the long-term outcome of orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC) in a single-center study.

METHODS: This study is a retrospective review of prospectively collected data. Between 1998 and 2009, 56 of 356 OLTs were performed in patients with HCC. Based on pathological examination of liver explants, patients were retrospectively categorized into 3 grou-ps: Milan + (n = 34), Milan -/UCSF + (n = 7) and UCSF - (n = 14).

RESULTS: Median follow-up period was 39.5 (1-124) mo. The 5-year overall survival rates in the Milan +, Milan -/UCSF + and UCSF-groups were 87.7%, 53.6% and 33.3%, respectively (P < 0.000). Within these groups, tumor recurrence was determined in 5.8%, 14.3% and 40% of patients, respectively (P < 0.011). Additionally, the presence of microvascular invasion within the explanted liver had a negative effect on the 5-year disease free survival (74.7% vs 46.7%, P < 0.044).

CONCLUSION: The Milan criteria are reliable in the selection of suitable candidates for OLT for the treatment of HCC. For cases of OLT involving living donors, the UCSF criteria may be applied.

Successful liver transplantation for hilar cholangiocarcinoma

PURPOSE OF REVIEW

The purpose of this review is to present recent data demonstrating the success of neoadjuvant therapy followed by liver transplantation for hilar cholangiocarcinoma.

RECENT FINDINGS

The most recent outcomes of a protocol involving neoadjuvant therapy followed by liver transplant for hilar cholangiocarcinoma, placed in context with the most recent data regarding outcomes for surgical resection, are discussed. Data involving the observation and management of an increased rate of vascular complications following this aggressive protocol are described. Additionally, factors which may predict disease recurrence along with the implications of these data on organ allocation policy are reviewed.

SUMMARY

For patients with early stage hilar cholangiocarcinoma which is unresectable or arising in the setting of primary sclerosing cholangitis, neoadjuvant chemoradiotherapy followed by liver transplantation provides excellent survival benefit. Outcomes are notably superior to other treatment options, including resection. The protocol, however, requires extensive involvement and expertise from multiple specialties to ensure success.

Predictors of disease recurrence following neoadjuvant chemoradiotherapy and liver transplantation for unresectable perihilar cholangiocarcinoma

BACKGROUND

Sixty-five patients with unresectable hilar cholangiocarcinoma (CCA) have undergone orthotopic liver transplantation (OLT) after neoadjuvant chemoradiotherapy per a clinical care protocol developed in 1993. We reviewed our experience with the aim to identify clinicopathological predictors of disease recurrence.

METHODS

All patients with CCA that underwent OLT at our institution between 1993 and January 1, 2006 were treated in accord with our published protocol. We analyzed multiple clinical and explant pathologic factors using Cox regression analysis.

RESULTS

Sixty-five patients with CCA underwent OLT. Four patients died within six months due to postoperative complications. At last follow-up, 11 patients (17%) had developed recurrence seven to 64 months after OLT. Mean time to recurrence was 29 months, and eight patients had died from recurrent disease. Patient and disease-free survival were 76% and 60% five years after OLT. Predictors of recurrence were older age, pretransplant cancer antigen (CA) 19-9 >100 U/ml, prior cholecystectomy, mass on cross-sectional imaging, residual tumor in explant >2 cm, tumor grade and perineural invasion in explant. Underlying primary sclerosing cholangitis, percutaneous biliary intubation, gender, and other time points for CA 19-9 were not associated with recurrence. Prolonged staging-to-OLT intervals for patients transplanted after implementation of model for end-stage liver disease (MELD) showed a trend toward increased recurrence.

CONCLUSIONS

Older patients and those with high CA-19.9 levels, and larger tumors are more likely to develop recurrent disease. Prolonged waiting time may emerge as a significant risk factor with longer follow-up. These findings may guide patient selection, applicability of live donor transplantation and MELD score exceptions for this aggressive protocol.

Liver transplantation for incidental cholangiocarcinoma: analysis of the Canadian experience

Cholangiocarcinoma is a biliary tumor, which not infrequently complicates primary sclerosing cholangitis. It carries a poor prognosis and, with the exception of carefully selected individuals in research protocols, contraindicates orthotopic liver transplantation. There has been some suggestion that cholangiocarcinomas incidentally discovered at the time of transplantation carry a better prognosis. The goal of this retrospective study was to perform a national review of outcomes after liver transplantation in Canadian recipients found to have incidental cholangiocarcinoma in their explanted native liver. Six of the seven liver transplant centers in Canada provided clinical and follow-up information on all liver transplant recipients found to have incidental cholangiocarcinoma in their explants. The diagnosis or suspicion of cholangiocarcinoma prior to transplantation were exclusion criteria for this study. Ten individuals with cholangiocarcinoma were transplanted between 1996 and 2003. The median duration of follow-up was 28 months. Eight of the 10 had PSC. All of the tumors were stage I or II. The 3-year survival for these patients was 30%. The median time to recurrence was 26 months (95% confidence interval 13-37), and the median time to death was 30 months (95% confidence interval 28-53). In conclusion, although early survival of patients transplanted for incidental cholangiocarcinoma appears good, intermediate- and long-term survival rates are not better than for individuals historically transplanted with known cholangiocarcinoma. Aggressive investigation for cholangiocarcinoma is mandated. Incidentally found tumours remain a difficult treatment problem, and prospective adjuvant chemo-, radio-, and immunotherapies should be investigated.

Clinicopathological features of incidental hepatocellular carcinoma in liver transplantation

The incidence of detecting hepatocellular carcinoma (HCC) in a removed recipient liver after a liver transplant is not rare. The clinical features are expected to be different from the preoperatively diagnosed HCC. The aim of this study was to evaluate the clinicopathological features of incidental HCC. This study retrospectively analyzed five cases of incidental HCC among 51 liver transplant cases of HCC operated from September 1996 to February 2002. The proportion of an incidental HCC was 9.8%. The mean age was 46.2 years with a higher prevalence in may (80%, four cases). The alpha-fetoprotein level was normal or mildly elevated. HBsAg was positive in all cases. Imaging studies revealed regenerative or dysplastic nodules, or no specific lesion. The pathological findings demonstrated a mean size of 1.16 cm, multiplicity in three cases (60%), no microvascular invasion, and Edmonson grade I (60%) and II (40%). There was no recurrence of the HCC. However, two patients died due to an intracranial hemorrhage and a graft failure, respectively. In conclusion, incidentally found HCC showed less invasive pathological features and a better prognosis.

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 cholangiocellular carcinoma: analysis of a single-center experience and review of the literature

Cholangiocellular carcinoma (CCC) is a biliary malignancy that frequently presents in advanced unresectable stages. The role of liver transplantation (LT) as a surgical modality is unclear. The goal of this study is to evaluate outcomes of patients with CCC undergoing LT. A retrospective analysis of all patients undergoing LT was undertaken. Only those patients with the pathological diagnosis of CCC were included on the study. Patients were divided into two groups based on primary tumor location: extrahepatic (EH)-CCC and intrahepatic (IH)-CCC. The Kaplan-Meier method was used to calculate overall and recurrence-free survival. Log-rank analysis was used to determine the significance of prognostic variables. Twenty-five patients were identified: 9 patients with EH-CCC (5 patients, Klatskin-type; 2 patients, the middle third; and 2 patients, the distal third) and 16 patients with IH-CCC. Mean age was 47.1 +/- 10.6 years. There were 14 men and 11 women. Tumor stage was local (stages I and II; n = 9) or advanced (stages III and IV; n = 16). Overall and disease-free survival rates were 71% and 67% at 1 year and 35% and 32% at 3 years, respectively. Analysis of variables showed statistically significant improved outcomes (P < .05) for the absence of contiguous organ invasion at LT, small tumor size, and single tumor foci. This study indicates that early survival after LT for CCC is acceptable. Three-year disease-free survival is achieved in approximately 30% of patients. These outcomes can be improved by applying strict selection criteria based on prognostic variables identified in this study.