1
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Martinino A, Bucaro A, Cardella F, Wazir I, Frongillo F, Ardito F, Giovinazzo F. Liver transplantation vs liver resection in HCC: promoting extensive collaborative research through a survival meta-analysis of meta-analyses. Front Oncol 2024; 14:1366607. [PMID: 38567152 PMCID: PMC10986178 DOI: 10.3389/fonc.2024.1366607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
Background HCC is a major global health concern, necessitating effective treatment strategies. This study conducts a meta-analysis of meta-analyses comparing liver resection (LR) and liver transplantation (LT) for HCC. Methods The systematic review included meta-analyses comparing liver resection vs. liver transplantation in HCC, following PRISMA guidelines. Primary outcomes included 5-year overall survival (OS) and disease-free survival (DFS). AMSTAR-2 assessed study quality. Citation matrix and hierarchical clustering validated the consistency of the included studies. Results A search identified 10 meta-analyses for inclusion. The median Pearson correlation coefficient for citations was 0.59 (IQR 0.41-0.65). LT showed better 5-year survival and disease-free survival in all HCC (OR): 0.79; 95% CI: 0.67-0.93, I^2:57% and OR: 0.44; 95% CI: 0.25-0.75, I^2:96%). Five-year survival in early HCC and ITT was 0.63 (95% CI: 0.50-0.78, I^2:0%) and 0.60 (95% CI: 0.39-0.92, I^2:0%). Salvage LT vs. Primary LT did not differ between 5-year survival and disease-free survival (OR: 0.62; 95% CI: 0.33-1.15, I^2:0% and 0.93; 95% CI: 0.82-1.04, I^2:0%). Conclusion Overall, the study underscores the superior survival outcomes associated with LT over LR in HCC treatment, supported by comprehensive meta-analysis and clustering analysis. There was no difference in survival or recurrence rate between salvage LT and primary LT. Therefore, considering the organ shortage, HCC can be resected and transplanted in case of recurrence.
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Affiliation(s)
| | - Angela Bucaro
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesca Cardella
- Surgical Oncology of Gastrointestinal Tract Unit, Vanvitelli University, Naples, Italy
| | - Ishaan Wazir
- Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Francesco Frongillo
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Ardito
- Hepatobilairy and General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Giovinazzo
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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2
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Chen B, Butler N, O'Rourke T, Hodgkinson P, Stuart K, Shih E, Leggett D, Pryor D, Liu H, Lee D. Refining stereotactic body radiation therapy as a bridge to transplantation for hepatocellular carcinoma: An institutional experience. J Med Imaging Radiat Oncol 2023; 67:299-307. [PMID: 36825762 DOI: 10.1111/1754-9485.13509] [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: 12/07/2021] [Accepted: 01/06/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) has been established as a safe and effective treatment for hepatocellular carcinoma (HCC). Currently, there are no consensus guidelines to advise optimal patient selection and radiotherapy planning parameters to minimise the risk of surgical and medical complications after liver transplant (LT) in patients who have had prior SBRT for HCC, whilst optimising treatment benefit. METHODS We performed a retrospective analysis of all adult patients who received liver SBRT as a bridge to LT at a tertiary institution between 2017 and 2019. RESULTS Nine patients received SBRT as bridging therapy to LT. HCC location varied from peripheral to central/hilar regions and HCC diameter was 13-54 mm. Median time between SBRT and LT was 141 days (range 27-461 days). Median operating time was 360 min (range 270-480 min). Four patients (44%) had visible SBRT reaction or fibrosis at the time of LT. SBRT reaction resulted in clinical impact in one patient (11%) only, where vascular clamping of the IVC was required for 10 min. CONCLUSION SBRT is a safe and effective treatment for HCC enabling patients to remain within LT criteria, even for lesions not amenable to other more conventional bridging therapies. We describe a preliminary decision pathway to guide the optimal use of SBRT as a bridge to LT developed in our institution.
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Affiliation(s)
- Beini Chen
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Nick Butler
- Department of Hepatobiliary and Pancreatic Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Queensland Liver Transplant Service, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Thomas O'Rourke
- Department of Hepatobiliary and Pancreatic Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Queensland Liver Transplant Service, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Peter Hodgkinson
- Department of Hepatobiliary and Pancreatic Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Queensland Liver Transplant Service, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Katherine Stuart
- Queensland Liver Transplant Service, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Edwin Shih
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - David Leggett
- University of Queensland, Brisbane, Queensland, Australia.,Department of Medical Imaging, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - David Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Howard Liu
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Dominique Lee
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia.,University of Sydney, Sydney, New South Wales, Australia
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3
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Batra RK. Utility of Liver Transplantation Within the Bounds of Non-futility. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00288-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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4
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Kudo A, Shinoda M, Ariizumi S, Kumamoto T, Katayama M, Otsubo T, Endo I, Kitagawa Y, Tanabe M, Yamamoto M. Des-gamma-carboxy prothrombin affects the survival of HCC patients with marginal liver function and curative treatment: ACRoS1402. J Cancer Res Clin Oncol 2020; 146:2949-2956. [PMID: 32462296 DOI: 10.1007/s00432-020-03270-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/20/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE Considering the initial treatment of hepatocellular carcinoma (HCC), the best prognostic index for Child-Pugh classes B and C (CP-BC) patients has not been yet established. This study aimed to elucidate the risk factors for disease-free survival (DFS) and overall survival (OS) in multicenter patients with a poor liver functional reserve after curative treatment. METHODS Between April 2000 and April 2014, 212 CP-BC patients who received treatment in five high-volume centers in Japan were included in this study. CP-B and C patients were 206 and 6, respectively. Cox proportional hazard regression analyses for DFS and OS were performed to estimate the risk factors. RESULTS The mean observation time was 1132 days. Mean Child-Pugh score and indocyanine green retention rate at 15 min were 7.5 and 31.5%, respectively. Histological chronic hepatitis and liver cirrhosis were observed in 20% and 74% patients, respectively. In the multivariate analysis, the risk factors for DFS were des-gamma-carboxy prothrombin (DCP) [hazard ratio (HR), 1.6; P = 0.012] and treatment without liver transplantation. Moreover, DCP was identified as an independent risk factor for OS (HR, 1.7; P = 0.01). Tumor size, number, tumor thrombus, Milan criteria, liver cirrhosis, and treatment without liver transplantation were not identified as risk factors for OS. The 5-year OS in patients with high serum DCP levels (< 90 mAU/mL) was significantly better than that in those with low serum DCP levels (P = 0.003). CONCLUSIONS Serum DCP value before treatment predicted both DFS and OS in CP-BC patients with HCC.
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Affiliation(s)
- Atsushi Kudo
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Masahiro Shinoda
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Shunichi Ariizumi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takafumi Kumamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Kanagawa, Japan
| | - Masafumi Katayama
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Takehito Otsubo
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Kanagawa, Japan
| | - Yuko Kitagawa
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
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Advantage of early liver transplantation whenever indicated for hepatocellular carcinoma recurrence after primary liver resection. Biomed J 2019; 42:335-342. [PMID: 31783994 PMCID: PMC6888715 DOI: 10.1016/j.bj.2019.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/26/2018] [Accepted: 04/09/2019] [Indexed: 12/16/2022] Open
Abstract
Background Liver transplantation (LT) for recurrent hepatocellular carcinoma (HCC) following liver resection (LR) has been considered a promising strategy for improving patient's outcome. The study aimed to analyse patients from primary LR to LT for HCC and to provide additional information for decision-making in therapeutic strategies for patients with HCC. Methods Among 776 LTs, a retrospective analysis of patients who had undergone LT for recurrent HCC after primary LR between May 2005 and 2017 February was performed. Results During the follow-up period, the overall recurrence-free survival rates at 1, 3 and 5 years were 84.8%, 68.2% and 68.2%, and disease-specific overall-survival rates were 95.7%, 74.4% and 66.7% at 1, 3 and 5 years after LT, respectively. Beyond University of California at San Francisco (UCSF) transplantation criteria (p = 0.018, hazard ratio (HR) = 12.70), maximum tumor size ≥ 5 cm at LR (p = 0.012, HR = 7.90) and period between post-LR HCC recurrence and LT ≥ 1 year (p = 0.030, HR = 7.57) were prognostic factors of HCC recurrence after LT. Moreover, HCC recurrence after LT was the solely independent risk factor affecting overall survival of patients. Conclusion Large tumor size at LR should be taken into cautious tending to HCC recurrence even after salvage LT. Importantly, LT should be considered as soon as possible preferably within 1 year whenever post-LR recurrent HCC meets transplantation criteria.
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6
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Lee TC, Morris MC, Patel SH, Shah SA. Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors. Surg Oncol Clin N Am 2019; 28:763-782. [PMID: 31472918 DOI: 10.1016/j.soc.2019.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.
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Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Sameer H Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA.
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7
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Mahmud N, John B, Taddei TH, Goldberg DS. Pre-transplant alpha-fetoprotein is associated with post-transplant hepatocellular carcinoma recurrence mortality. Clin Transplant 2019; 33:e13634. [PMID: 31177570 DOI: 10.1111/ctr.13634] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/01/2019] [Accepted: 06/04/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although liver transplantation may potentially cure hepatocellular carcinoma (HCC), the risk of HCC recurrence is 8%-20% at five years post-transplant. Pre-transplant alpha-fetoprotein (AFP) is a predictor of HCC recurrence, but it is unknown if pre-transplant AFP also predicts survival in patients with recurrence. METHODS We performed a retrospective cohort study using the United Network for Organ Sharing (UNOS) database between 2002 and 2016. We identified adult transplant recipients with HCC recurrence after liver transplantation for HCC and used Cox regression to compare patient survival among different maximum pre-transplant AFP levels. RESULTS The cohort (N = 1164) was primarily male, white, and with hepatitis C liver disease. The median time to HCC recurrence was 11.6 months (interquartile range 6.1-26.3). In Cox regression analysis, increasing pre-transplant AFP was associated with poorer survival when adjusting for age, pre-transplant model for end-stage liver disease (MELD), and time to HCC recurrence. For example, patients with pre-transplant AFP ≥500ng/mL had a 1.6-fold higher risk of death versus those with AFP ≤20ng/mL (P < 0.001). CONCLUSION Pre-transplant AFP is independently associated with survival in patients with HCC recurrence. These findings further contextualize the importance of pre-transplant AFP in liver transplantation and may improve prognostication for patients with HCC recurrence.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Binu John
- Virginia Commonwealth University, Richmond, Virginia.,McGuire VA Medical Center, Richmond, Virginia
| | - Tamar H Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - David S Goldberg
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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8
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Mahmud N, Shaked A, Olthoff KM, Goldberg DS. Differences in Posttransplant Hepatocellular Carcinoma Recurrence by Etiology of Liver Disease. Liver Transpl 2019; 25:388-398. [PMID: 30362249 PMCID: PMC6395513 DOI: 10.1002/lt.25363] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/17/2018] [Indexed: 01/10/2023]
Abstract
The 5-year incidence of posttransplant hepatocellular carcinoma (HCC) recurrence is 8%-20%. Several studies have evaluated pretransplant risk factors for HCC recurrence, but nearly all data have treated HCC as a homogeneous condition across all etiologies of liver disease despite differences in tumor biology and baseline incidence of HCC. We sought to evaluate the impact of etiology of liver disease, maximum pretransplant alpha-fetoprotein (AFP), and the interaction of the 2 factors on the risk of HCC recurrence. We performed a retrospective cohort study of HCC transplant recipients using United Network for Organ Sharing (UNOS) data from 2002 to 2016. A competing risks regression was performed to identify variables associated with HCC recurrence and an interaction term between etiology and maximum AFP category. Among 18,406 recipients, 1484 patients experienced HCC recurrence over 3.1 years of median follow-up time. There was a significant interaction between AFP category and etiology of liver disease (P < 0.001). Among patients with a maximum AFP <100 ng/mL, those with alcoholic liver disease had the lowest risk of recurrence. In contrast, in patients with a maximum AFP of 100-499, 500-1000, or >1000 ng/mL, those with alcoholic liver disease had the highest risk of HCC recurrence among all etiologies. In conclusion, risk of HCC recurrence differs by etiology of liver disease, and the significance of elevated pretransplant AFP varies by etiology. Patients with alcoholic liver disease and elevated maximum AFP are at a uniquely high risk of HCC recurrence. These findings have potential UNOS policy implications because the transplant selection process may ultimately benefit from etiology-specific criteria.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Abraham Shaked
- Division of Transplant Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kim M Olthoff
- Division of Transplant Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - David S Goldberg
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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9
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Kotewall CN, Cheung TT. Optimizing hepatectomy for hepatocellular carcinoma in Asia-patient selection and special considerations. Transl Gastroenterol Hepatol 2018; 3:75. [PMID: 30505962 DOI: 10.21037/tgh.2018.09.09] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/05/2018] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a common affliction in Asia. The treatment of HCC depends on the tumor status as well as the underlying liver function. Resection is the cornerstone of surgical management of HCC. For those unfit to undergo resection, local ablative therapy is a viable alternative. For patients with multiple small unresectable HCCs, liver transplantation offers another option, having the simultaneous benefit of removing the cancer in addition to replacing the pre-malignant and cirrhotic liver together. However, the paucity of liver grafts limits the applicability of this operation. In assessing for the appropriate treatment, the traditional TNM staging is not widely applied to HCC. Conventionally, doctors in the West have relied on the Barcelona staging system. Asian surgeons, on the other hand, have long adopted a more aggressive approach for their patients. Borne out of the need for a system which better suited Asian patients, the Hong Kong guidelines have been established. For the surgical resection of HCC, considerations must take into account issues regarding the tumor, the underlying liver and the patient. For the tumor, the size, the presence vascular invasion and presence of extra-hepatic metastasis will determine operability. Another important issue is the liver function and, by extension, the estimated residual liver volume after resection. Thirdly, patient factors i.e., fitness to undergo general anesthesia must be properly assessed. With improved surgical technique and better patient selection, peri-operative morbidity and long-term survival results after operation have improved drastically over the past decades.
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Affiliation(s)
| | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
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10
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Djokic M, Cemazar M, Popovic P, Kos B, Dezman R, Bosnjak M, Zakelj MN, Miklavcic D, Potrc S, Stabuc B, Tomazic A, Sersa G, Trotovsek B. Electrochemotherapy as treatment option for hepatocellular carcinoma, a prospective pilot study. Eur J Surg Oncol 2018; 44:651-657. [PMID: 29402556 DOI: 10.1016/j.ejso.2018.01.090] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/21/2017] [Accepted: 01/16/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Electrochemotherapy provides non-thermal ablation of cutaneous as well as deep seated tumors. Based on positive results of the treatment of colorectal liver metastases, we conducted a prospective pilot study on hepatocellular carcinomas with the aim of testing the feasibility, safety and effectiveness of electrochemotherapy. PATIENTS AND METHODS Electrochemotherapy with bleomycin was performed on 17 hepatocellular carcinomas in 10 patients using a previously established protocol. The procedure was performed during open surgery and the patients were followed for median 20.5 months. RESULTS Electrochemotherapy was feasible for all 17 lesions, and no treatment-related adverse events or major post-operative complications were observed. The median size of the treated lesions was 24 mm (range 8-41 mm), located either centrally, i.e., near the major hepatic vessels, or peripherally. The complete response rate at 3-6 months was 80% per patient and 88% per treated lesion. CONCLUSIONS Electrochemotherapy of hepatocellular carcinoma proved to be a feasible and safe treatment in all 10 patients included in this study. To evaluate the effectiveness of this method, longer observation period is needed; however the results at medium observation time of 20.5 months after treatment are encouraging, in 15 out of 17 lesions complete response was obtained. Electrochemotherapy is predominantly applicable in patients with impaired liver function due to liver cirrhosis and/or with lesions where a high-risk operation is needed to achieve curative intent, given the intra/perioperative risk for high morbidity and mortality.
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Affiliation(s)
- Mihajlo Djokic
- University Medical Centre Ljubljana, Department of Abdominal Surgery, Zaloska 7, SI-1000 Ljubljana, Slovenia
| | - Maja Cemazar
- Institute of Oncology Ljubljana, Department of Experimental Oncology, Zaloska 2, SI-1000 Ljubljana, Slovenia; University of Primorska, Faculty of Health Sciences, Polje 42, SI-6310 Izola, Slovenia
| | - Peter Popovic
- University Medical Centre Ljubljana, Institute of Radiology, Zaloska 7, SI-1000 Ljubljana, Slovenia
| | - Bor Kos
- University of Ljubljana, Faculty of Electrical Engineering, Trzaska 25, Ljubljana SI-1000, Slovenia
| | - Rok Dezman
- University Medical Centre Ljubljana, Institute of Radiology, Zaloska 7, SI-1000 Ljubljana, Slovenia
| | - Masa Bosnjak
- Institute of Oncology Ljubljana, Department of Experimental Oncology, Zaloska 2, SI-1000 Ljubljana, Slovenia
| | - Martina Niksic Zakelj
- Institute of Oncology Ljubljana, Department of Experimental Oncology, Zaloska 2, SI-1000 Ljubljana, Slovenia
| | - Damijan Miklavcic
- University of Ljubljana, Faculty of Electrical Engineering, Trzaska 25, Ljubljana SI-1000, Slovenia
| | - Stojan Potrc
- University Clinical Centre Maribor, Department of Abdominal Surgery, Ljubljanska ulica 5, SI-2000 Maribor, Slovenia
| | - Borut Stabuc
- University Medical Centre Ljubljana, Department of Gastroenterology, Zaloska 7, SI-1000 Ljubljana, Slovenia
| | - Ales Tomazic
- University Medical Centre Ljubljana, Department of Abdominal Surgery, Zaloska 7, SI-1000 Ljubljana, Slovenia
| | - Gregor Sersa
- Institute of Oncology Ljubljana, Department of Experimental Oncology, Zaloska 2, SI-1000 Ljubljana, Slovenia; University of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, SI-1000 Ljubljana, Slovenia.
| | - Blaz Trotovsek
- University Medical Centre Ljubljana, Department of Abdominal Surgery, Zaloska 7, SI-1000 Ljubljana, Slovenia.
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11
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Imura S, Teraoku H, Yoshikawa M, Ishikawa D, Yamada S, Saito Y, Iwahashi S, Ikemoto T, Morine Y, Shimada M. Potential predictive factors for microvascular invasion in hepatocellular carcinoma classified within the Milan criteria. Int J Clin Oncol 2017; 23:98-103. [PMID: 28875240 DOI: 10.1007/s10147-017-1189-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 08/23/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Microvascular invasion (mvi) is an important risk factor for recurrent hepatocellular carcinoma (HCC), even after curative liver resection or orthotopic liver transplantation. However, mvi is difficult to detect preoperatively. The aim of this study was to clarify the risk factors of postoperative recurrence and investigate predictive factors of mvi before hepatectomy for HCC classified within the Milan criteria. METHODS One hundred fifty-nine patients with hepatocellular carcinoma (HCC) classified within the Milan criteria, who underwent hepatectomy, were enrolled in this study. We investigated the risk factors of recurrence. In addition, we divided them into two groups: mvi-negative group and mvi-positive group, based on pathological findings after surgery. We compared the clinicopathological factors between the two groups and determined the risk factors for mvi. RESULTS Overall survival rate at 1, 3, and 5 years were 91.6%, 80.5%, and 74.9%, and the recurrence-free survival rate at 1, 3, and 5-years were 72.3%, 51.6%, and 37.2%. Risk factor analysis for tumor recurrence revealed that total bilirubin, albumin, ICGR15, AFP-L3, tumor number, mvi, and tumor stage had a significant predictive value. Multivariate analysis revealed that tumor number and mvi were significant independent risk factors for tumor recurrence. Predictive analysis for risk factors of mvi revealed that multiple tumors and AFP-L3 > 10% were significant independent risk factors for mvi in HCC classified within the Milan criteria. CONCLUSIONS The mvi was one of the independent risk factors for tumor recurrence in HCC classified within the Milan criteria. Multiple tumors and high AFP-L3 value were independent predictive factors for mvi.
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Affiliation(s)
- Satoru Imura
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan.
| | - Hiroki Teraoku
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Masato Yoshikawa
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Daichi Ishikawa
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Shinichiro Yamada
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Yu Saito
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Shuichi Iwahashi
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Tetsuya Ikemoto
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Yuji Morine
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Mitsuo Shimada
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
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12
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Locoregional Therapy With Curative Intent Versus Primary Liver Transplant for Hepatocellular Carcinoma. Transplantation 2017; 101:e249-e257. [DOI: 10.1097/tp.0000000000001730] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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13
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Park MS, Lee KW, Kim H, Choi Y, Hong G, Yi NJ, Suh KS. Primary Living-donor Liver Transplantation Is Not the Optimal Treatment Choice in Patients With Early Hepatocellular Carcinoma With Poor Tumor Biology. Transplant Proc 2017; 49:1103-1108. [DOI: 10.1016/j.transproceed.2017.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Donat M, Alonso S, Pereira F, Ferrero E, Carrión L, Acin-Gándara D, Moreno E. Impact of Histological Factors of Hepatocellular Carcinoma on the Outcome of Liver Transplantation. Transplant Proc 2017; 48:1968-77. [PMID: 27569930 DOI: 10.1016/j.transproceed.2016.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 04/10/2016] [Accepted: 04/27/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to identify predictors of overall survival (OS), disease-free survival (DFS), and recurrence in a cohort of 151 patients with hepatocellular carcinoma (HCC) and cirrhosis who were treated by liver transplantation (LT). PATIENTS AND METHODS A retrospective database of patients undergoing LT for radiologically diagnosed HCC at "12 de Octubre" Hospital, Madrid during 1986-2006 was analyzed. RESULTS The median follow-up was 67.44 months (SD = 55.7 months). Overall 1-, 3-, 5-, and 10-year survival was 87.5%, 73.7%, 64.1% and 43.4%, respectively. The 5-year OS of patients beyond the Milan criteria was 47.14%, whereas that of patients within the Milan criteria was 70.13% (P = .011). The 5-year OS of patients beyond the Milan criteria and with microvascular invasion (MVI) was 27.27%, whereas that of patients beyond the Milan criteria and without MVI criteria was 57.89% (P = .003). Multivariate analysis of prognostic factors revealed MVI and G3 to be independent and statistically significant factors affecting OS (P < .0001 and P = .045, respectively), DFS (P < .0001 and P = .004, respectively), and recurrence (P = .0002 and P = .028, respectively). Multivariate analysis of prognostic factors also revealed preoperative fine-needle aspiration (FNA) to be an independent negative statistically significant factor affecting recurrence (P = .0022). Multivariate analysis of predictive MVI factors revealed preoperative α-fetoprotein (AFP) levels >200 ng/mL to be an independent positive and statistically significant predictor of MVI (P = .0004). CONCLUSION MVI and G3 are independent negative factors affecting OS, DFS, and recurrence. The presence of MVI or AFP levels >200 ng/mL represent a contraindication for LT, as long as the patient is beyond the Milan criteria.
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Affiliation(s)
- M Donat
- Department of General and Visceral Surgery, Infanta Leonor Hospital, Madrid, Spain
| | - S Alonso
- Department of General and Visceral Surgery, Fuenlabrada University Hospital, Madrid, Spain.
| | - F Pereira
- Department of General and Visceral Surgery, Fuenlabrada University Hospital, Madrid, Spain
| | - E Ferrero
- Department of General and Visceral Surgery, "12 de Octubre" University Hospital, Madrid, Spain
| | - L Carrión
- Department of General and Visceral Surgery, Fuenlabrada University Hospital, Madrid, Spain
| | - D Acin-Gándara
- Department of General and Visceral Surgery, Fuenlabrada University Hospital, Madrid, Spain
| | - E Moreno
- Department of General and Visceral Surgery, "12 de Octubre" University Hospital, Madrid, Spain
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Niessen C, Thumann S, Beyer L, Pregler B, Kramer J, Lang S, Teufel A, Jung EM, Stroszczynski C, Wiggermann P. Percutaneous Irreversible Electroporation: Long-term survival analysis of 71 patients with inoperable malignant hepatic tumors. Sci Rep 2017; 7:43687. [PMID: 28266600 PMCID: PMC5339813 DOI: 10.1038/srep43687] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/30/2017] [Indexed: 12/18/2022] Open
Abstract
Aim of this retrospective analysis was to evaluate the survival times after percutaneous irreversible electroporation (IRE) in inoperable liver tumors not amenable to thermal ablation. 71 patients (14 females, 57 males, median age 63.5 ± 10.8 years) with 103 liver tumors were treated in 83 interventions using IRE (NanoKnife® system). The median tumor short-axis diameter was 1.9 cm (minimum 0.4 cm, maximum 4.5 cm). 35 patients had primary liver tumors and 36 patients had liver metastases. The Kaplan-Meier method was employed to calculate the survival rates, and the different groups were compared using multivariate log-rank and Wilcoxon tests. The overall median survival time was 26.3 months; the median survival of patients with primary land secondary liver cancer did not significantly differ (26.8 vs. 19.9 months; p = 0.41). Patients with a tumor diameter >3 cm (p < 0.001) or more than 2 lesions (p < 0.005) died significantly earlier than patients with smaller or fewer tumors. Patients with hepatocellular carcinoma and Child-Pugh class B or C cirrhosis died significantly earlier than patients with Child-Pugh class A (p < 0.05). Patients with very early stage HCC survived significantly longer than patients with early stage HCC with a median survival of 22.3 vs. 13.7 months (p < 0.05).
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Affiliation(s)
- C. Niessen
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - S. Thumann
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - L. Beyer
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - B. Pregler
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - J. Kramer
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - S. Lang
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - A. Teufel
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - E. M. Jung
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - C. Stroszczynski
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - P. Wiggermann
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
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Peng J, Li JJ, Li J, Li HW, Xu GP, Jia RR, Zhang XN, Zhao Y. Could ADC values be a promising diagnostic criterion for differentiating malignant and benign hepatic lesions in Asian populations: A meta-analysis. Medicine (Baltimore) 2016; 95:e5470. [PMID: 27902599 PMCID: PMC5134810 DOI: 10.1097/md.0000000000005470] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Liver cancer exhibits geographic and ethnic differences in its prevalence and biology, which implies that it is impractical to develop universal guidelines for all patients. Thus, a meta-analysis was conducted to identify the accuracy of apparent diffusion coefficients (ADCs) for discriminating malignant from benign liver lesions in Asians. METHODS Eligible studies published in PubMed, Ovid, and Embase/Medline were updated onto October 2014. STATA 12.0 and Meta-Disc 1.4 were used to perform this meta-analysis. RESULTS Eight studies comprising 661 benign liver lesions and 598 malignant liver lesions fulfilled all the inclusion criteria. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 0.88 (95% confidence interval [CI] 0.75-0.95), 0.93 (95% CI 0.86-0.97), 12.42 (95% CI 6.09-25.31), 0.13 (95% CI 0.06-0.29), and 95.58 (95% CI 35.29-258.89), respectively. Overall, the area under the summary receiver-operating characteristic curve was 0.96 (95% CI 0.94-0.98). Heterogeneity was found to originate potentially from the type of benign lesion. A subgroup analysis showed that differentiating between hemangiomas, cysts, and malignant liver lesions produced a significantly higher diagnostic accuracy than that of solid liver lesions. CONCLUSION Our meta-analysis indicated that ADC could be promising for characterizing liver lesions among Asians, indicating that the ADC value is a promising diagnostic criterion candidate. Meanwhile, the use of dual b values could be sufficient for liver lesion characterization. However, large-scale, high-quality trials should be conducted to identify specific standards, including cut-off values for further development of diffusion-weighted imaging as a routine clinical application among Asian populations.
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Zhu Q, Yuan B, Qiao GL, Yan JJ, Li Y, Duan R, Yan YQ. Prognostic factors for survival after hepatic resection of early hepatocellular carcinoma in HBV-related cirrhotic patients. Clin Res Hepatol Gastroenterol 2016; 40:418-27. [PMID: 26823044 DOI: 10.1016/j.clinre.2015.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 12/07/2015] [Accepted: 12/14/2015] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The study aimed to identify clinico-pathologic factors that predict survival in early hepatocellular carcinoma (HCC) patients with hepatitis B virus (HBV)-related cirrhosis undergoing liver resection. METHODS A population-based cohort was investigated to identify cirrhotic patients with confirmed early HCC (tumor size≤5cm and absence of nodal involvement, metastases, or major vascular invasion) after hepatic resection at the Eastern Hepatobiliary Surgery Hospital (Shanghai, China) from April 2005 and November 2010 using the Surveillance, Epidemiology, and End Results (SEER) database. These patients were studied retrospectively in terms of their clinical characteristics and prognostic factors. Predictors for survival were evaluated using Kaplan-Meier methods and Cox proportional hazards models. Besides, a simple prognostic scoring system was proposed to stratify these patients. RESULTS Of 537 (2.6% of all HCC patients in this period) cirrhotic patients with early HCC identified who had underwent liver resection, 87% were male. Median tumor size was 2.9cm, and 67% of patients had tumors>2cm. Following hepatic resection, overall median and 5-year survival were 75 months and 58%, respectively. Tumor size>2cm (hazard ratio [HR]=1.56), multifocality (HR=1.34), non-anatomic resection (HR=1.44) and vascular invasion (HR=2.03) were associated with worse prognosis (P<0.05). Moreover, these patients could be further stratified into 4 distinct prognostic groups based on the prognostic scoring system developed. CONCLUSION Tumor size>2cm, multifocality, non-anatomic resection and vascular invasion may be used to stratify HBV-related cirrhotic patients with early HCC after resection. Besides, these data also indicate that pathologic staging is important even in small HCC.
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Affiliation(s)
- Qian Zhu
- Department of Hepatobiliary Surgery, Jingmen First People's Hospital, 67, Xiangshan Avenue, 448000 Jingmen, Hubei Province, China
| | - Bo Yuan
- Department of Hepatobiliary Surgery, 455 Hospital of People's Liberation Army, 200052 Shanghai, China
| | - Guo-Liang Qiao
- Department of Medical Oncology, Capital Medical University Cancer Center, Beijing Shijitan Hospital, 100038 Beijing, China
| | - Jian-Jun Yan
- First Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, 200438 Shanghai, China
| | - Yun Li
- Department of Hepatobiliary Surgery, Jingmen First People's Hospital, 67, Xiangshan Avenue, 448000 Jingmen, Hubei Province, China
| | - Rui Duan
- Department of Hepatobiliary Surgery, Jingmen First People's Hospital, 67, Xiangshan Avenue, 448000 Jingmen, Hubei Province, China
| | - Yi-Qun Yan
- First Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, 200438 Shanghai, China.
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Post-resection recurrence of hepatocellular carcinoma in cirrhotic patients: Is thrombocytopenia a risk factor for recurrence? Surg Oncol 2016; 25:364-369. [PMID: 27916167 DOI: 10.1016/j.suronc.2016.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 02/08/2023]
Abstract
PURPOSE Liver resection is the main treatment for hepatocellular carcinoma (HCC) patients with sufficient liver reserve. However, the long-term outcomes are dismal because the recurrence rate is high, especially in cirrhotic patients. The role of platelets as a predictive factor for HCC recurrence is still controversial. The aim of this study was to assess the influence of the preoperative platelet count on HCC recurrence after liver resection in patients with liver cirrhosis. STUDY DESIGN Between 2004 and 2013, 233 HCC patients with pathologically proven liver cirrhosis underwent liver resection and were enrolled in this study. RESULTS Recurrence occurred in 125 patients (53.6%), predominantly within the remnant liver (100 patients, 42.9%). The 1-, 3-, and 5-year disease-free survival (DFS) rates were 71.4%, 48.1%, and 40.5%, respectively. The predictive factors for DFS were analyzed with Cox's proportional hazard regression model. In the multivariable analysis, the preoperative platelet count (p = 0.021) and pT stage (p = 0.01) were the only significant independent predictors of HCC recurrence. The recurrence rate was clearly stratified by the preoperative platelet count. The optimal cut-off value of 135 × 103/μL on a receiver operating characteristic curve corresponded to the maximum sensitivity and specificity of prediction. The DFS of patients with low preoperative platelet counts was significantly worse than that of patients with high preoperative platelet counts (p = 0.006, log-rank test). CONCLUSIONS Thrombocytopenia is a significant predictor of HCC recurrence after liver resection in cirrhotic patients. However, the pathophysiological mechanism underlying this finding requires clarification.
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Toyoda H, Lai PBS, O'Beirne J, Chong CC, Berhane S, Reeves H, Manas D, Fox RP, Yeo W, Mo F, Chan AWH, Tada T, Iñarrairaegui M, Vogel A, Schweitzer N, Chan SL, Sangro B, Kumada T, Johnson PJ. Long-term impact of liver function on curative therapy for hepatocellular carcinoma: application of the ALBI grade. Br J Cancer 2016; 114:744-50. [PMID: 27022825 PMCID: PMC4984858 DOI: 10.1038/bjc.2016.33] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/17/2015] [Accepted: 01/18/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Application of curative therapy for hepatocellular carcinoma is crucially dependent on underlying liver function. Using the recently described ALBI grade we examined the long-term impact of liver dysfunction on survival of early-stage hepatocellular carcinoma (HCC) patients. METHODS This cohort study comprised 2559 HCC patients from different geographic regions, all treated with curative intent. We also examined the relation between indocyanine green (ICG) clearance and ALBI score. Survival was measured from the date of treatment to the date of death or last follow-up. RESULTS The ALBI score correlated well with ICG clearance. Among those undergoing surgical resection, patients with ALBI grade-1 (good liver function) survived approximately twice as long as those with ALBI grade-2 (less good liver function), although more than 90% of these patients were classified as Child-Pugh (C-P) grade A. In the cohort receiving ablative therapies, there was a similar difference in survival between ALBI grade-1 and grade-2. Cox regression analysis confirmed that the ALBI score along with age, gender, aetiology and tumour factors (AFP, tumour size/number and vascular invasion) independently influenced survival in HCC patients receiving curative treatments. CONCLUSIONS The ALBI score represents a simple approach to the assessment of liver function in patients with HCC. After potentially curative therapy, those with ALBI grade-1 survived approximately twice as long as those with ALBI grade-2. These data suggest that ALBI grade-1 patients are appropriately treated with surgical resection whereas ALBI grade-2 patients may, where the option exists, be more suitable for liver transplantation or the less invasive curative ablative therapies.
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Affiliation(s)
- Hidenori Toyoda
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu 503-8052, Japan
| | - Paul BS Lai
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - James O'Beirne
- The Sheila Sherlock Liver Centre, Royal Free Hospital, London NW3 2QG, UK
| | - Charing C Chong
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - Sarah Berhane
- Department of Molecular and Clinical Cancer Medicine, The Duncan Building, Daulby Street, University of Liverpool, Liverpool L69 3GA, UK
| | - Helen Reeves
- Northern Institute for Cancer Research, Paul O'Gorman Building, Medical School, Framlington Place, Newcastle upon Tyne NE2 4HH, UK
- The Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne NHS Foundation Trust, The Freeman Hospital, Freeman Road, Newcastle upon Tyne, Tyne and Wear NE7 7DN, UK
| | - Derek Manas
- The Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne NHS Foundation Trust, The Freeman Hospital, Freeman Road, Newcastle upon Tyne, Tyne and Wear NE7 7DN, UK
| | - Richard P Fox
- Cancer Research UK Clinical Trials Unit, School of Cancer Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Winnie Yeo
- State Key Laboratory in Oncology in South China, Sir YK Pao Centre for Cancer, Department of Clinical Oncology, Chinese University of Hong Kong, Hong Kong Cancer Institute, Hong Kong, China
| | - Frankie Mo
- State Key Laboratory in Oncology in South China, Sir YK Pao Centre for Cancer, Department of Clinical Oncology, Chinese University of Hong Kong, Hong Kong Cancer Institute, Hong Kong, China
| | - Anthony WH Chan
- Department of Anatomical and Cellular Pathology, Chinese University of Hong Kong, Hong Kong Cancer Institute, Hong Kong, China
| | - Toshifumi Tada
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu 503-8052, Japan
| | - Mercedes Iñarrairaegui
- Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra, and Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Pamplona, Spain
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, Carl Neuberg Straβe 1, 30625 Hannover, Germany
| | - Nora Schweitzer
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, Carl Neuberg Straβe 1, 30625 Hannover, Germany
| | - Stephen L Chan
- State Key Laboratory in Oncology in South China, Sir YK Pao Centre for Cancer, Department of Clinical Oncology, Chinese University of Hong Kong, Hong Kong Cancer Institute, Hong Kong, China
| | - Bruno Sangro
- Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra, and Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Pamplona, Spain
| | - Takashi Kumada
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu 503-8052, Japan
| | - Philip J Johnson
- Department of Molecular and Clinical Cancer Medicine, The Duncan Building, Daulby Street, University of Liverpool, Liverpool L69 3GA, UK
- The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Bebington, Wirral CH63 4JY, UK
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Kamiyama T, Yokoo H, Kakisaka T, Orimo T, Wakayama K, Kamachi H, Tsuruga Y, Yamashita K, Shimamura T, Todo S, Taketomi A. Multiplication of alpha-fetoprotein and protein induced by vitamin K absence-II is a powerful predictor of prognosis and recurrence in hepatocellular carcinoma patients after a hepatectomy. Hepatol Res 2015; 45:E21-31. [PMID: 25382703 DOI: 10.1111/hepr.12451] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/29/2014] [Accepted: 11/05/2014] [Indexed: 02/05/2023]
Abstract
AIM To evaluate the oncological implications of multiplication of α-fetoprotein (AFP) and protein induced by vitamin K absence or antagonists-II (PIVKA-II) in patients with hepatocellular carcinoma (HCC). METHODS Data were prospectively collected from 516 consecutive patients who underwent a curative primary hepatectomy for HCC between 1998 and 2010. The AP-factor (AFP × PIVKA-II) was evaluated in relation to 2-year survival outcomes by receiver-operator curve analysis to determine the cut-off values. Patient survival, recurrence-free survival and risk factors were analyzed in accordance with the preoperative AP-factor. RESULTS The AP-factor was categorized into three groups depending on the serum concentrations of AFP and PIVKA-II as follows: AP1 (n = 206; AFP < 200 ng/mL and PIVKA-II < 100 mAU/mL), AP2 (n = 152; AFP × PIVKA-II < 10(5) ) and AP3 (n = 158; AFP × PIVKA-II ≥ 10(5) ). The AP-factor was found to be significantly related to pathological factors such as differentiation, portal vein invasion, hepatic vein invasion and intrahepatic metastasis. Multivariate analysis was performed to identify the risk factors for survival and recurrence. Albumin, AP-factor and pathological factors including portal vein invasion, hepatic vein invasion and intrahepatic metastasis are independent risk factors for survival. Tumor number, AP-factor, and a non-cancerous liver were determinants of recurrence. CONCLUSION The AP-factor is closely related to differentiation and microscopic vascular invasion, and was selected by multivariate analysis as an independent factor for survival and recurrence, in HCC. Patients hopeful of obtaining good outcomes after a hepatectomy could be selected by the AP-factor evaluation.
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Affiliation(s)
- Toshiya Kamiyama
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hideki Yokoo
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tatsuhiko Kakisaka
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tatsuya Orimo
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kenji Wakayama
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hirofumi Kamachi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yosuke Tsuruga
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kenichiro Yamashita
- Departments of Transplantation Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tsuyoshi Shimamura
- Department of Organ Transplantation, Hokkaido University Hospital, Sapporo, Japan
| | - Satoru Todo
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Outcomes of liver resection for hepatocellular carcinoma in liver transplantation era. Eur J Surg Oncol 2015; 41:1144-52. [PMID: 26163047 DOI: 10.1016/j.ejso.2015.05.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/24/2015] [Accepted: 05/31/2015] [Indexed: 12/16/2022] Open
Abstract
AIMS Surgical treatment for early-stage hepatocellular carcinoma (HCC) is toward transplantation. However, liver resection remains the major surgical treatment for HCC in Asia. This study is to examine the results of liver resection when liver transplantation became an option of treatment for early-stage HCC. METHODS In this retrospective cohort study, 1639 patients with resectable HCC were reviewed and divided into two groups. In the 1st period (2002-2005), all 679 patients received liver resection. In the 2nd period (2006-2010), 916 patients had liver resection and 44 patients jointed liver transplantation program. The results of treatment in these two periods were analyzed. RESULTS The characteristics of tumors were the most important factors of tumor recurrence after liver resection. Liver function reserve, characteristics of tumors, and surgeons' endeavor were all independent factors for overall survival after liver resection. When the patients with oligo-nodular tumors or portal hypertension with low platelet count had liver transplantation rather than liver resection in the 2nd period, the survival rates in the 2nd period were improved. When the patients in the 1st period with low platelet count (≤105 × 10(3)/uL) were subtracted, the 5-year survival rate of the patients with one-segmentectomy for small-sized HCC in the 1st period was similar to those in the 2nd period and transplant patients. CONCLUSIONS The outcomes of liver resection were improved while liver transplantation was performed for the patients with suspicious portal hypertension. Platelet count, 105 × 10(3)/uL, could be a watershed for early stage HCC patients to undergo liver resection or liver transplantation.
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Abstract
The benefits of applying comparative effectiveness research (CER) strategies to the management of cancer are important. As the incidence of cancer increases both in the United States and worldwide, accurate analysis of which tests and treatments should be applied in which situations is critical, both in terms of measurable and meaningful clinical outcomes and health care costs. In the last 20 years alone, multiple controversies have arisen in the diagnosis and treatment of primary and metastatic tumors of the liver, making the management of liver malignancies a prime example of CER. Contributing factors to the development of these controversies include improvements in molecular characterization of these diseases and technological advances in surgery and radiology. The relative speed of these advances has outpaced data from clinical trials, in turn making robust data to inform clinical practice lacking. Indeed, many of the current treatment recommendations for the management of liver malignancies are based primarily on retrospective data. We herein review select CER issues concerning select decision-making topics in the management of liver malignancies.
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Ofosu A, Gurakar A. Current Concepts in Hepatocellular Carcinoma and Liver Transplantation: A Review and 2014 Update. Euroasian J Hepatogastroenterol 2015; 5:19-25. [PMID: 29201680 PMCID: PMC5578514 DOI: 10.5005/jp-journals-10018-1123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/25/2015] [Indexed: 12/13/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Multiple treatment modalities for HCC are available, depending on size and number of tumor. Liver transplantation offers the most reasonable option for curative treatment, because it simultaneously removes the burden of the diseased liver. The Milan criteria currently remain the benchmark for the selection of patients with HCC for transplantation. However, there is considerable and promising interest in expanding the eligibility criteria to include the University of California San Francisco criteria. Liver transplantation (LT) has progressed during the past decade. The introduction of living donor LT has provided a means of expanding organ transplant, but with some inherent concerns. Herein, we reviewed the diagnosis and management of HCC with emphasis on the current concepts of liver transplantation for the treatment of HCC.
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Affiliation(s)
- Andrew Ofosu
- Department of Medicine, MedStar Harbor Hospital, Maryland, USA
| | - Ahmet Gurakar
- Department of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Maryland, USA
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Liver Transplantation for Hepatocellular Carcinoma. CURRENT TRANSPLANTATION REPORTS 2014. [DOI: 10.1007/s40472-014-0028-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Seshadri RM, Besur S, Niemeyer DJ, Templin M, McKillop IH, Swan RZ, Martinie JB, Russo MW, Iannitti DA. Survival analysis of patients with stage I and II hepatocellular carcinoma after a liver transplantation or liver resection. HPB (Oxford) 2014; 16:1102-9. [PMID: 24964271 PMCID: PMC4253334 DOI: 10.1111/hpb.12300] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 05/21/2014] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Liver transplantation (LT) is a treatment option in select patients with hepatocellular carcinoma (HCC). The aim of the present study was to compare survival in Stage I or II HCC patients undergoing either liver transplant (LT) or a liver resection (LR). METHOD The study is a retrospective analysis of the National Cancer Data Base (1998-2011). In total, 148,882 patients with liver cancer were identified, of which 5-year survival data (1998-2006) were available for 64,227 patients. Patients were stratified by the American Joint Committee on Cancer (AJCC) clinical stage I and II. Kaplan-Meier curves and log-rank tests were used for statistical analysis. RESULTS 3340 HCC patients met analysis criteria. Among stage I HCC, 860 had LT and 871 had LR. Among stage II HCC, 833 had LT and 776 LR. In stage I patients the median survival for LT and LR were 127.9 and 56.7 months, respectively, (P < 0.0001) and in stage II patients the median survival was 110.8 and 42.8 months (P < 0.0001). Unlike LT patients, LR patients with Stage I HCC had a longer median survival compared with Stage II patients (P = 0.0002). CONCLUSION Liver transplantation offers a survival advantage compared with a liver resection among patients with Stage I and II HCC. LT is the best surgical treatment for early stage (I/II) HCC in patients with advanced fibrosis or cirrhosis, whereas LR provides equivalent outcomes to LT in patients without advanced fibrosis and should be considered as the first surgical option.
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Affiliation(s)
- Ramanathan M Seshadri
- Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical CenterCharlotte, NC, USA
| | - Siddesh Besur
- Division of Hepatology, Department of Internal Medicine, Carolinas Medical CenterCharlotte, NC, USA
| | - David J Niemeyer
- Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical CenterCharlotte, NC, USA
| | - Megan Templin
- Dickson Advanced Analytics Group, Carolinas Medical CenterCharlotte, NC, USA
| | - Iain H McKillop
- Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical CenterCharlotte, NC, USA
| | - Ryan Z Swan
- Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical CenterCharlotte, NC, USA
| | - John B Martinie
- Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical CenterCharlotte, NC, USA
| | - Mark W Russo
- Division of Hepatology, Department of Internal Medicine, Carolinas Medical CenterCharlotte, NC, USA
| | - David A Iannitti
- Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical CenterCharlotte, NC, USA,Correspondence David A. Iannitti, Department of Surgery, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28203, USA. Tel: +1 704 355 6220. Fax: +1 704 355 5619. E-mail:
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Sapisochin G, Sevilla EFD, Echeverri J, Charco R. Management of “very early” hepatocellular carcinoma on cirrhotic patients. World J Hepatol 2014; 6:766-775. [PMID: 25429314 PMCID: PMC4243150 DOI: 10.4254/wjh.v6.i11.766] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/29/2014] [Accepted: 10/16/2014] [Indexed: 02/06/2023] Open
Abstract
Due to the advances in screening of cirrhotic patients, hepatocellular carcinoma (HCC) is being diagnosed in earlier stages. For this reason the number of patients diagnosed of very early HCC (single tumors ≤ 2 cm) is continuously increasing. Once a patient has been diagnosed with this condition, treatment strategies include liver resection, local therapies or liver transplantation. The decision on which therapy should the patient undergo depends on the general patients performance status and liver disease. Anyway, even in patients with similar conditions, the best treatment offer is debatable. In this review we analyze the state of the art on the management of very early HCC on cirrhotic patients to address the best treatment strategy for this patient population.
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Motoyama H, Kobayashi A, Yokoyama T, Shimizu A, Furusawa N, Sakai H, Kitagawa N, Ohkubo Y, Tsukahara T, Miyagawa SI. Liver failure after hepatocellular carcinoma surgery. Langenbecks Arch Surg 2014; 399:1047-55. [PMID: 25335877 DOI: 10.1007/s00423-014-1252-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 10/01/2014] [Indexed: 12/28/2022]
Abstract
PURPOSE The aim of this study was to construct a prediction model for posthepatectomy liver failure (PHLF), as defined by the International Study Group of Liver Surgery, and evaluate its accuracy in hepatocellular carcinoma (HCC) patients with cirrhosis or chronic hepatitis. METHODS A total of 277 consecutive hepatectomies for HCC between 2005 and 2013 were analyzed retrospectively. Multivariate logistic regression analysis was used to develop a predictive model for PHLF. The sensitivity, specificity, and area under the receiver operating characteristic (AUROC) curve were evaluated. The Hosmer-Lemeshow goodness-of-fit test was used to assess the model calibration. The constructed model was internally validated by k-fold cross-validation (k=5). RESULTS PHLF developed in 12.6% of hepatectomies. Multivariate analysis identified the following variables as predictors of PHLF: elevated preoperative serum bilirubin level, elevated preoperative international normalized ratio, and intraoperative packed red blood cell transfusion. The predictive model allowed discrimination between patients who developed PHLF and those who did not, with a sensitivity of 82.9%, specificity of 72.3%, and AUROC curve of 0.81 (95% CI, 0.74 to 0.89). The Hosmer-Lemeshow test indicated a good fit (P=0.545). The AUROC curve of the developed model was significantly greater than that of the model for end-stage liver disease (MELD) score (P=0.014), suggesting that the former model is better at predicting the PHLF than the latter one. CONCLUSIONS The developed model could be useful for predicting the occurrence of PHLF in HCC patients with underlying liver disease.
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Affiliation(s)
- Hiroaki Motoyama
- First Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
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Menon KV, Hakeem AR, Heaton ND. Review article: liver transplantation for hepatocellular carcinoma - a critical appraisal of the current worldwide listing criteria. Aliment Pharmacol Ther 2014; 40:893-902. [PMID: 25155143 DOI: 10.1111/apt.12922] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 01/16/2014] [Accepted: 07/27/2014] [Indexed: 12/08/2022]
Abstract
BACKGROUND Liver transplantation (LT) plays an important role in the management of patients with hepatocellular carcinoma (HCC). Although early results following LT for HCC were poor, since the introduction of the Milan criteria in 1996 morphological criteria have since been well established. Thereafter, various expansions of the Milan criteria were introduced worldwide. Listing criteria for LT for HCC in the United Kingdom (UK) initially conformed to the Milan criteria but were re-defined in 2009 by expansion of the Milan criteria. AIMS To look at the evidence in literature on listing criteria and management of HCC worldwide in comparison with the UK. Secondly, we aim to review worldwide vs. UK literature on prioritisation models, loco-regional therapy protocols and role of alpha-fetoprotein (AFP) in LT for HCC. METHODS An electronic literature search with Medline was carried out to identify articles related to LT for HCC. RESULTS Although various expansions of the Milan criteria have been described, they remain the gold standard against which other criteria are measured. The UK criteria are an expansion of the Milan criteria that go beyond Milan and University of California, San Francisco (UCSF) criteria. The current UK listing criteria for LT for HCC when compared to the worldwide criteria have a worse survival benefit (projected 5-year survival between 35-50%) when plotted on the metroticket calculator. CONCLUSIONS In keeping with most transplant centres worldwide, the UK have adopted expansions to Milan to allow more patients to benefit from LT. However, currently, as it stands the UK criteria when plotted in the modification of the Metroticket model project worse survival that would seem unjustified.
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Affiliation(s)
- K V Menon
- Institute of Liver Studies, Kings College Hospital, London, UK
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Dai WC, Chan SC, Chok KSH, Cheung TT, Sharr WW, Chan ACY, Tsang SHY, Fung JYY, Poon RTP, Fan ST, Lo CM. Good longterm survival after primary living donor liver transplantation for solitary hepatocellular carcinomas up to 8 cm in diameter. HPB (Oxford) 2014; 16:749-57. [PMID: 24467735 PMCID: PMC4113258 DOI: 10.1111/hpb.12212] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 11/20/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES There is controversy over whether hepatocellular carcinoma (HCC) should be primarily treated with living donor liver transplantation (LDLT) if liver resection (LR) can be effective. This retrospective study was conducted to compare survival outcomes in patients treated with either modality for solitary HCC measuring ≤8 cm in diameter. METHODS Outcomes in patients with solitary HCC primarily treated by LDLT were analysed. Patients with solitary HCC of similar sizes with or without microvascular invasion primarily treated with LR were selected at a ratio of 6 : 1 for comparison. RESULTS In-hospital mortality amounted to 0% and 1.3% in the LDLT (n = 50) and LR (n = 300) groups, respectively (P = 0.918). Complication rates were 34% and 20% in the LDLT and LR groups, respectively (P = 0.027). Rates of 1-, 3-, 5- and 10-year overall survival were 98%, 94%, 89% and 83%, respectively, in the LDLT group and 95%, 85%, 76% and 56%, respectively, in the LR group (P = 0.013). Rates of 1-, 3-, 5- and 10-year disease-free survival were 96%, 90%, 87% and 81%, respectively, in the LDLT group and 81%, 64%, 57% and 40%, respectively, in the LR group (P < 0.0001). CONCLUSIONS Living donor liver transplantation surpassed LR in survival outcomes, achieving a 10-year overall survival rate 1.5 times as high and a 10-year disease-free survival rate twice as high as those facilitated by LR. However, it entailed more complications, in addition to the inevitable risks to the donor.
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Affiliation(s)
- Wing Chiu Dai
- Department of Surgery, University of Hong KongHong Kong, China
| | - See Ching Chan
- Department of Surgery, University of Hong KongHong Kong, China
| | | | - Tan To Cheung
- Department of Surgery, University of Hong KongHong Kong, China
| | - William W Sharr
- Department of Surgery, University of Hong KongHong Kong, China
| | - Albert C Y Chan
- Department of Surgery, University of Hong KongHong Kong, China
| | - Simon H Y Tsang
- Department of Surgery, University of Hong KongHong Kong, China
| | - James Y Y Fung
- Department of Medicine, University of Hong KongHong Kong, China
| | - Ronnie T P Poon
- Department of Surgery, University of Hong KongHong Kong, China
| | - Sheung Tat Fan
- Department of Surgery, University of Hong KongHong Kong, China
| | - Chung Mau Lo
- Department of Surgery, University of Hong KongHong Kong, China
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Narayanan G, Froud T, Suthar R, Barbery K. Irreversible electroporation of hepatic malignancy. Semin Intervent Radiol 2014; 30:67-73. [PMID: 24436519 DOI: 10.1055/s-0033-1333655] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Hepatocellular carcinoma (HCC) is a worldwide problem of epidemic proportions, best treated in a multidisciplinary setting. Major advances have been made in all specialties that manage patients with HCC, with surgical options at one end of the spectrum and palliative chemotherapy on the other, and the vast majority of patients require the involvement and expertise of interventional oncology. Several ablative and transarterial technologies are currently available. Irreversible electroporation (IRE) is a new ablative technology that uses high-voltage, low-energy DC current to create nanopores in the cell membrane, disrupting the homeostasis mechanism and inducing cell death by initiating apoptosis. This article discusses the evolution of IRE as well as its safety and efficacy in the context of other ablative therapies in the treatment of hepatic malignancies.
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Affiliation(s)
| | - Tatiana Froud
- Miller School of Medicine, University of Miami, Miami, Florida
| | - Rekhaben Suthar
- Miller School of Medicine, University of Miami, Miami, Florida
| | - Katuska Barbery
- Miller School of Medicine, University of Miami, Miami, Florida
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Xu XS, Liu C, Qu K, Song YZ, Zhang P, Zhang YL. Liver transplantation versus liver resection for hepatocellular carcinoma: a meta-analysis. Hepatobiliary Pancreat Dis Int 2014; 13:234-41. [PMID: 24919605 DOI: 10.1016/s1499-3872(14)60037-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Xin-Sen Xu
- Department of Hepatobiliary Surgery, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an 710061, China.
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Proneth A, Zeman F, Schlitt HJ, Schnitzbauer AA. Is Resection or Transplantation the ideal Treatment in Patients with Hepatocellular Carcinoma in Cirrhosis if Both Are Possible? A Systematic Review and Metaanalysis. Ann Surg Oncol 2014; 21:3096-107. [DOI: 10.1245/s10434-014-3808-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Indexed: 02/06/2023]
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Gu L, Liu H, Fan L, Lv Y, Cui Z, Luo Y, Liu Y, Li G, Li C, Ma J. Treatment outcomes of transcatheter arterial chemoembolization combined with local ablative therapy versus monotherapy in hepatocellular carcinoma: a meta-analysis. J Cancer Res Clin Oncol 2014; 140:199-210. [PMID: 24077865 DOI: 10.1007/s00432-013-1528-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 09/13/2013] [Indexed: 12/16/2022]
Abstract
PURPOSE To evaluate the effectiveness comparing the combination of TACE with local ablative therapy and monotherapy on the treatment of HCC using meta-analytical techniques. METHODS Randomized controlled trials and clinical studies comparing TACE plus local ablative therapy with monotherapy for HCC were included in this meta-analysis. Response rate, 1-, 2-, 3-, and 5-year survival rate, and overall survival (OS) were analyzed and compared. RESULTS Eighteen studies included a total of 2,120 patients with HCC 1,071 and 1,049 patients for treatment with combination therapy and monotherapy, respectively. The combination therapy group had a significantly better survival in terms of 1-, 2-, 3-, and 5-year survival rate (RR 1.10, 95 % CI 1.03–1.18, P = 0.005; RR 1.20, 95 % CI 1.10–1.30, P < 0.0001; RR 1.43, 95 % CI 1.18–1.73, P < 0.0001; RR 1.40, 95 % CI 1.22–1.61, P < 0.0001, respectively), OS (HR 0.66, 95 % CI 0.51–0.85, P = 0.001), and response rate (RR 1.54, 95 % CI 1.09–2.18, P = 0.013) than that monotherapy group in patients with HCC. CONCLUSIONS The meta-analysis indicates that the combination of TACE with local ablative therapy was superior to monotherapy in the treatment for patients with HCC.
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Pure laparoscopic liver resection reduces surgical site infections and hospital stay. Results of a case-matched control study in 50 patients. Langenbecks Arch Surg 2014; 399:307-14. [PMID: 24526221 DOI: 10.1007/s00423-014-1169-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 01/24/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic resection is an emerging tool in surgical oncology, but its role in liver tumors is far from being universally accepted. METHODS We designed a case-matched control study, comparing laparoscopic (LAP) vs. open hepatectomies (OP) performed in the same center during the same period of time. Fifty LAP were performed (34 liver metastases, 7 hepatocellular carcinomas, 2 hydatid cysts, and 5 benign tumors). Cases were compared with 100 OP matched according to: diagnosis, number of lesions, type of resection, age, ASA score, and ECOG performance status. We evaluated intraoperative and postoperative parameters, focusing on morbidity and mortality. RESULTS Preoperative data were comparable in both groups. Operative features were similar in terms of overall morbidity 18 (36 %) vs. 36 (36 %), p = 1; intraoperative bleeding, 401 (18-2192) vs. 475 (20-2000) mL, p = 0.89; pedicle clamping, 37 (74 %) vs. 88 (88 %), p = 0.55; margin, 0.6 (0-5) vs. 0.65 (0-5) cm, p = 0.94, and mortality p = 0.65 for the LAP and OP groups, respectively. There was a significant decrease in surgical site infections 1 (2 %) vs. 18 (18 %) p = 0.007 in the LAP group. Operative time was longer: 295 (120-600) vs. 200 (70-450) min (p = 0.0001), and hospital stay significantly shorter: 4 (1-60) vs. 7 (3-44) days, p = 0.0001 with less readmissions (0 vs. 7 %) in the LAP. DISCUSSION In adequately selected patients, laparoscopic hepatectomy is feasible, safe, shortens hospital stay, and decreases surgical site infections.
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New approach for cirrhotic patients with single HCC after 20 years of management? Ann Surg 2014; 261:e109. [PMID: 24424145 DOI: 10.1097/sla.0000000000000523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wong RJ, Wantuck J, Valenzuela A, Ahmed A, Bonham C, Gallo A, Melcher ML, Lutchman G, Concepcion W, Esquivel C, Garcia G, Daugherty T, Nguyen MH. Primary surgical resection versus liver transplantation for transplant-eligible hepatocellular carcinoma patients. Dig Dis Sci 2014; 59:183-91. [PMID: 24282054 DOI: 10.1007/s10620-013-2947-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 11/11/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a leading cause of mortality worldwide. Existing studies comparing outcomes after liver transplantation (LT) versus surgical resection among transplant-eligible patients are conflicting. AIM The purpose of this study was to compare long-term survival between consecutive transplant-eligible HCC patients treated with resection versus LT. METHODS The present retrospective matched case cohort study compares long-term survival outcomes between consecutive transplant-eligible HCC patients treated with resection versus LT using intention-to-treat (ITT) and as-treated models. Resection patients were matched to LT patients by age, sex, and etiology of HCC in a 1:2 ratio. RESULTS The study included 171 patients (57 resection and 114 LT). Resection patients had greater post-treatment tumor recurrence (43.9 vs. 12.9 %, p < 0.001) compared to LT patients. In the as-treated model of the pre-model for end stage liver disease (MELD) era, LT patients had significantly better 5-year survival compared to resection patients (100 vs. 69.5 %, p = 0.04), but no difference was seen in the ITT model. In the multivariate Cox proportional hazards model, inclusive of age, sex, ethnicity, tumor stage, and MELD era (pre-MELD vs. post-MELD), treatment with resection was an independent predictor of poorer survival (HR 2.72; 95 % CI, 1.08-6.86). CONCLUSION Transplant-eligible HCC patients who received LT had significantly better survival than those treated with resection, suggesting that patients who can successfully remain on LT listing and actually undergo LT have better outcomes.
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Affiliation(s)
- Robert J Wong
- Liver Transplant Program, Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, 750 Welch Road, Suite 210, Palo Alto, CA, 94304, USA,
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Chaib E, Amaku M, Coutinho FAB, Lopez LF, Burattini MN, D’Albuquerque LAC, Massad E. A mathematical model for optimizing the indications of liver transplantation in patients with hepatocellular carcinoma. Theor Biol Med Model 2013; 10:60. [PMID: 24139285 PMCID: PMC4016553 DOI: 10.1186/1742-4682-10-60] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 10/10/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The criteria for organ sharing has developed a system that prioritizes liver transplantation (LT) for patients with hepatocellular carcinoma (HCC) who have the highest risk of wait-list mortality. In some countries this model allows patients only within the Milan Criteria (MC, defined by the presence of a single nodule up to 5 cm, up to three nodules none larger than 3 cm, with no evidence of extrahepatic spread or macrovascular invasion) to be evaluated for liver transplantation. This police implies that some patients with HCC slightly more advanced than those allowed by the current strict selection criteria will be excluded, even though LT for these patients might be associated with acceptable long-term outcomes. METHODS We propose a mathematical approach to study the consequences of relaxing the MC for patients with HCC that do not comply with the current rules for inclusion in the transplantation candidate list. We consider overall 5-years survival rates compatible with the ones reported in the literature. We calculate the best strategy that would minimize the total mortality of the affected population, that is, the total number of people in both groups of HCC patients that die after 5 years of the implementation of the strategy, either by post-transplantation death or by death due to the basic HCC. We illustrate the above analysis with a simulation of a theoretical population of 1,500 HCC patients with tumor size exponentially. The parameter λ obtained from the literature was equal to 0.3. As the total number of patients in these real samples was 327 patients, this implied in an average size of 3.3 cm and a 95% confidence interval of [2.9; 3.7]. The total number of available livers to be grafted was assumed to be 500. RESULTS With 1500 patients in the waiting list and 500 grafts available we simulated the total number of deaths in both transplanted and non-transplanted HCC patients after 5 years as a function of the tumor size of transplanted patients. The total number of deaths drops down monotonically with tumor size, reaching a minimum at size equals to 7 cm, increasing from thereafter. With tumor size equals to 10 cm the total mortality is equal to the 5 cm threshold of the Milan criteria. CONCLUSION We concluded that it is possible to include patients with tumor size up to 10 cm without increasing the total mortality of this population.
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Affiliation(s)
- Eleazar Chaib
- Department of Gastroenterology, Liver and Pancreas Transplantation Surgery Unit, LIM 37, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Marcos Amaku
- Department of Medical Informatics, LIM 01, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Francisco AB Coutinho
- Department of Medical Informatics, LIM 01, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Luis F Lopez
- Department of Medical Informatics, LIM 01, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Marcelo N Burattini
- Department of Medical Informatics, LIM 01, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Luiz AC D’Albuquerque
- Department of Gastroenterology, Liver and Pancreas Transplantation Surgery Unit, LIM 37, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Eduardo Massad
- Department of Medical Informatics, LIM 01, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
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Liver transplantation for hepatocellular carcinoma recurrence after liver resection: why deny this chance of cure? J Clin Gastroenterol 2013. [PMID: 23188072 DOI: 10.1097/mcg.0b013e31826e6caf] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Liver transplantation (LT) after liver resection (LR) for hepatocellular carcinoma (HCC) recurrence may be associated with poor patient long-term results and higher perioperative patient morbidity and mortality. This study focused on short-term and long-term outcomes of LT recipients due to HCC recurrence after LR in a single-institution cohort, and in highly comparable case-matched subgroups. METHODS Between 2000 and 2009, 570 consecutive patients with documented HCC underwent LR (n=355, 62.2%) or LT (n=215, 37.8%) at our Institute. The case-matched analysis was between 2 groups: group A1, LT recipients who had already undergone LR (n=26); group B1, LT recipients who had not already undergone LR (n=26). RESULTS Patient morbidity was higher in the A1 group in terms of packed red blood cell units transfused, fresh frozen plasma units transfused, median operative time, postoperative bleeding, and postoperative reoperations. No differences were detected in terms of patient mortality, patient survival, and patient recurrence-free survival at the univariate and multivariate analysis. CONCLUSIONS Although LT among patients who have already undergone LR is associated with higher risk of patient morbidity, patient long-term survival and recurrence-free survival is not impaired. Therefore, there do not seem to be any valid reasons to deny the chance of LT to patients who have already undergone LR.
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[Radiofrequency ablation of hepatocellular carcinoma]. Wien Med Wochenschr 2013; 163:132-6. [PMID: 23515886 DOI: 10.1007/s10354-013-0176-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 01/08/2013] [Indexed: 01/21/2023]
Abstract
Percutaneous radiofrequency ablation (RFA) is well established in the treatment of hepatocellular carcinoma (HCC). Due to its curative potential, it is the method of choice for non resectable BCLC (Barcelona Liver Clinic) 0 and A. RFA challenges surgical resection for small HCC and is the method of choice in bridging for transplantation and recurrence after resection or transplantation. The technical feasibility of RFA depends on the size and location of the HCC and the availability of ablation techniques (one needle techniques, multi-needle techniques). More recently, stereotactic multi-needle techniques with 3D trajectory planning and guided needle placement substantially improve the spectrum of treatable lesions including large volume tumors. Treatment success depends on the realization of ablations with large intentional margins of tumor free tissue (A0 ablation in analogy to R0 resection), which has to be documented by fusion of post- with pre-ablation images, and confirmed during follow-up imaging.
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Resection or transplantation for early hepatocellular carcinoma in a cirrhotic liver: does size define the best oncological strategy? Ann Surg 2013; 256:883-91. [PMID: 23108125 DOI: 10.1097/sla.0b013e318273bad0] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Resection and liver transplantation (LT) are the only curative options for hepatocellular carcinoma in cirrhotic patients (HCC-cirr). OBJECTIVE We tried to define the best primary intention-to-treat strategy in patients undergoing either resection or LT for early single HCC-cirr (≤5 cm). METHODS From 1990 to 2010, 198 patients with early HCC-cirr underwent either resection (group R, n = 97) or LT (group T, n = 101) as the primary procedure. Our policy was to prioritize Childs A patients with peripheral lesions for resection rather than LT. Patient and tumor characteristics, and outcomes (recurrence-free survival [RFS] and overall survival [OS]), were studied. RESULTS A longer diagnosis-to-surgery interval, more Child Pugh B/C patients, and more tumor nodules (on histopathological examination) were found in group T patients. The postoperative mortality (4.1% vs 3.0%, P = 0.72) and rate of major complications (19.1% vs 24.7%, P = 0.35) were similar in groups R and T, respectively, whereas tumor recurrence was higher in group R (62% vs 10% in group T, P < 0.0001). The 5-year OS (75% vs 52%, P = 0.0008) and RFS (72% vs 20%, P < 0.0001) were better in group T; similarly, more patients were disease free at last follow-up (27% vs 62%, P < 0.0001). Resection as the surgical procedure, tumor diameter 3 cm or more on histology, and microvascular tumor invasion were poor prognostic factors for OS and RFS. Including dropout patients from LT list in the analysis, the outcomes in group T were still better (70% and 61% vs 51% and 36% at 5 and 10 years, P = 0.01). CONCLUSIONS On an intention-to-treat basis, LT is associated with the best survival outcomes in patients with early HCC-cirr. Resection may achieve comparable OS in patients with single HCC-cirr of size smaller than 3 cm; however, the RFS still remains lower than that in patients of group T. This study could serve as a guide for HCC-cirr patients who are candidates for either resection or LT.
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Identification of recurrence related microRNAs in hepatocellular carcinoma after surgical resection. Int J Mol Sci 2013; 14:1105-18. [PMID: 23299437 PMCID: PMC3565310 DOI: 10.3390/ijms14011105] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 12/11/2012] [Accepted: 12/24/2012] [Indexed: 12/24/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most aggressive human cancers with a high frequency of post-surgical recurrence. It is very critical to diagnose HCC recurrence at an early stage for a better therapeutic treatment. In this study, we examined the microRNA (miRNA) expression profiling in tumor tissues obtained from early and late recurrent HCC patients post-resection, using a microarray assay. A total of 32 miRNAs were identified to be differentially expressed during the progression of recurrence. Among these, 16 miRNAs were upregulated and 16 were downregulated. In addition, this miRNA expression signature was further validated by quantitative real-time polymerase chain reaction (qRT-PCR) analysis. Moreover, functional annotation of predicted target genes of these recurrent HCC-related miRNAs indicates that multiple biological pathways (i.e., focal adhesion pathway, cancer-related pathways and mitogen-activated protein kinase (MAPK) signaling) that are all critical for cancer development and progression, may participate in the recurrence of HCC. Our data suggest potential molecular mechanisms underpinning miRNA-controlled HCC recurrence, and support the notion that miRNA expression signature and miRNA-based therapy can be useful tools for a better diagnosis and treatment stratification of this disease.
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Kohi MP, Fidelman N, Naeger DM, LaBerge JM, Gordon RL, Kerlan RK. Hepatotoxicity after transarterial chemoembolization and transjugular intrahepatic portosystemic shunt: do two rights make a wrong? J Vasc Interv Radiol 2012. [PMID: 23176968 DOI: 10.1016/j.jvir.2012.08.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To compare the rates of hepatotoxicity after transarterial chemoembolization for hepatocellular carcinoma (HCC) in patients with and without a transjugular intrahepatic portosystemic shunt (TIPS) who were stratified into comparable risk groups. MATERIALS AND METHODS A retrospective review of patients with HCC who were treated with transarterial chemoembolization between January 2005 and December 2009 was performed. Of 158 patients with comparable model for end-stage liver disease (MELD) scores, 10 had a patent TIPS. Hepatobiliary severe adverse events (SAEs) occurring after transarterial chemoembolization were documented. In addition, 1-year survival and liver transplantation rate after transarterial chemoembolization were calculated in each group. RESULTS The incidence of hepatobiliary SAEs after transarterial chemoembolization was nearly two times higher in patients with a TIPS (70%) than in patients without a TIPS (36%; P=.046). The liver transplantation rate 1 year after transarterial chemoembolization was 2.5 times higher in patients with a TIPS (80%) than in patients without a TIPS (32%; P=.004). There was no significant difference in 1-year survival between the two groups after transarterial chemoembolization. CONCLUSIONS Patients with HCC and a patent TIPS are more likely to develop significant hepatotoxicity after transarterial chemoembolization than comparable patients without a TIPS in place.
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Affiliation(s)
- Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94143, USA.
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Liu F, Wei Y, Wang W, Chen K, Yan L, Wen T, Zhao J, Xu M, Li B. Salvage liver transplantation for recurrent hepatocellular carcinoma within UCSF criteria after liver resection. PLoS One 2012; 7:e48932. [PMID: 23145027 PMCID: PMC3493590 DOI: 10.1371/journal.pone.0048932] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 10/02/2012] [Indexed: 02/05/2023] Open
Abstract
Background Salvage liver transplantation (SLT) is restricted to patients who develop hepatocellular carcinoma (HCC) recurrence within Milan criteria (MC). Little is known about outcomes for SLT in patients with recurrent HCC within University of California San Francisco (UCSF) criteria after liver resection (LR). Methods Between January 2001 and December 2011, 380 patients with HCC meeting UCSF criteria, 200 of which were resected (LR group) from a perspective of SLT in case of recurrence, and 180 directly underwent LT (PLT). We compared patient characteristics, perioperative and long-term outcomes between SLT and PLT groups. We also assessed the outcome of LR and PLT groups. Results Among the 200 patients in LR group, 86 (43%) developed HCC recurrence and 15/86 (17%) of these patients presented HCC recurrence outside UCSF criteria. Only 39 of the 86 patients underwent SLT, a transplantation rate of 45% of patients with HCC recurrence. Compared with PLT group, LR group showed lower overall survival rate (P = 0.005) and higher recurrence rate (P = 0.006). Although intraoperative blood loss and required blood transfusion were more frequent in SLT group, the perioperative mortality and posttransplant complications were similar in SLT and PLT groups. The overall survival and recurrence rates did not significantly differ between the two groups. When stratifying by graft type in the SLT group, overall survival and recurrence rates did not significantly differ between deceased donor LT (DDLT) and living donor LT (LDLT) groups. In the subgroup analysis by MC, similar results were observed between patients with recurrent HCC meeting MC and patients with recurrent HCC beyond MC but within UCSF criteria. Conclusion Our single institution experience demonstrated that prior hepatectomy and SLT for recurrent HCC within UCSF criteria was feasible and SLT could achieve the same outcome as PLT.
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Affiliation(s)
- Fei Liu
- Division of Liver Transplantation, Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yonggang Wei
- Division of Liver Transplantation, Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Wentao Wang
- Division of Liver Transplantation, Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Kefei Chen
- Division of Liver Transplantation, Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Lvnan Yan
- Division of Liver Transplantation, Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Tianfu Wen
- Division of Liver Transplantation, Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jichun Zhao
- Division of Liver Transplantation, Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Mingqing Xu
- Division of Liver Transplantation, Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bo Li
- Division of Liver Transplantation, Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
- * E-mail:
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Rahman A, Assifi MM, Pedroso FE, Maley WR, Sola JE, Lavu H, Winter JM, Yeo CJ, Koniaris LG. Is resection equivalent to transplantation for early cirrhotic patients with hepatocellular carcinoma? A meta-analysis. J Gastrointest Surg 2012; 16:1897-909. [PMID: 22836922 DOI: 10.1007/s11605-012-1973-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 07/15/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Whether liver resection or liver transplantation is optimal therapy for patients with hepatocellular carcinoma (HCC) remains undefined. A meta-analysis was conducted to answer this question. STUDY DESIGN This study performed a systematic review of the published literature between January 2000 and April 2012. RESULTS Nine retrospective studies, totaling 2,279 patients (989 resected and 1,290 transplanted), met the selection criteria. Older patients with larger tumors and less severe cirrhosis were identified in the resection group. At 1 year, resection demonstrated significantly higher overall [odds ratio (OR) = 1.54; 95 % confidence interval (CI), 1.19-1.98; p = 0.001], but equivalent disease-free survival (OR = 0.93; 95 % CI, 0.53-1.63; p = 0.80). At 5 years, there was no difference in overall survival (OR = 0.86; 95 % CI, 0.61-1.21; p = 0.38), but a higher disease-free survival in transplanted patients was observed (OR = 0.39; 95 % CI, 0.24-0.63; p < 0.001). When limiting our analysis to studies conducted in an intent-to-treat fashion, there was no difference in 5 year overall survival (OR = 1.18; 95 % CI, 0.92-1.51; p = 0.19), but a significantly higher disease-free survival (OR = 0.76; 95 % CI, 0.57-1.00; p = 0.05) in transplanted patients. At 10 years, transplantation had higher overall and disease-free survival rates. CONCLUSION Liver transplantation in patients with HCC results in increased late disease-free and overall survival when compared with liver resection. Nonetheless, the benefit of liver transplantation is offset by higher short-term mortality, donor organ availability, and long transplant wait times associated with more patient deaths. Understanding these differences in survival is helpful in guiding treatment. However, a properly controlled prospective trial is needed to define how best to treat HCC patients who are candidates for either therapy.
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Affiliation(s)
- Atiq Rahman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Sapisochin G, Castells L, Dopazo C, Bilbao I, Minguez B, Lázaro JL, Allende H, Balsells J, Caralt M, Charco R. Single HCC in cirrhotic patients: liver resection or liver transplantation? Long-term outcome according to an intention-to-treat basis. Ann Surg Oncol 2012; 20:1194-202. [PMID: 22965574 DOI: 10.1245/s10434-012-2655-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND Compensated cirrhotic patients with single hepatocellular carcinoma (HCC) ≤5 cm may benefit from both liver resection (LR) and liver transplantation (LT); however, the better 10-year actuarial survival of the two treatments remains unclear. We aimed to assess the long-term outcome of cirrhotic patients with single HCC ≤5 cm treated either with LR or LT on an intention-to-treat basis. METHODS A total of 217 cirrhotic patients with single HCC ≤5 cm were evaluated at our department: 95 were treated with LR (LR group), and 122 were included on the waiting list for LT (LT group). Patients in the LR group were divided into very early HCC (tumor size ≤2 cm) and early HCC (tumor size >2 cm). Median follow-up was 5.3 (range 0.1-18) years. RESULTS Tumor recurrence was 72 % in the LR group versus 16 % in the LT group (p < 0.001). 1-, 5-, and 10-year cumulative risk of recurrence was 18, 69, and 83 % in the LR group versus 4, 18, and 20 % in the LT group (p < 0.001). Ten-year actuarial survival was 33 % in the LR group versus 49 % in the LT group (p = 0.002). At HCC recurrence, 27.3 % were included on the waiting list for salvage transplantation (very early HCC group) versus 15.1 % (early HCC group) (p = 0.2). After salvage transplantation, HCC recurrence was 0 % (very early HCC group) versus 40 % (early HCC group) (p = 0.2). No significant differences were observed in 1-, 5-, and 10-year actuarial survival between the very early HCC group and the LT group (95, 55, and 50 % vs. 82, 62, and 50 %). CONCLUSIONS LR should be the treatment of choice for cirrhotic patients with very early HCC.
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Affiliation(s)
- Gonzalo Sapisochin
- Department of HBP Surgery and Transplantation, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain.
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Dhir M, Lyden ER, Smith LM, Are C. Comparison of outcomes of transplantation and resection in patients with early hepatocellular carcinoma: a meta-analysis. HPB (Oxford) 2012; 14:635-45. [PMID: 22882201 PMCID: PMC3461390 DOI: 10.1111/j.1477-2574.2012.00500.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Surgical decision making for patients with early hepatocellular carcinoma (HCC) and well-compensated cirrhosis remains controversial. The aim of the current study was to conduct a meta-analysis of published reports to compare survival outcomes after transplantation and resection, respectively, in patients with early HCC [i.e. HCC falling within the Milan Criteria (a solitary lesion measuring ≤5 cm or fewer than three lesions with a largest diameter of ≤3 cm, and absence of macroscopic vascular invasion or extrahepatic disease)] and well-compensated cirrhosis. METHODS A total of 990 abstracts were identified through a PubMed-based search. Ten articles comparing transplantation and resection in patients with early HCC were included in the meta-analysis. Meta-analysis was performed using stata 9.2 statistical software. RESULTS Outcomes were analysed for a total of 1763 patients with early HCC. The 5-year overall survival (OS) for all patients was 58% (transplantation: 63%; resection: 53%). Meta-analysis of all 10 studies revealed a survival advantage for transplantation [odds ratio (OR) 0.581, 95% confidence interval (CI) 0.359-0.939; P = 0.027]. Analysis of only those reports that utilized an 'intention-to-treat' strategy failed to demonstrate a survival advantage for either treatment approach (OR 0.600, 95% CI 0.291-1.237; P = 0.166). CONCLUSIONS The current study demonstrates a favourable outcome in patients with early HCC treated by either transplantation or resection. Although transplantation was noted to have a survival advantage in some settings, resection continues to be a viable treatment approach.
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Affiliation(s)
- Mashaal Dhir
- Department of Surgery, Division of Surgical Oncology, Eppley Cancer CenterOmaha, NE, USA
| | - Elizabeth R Lyden
- Department of Epidemiology and Biostatistics, College of Public HealthOmaha, NE, USA
| | - Lynette M Smith
- Department of Epidemiology and Biostatistics, College of Public HealthOmaha, NE, USA
| | - Chandrakanth Are
- Department of Surgery, Division of Surgical Oncology, Eppley Cancer CenterOmaha, NE, USA,Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical CenterOmaha, NE, USA
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Kim JM, Kwon CHD, Joh JW, Choi MS, Lee JH, Koh KC, Paik SW, Kim GS, Kim SJ, Lee SK, Yoo BC. Effectiveness of locoregional therapy before living donor liver transplantation in patients with hepatocellular carcinoma who meet the Milan criteria. Transplant Proc 2012; 44:403-8. [PMID: 22410028 DOI: 10.1016/j.transproceed.2012.01.067] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Many patients are diagnosed with hepatocellular carcinoma (HCC) within the Milan criteria. In Korea, these patients are preferentially treated with locoregional therapy (LRT) instead of living donor liver transplantation. We investigated the effectiveness of LRT in liver transplant recipients who met the Milan criteria at the time of HCC diagnosis and investigated risk factors for HCC recurrence. METHODS We retrospectively reviewed the medical records of patients diagnosed with HCC who met the Milan criteria between 2002 and 2008. RESULTS We performed 101 liver transplants for HCC during the study period. Seventy-one patients (70%) underwent pretransplant LRT. The disease-free survival rates at 1, 3, and 5 years in patients who received LRT were 96.6%, 93.1%, and 93.1%, and in those who did not receive LRT, 94.2%, 83.4%, and 83.4%, respectively. There were no differences between the 2 groups. Multivariate analysis showed that a low Model for End-Stage Liver Disease (MELD) score and microvascular invasion were independent predictors of HCC recurrence after transplantation. The MELD scores and rate of microvascular invasion were not statistically different in patients with or without previous LRT. CONCLUSION Pretransplant LRT for patients with HCC who met the Milan criteria at the time of diagnosis did not provide a clear benefit with respect to HCC recurrence after transplantation. If patients have suitable living donors, those who meet the Milan criteria should undergo a liver transplantation as soon as possible.
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Affiliation(s)
- J M Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Moon JI, Kwon CHD, Joh JW, Choi GS, Jung GO, Kim JM, Shin M, Choi SJ, Kim SJ, Lee SK. Primary versus salvage living donor liver transplantation for patients with hepatocellular carcinoma: impact of microvascular invasion on survival. Transplant Proc 2012; 44:487-93. [PMID: 22410053 DOI: 10.1016/j.transproceed.2011.11.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Salvage liver transplantation (LT) has been proposed for patients with a small hepatocellular carcinoma (HCC) and preserved liver function. Few reports have been issued on salvage LT in a living-donor (LD) LT setting. Therefore, we performed this study to evaluate differences in tumor invasiveness and other risk factors on survival after salvage versus primary LDLT. METHODS Between September 1996 and December 2008, 324 patients with HCC underwent LT. We excluded 138 patient from the analysis, leaving 186 HCC patients for analysis, including 17 (9.1%) who had undergone earlier resection, the salvage LDLT cohort. The other 169 patients underwent primary LDLT. RESULTS Intrahepatic metastasis, Edmonson-Steiner histologic grade, microscopic vascular invasion, and preoperative serum alpha-fetoprotein levels significantly influenced tumor recurrence. Microscopic vascular invasion, intrahepatic metastasis, Edmonson-Steiner histologic grade, and treatment by salvage LDLT were significantly associated with poor patient survival univariate analysis. However, only microscopic vascular invasion was significant on multivariate analysis. The treatment modality (primary or salvage LDLT) was not observed to affect overall or disease-free survival significantly on multivariate analysis. Disease-free survival was significantly better in the primary than in the salvage LDLT group. Furthermore, patients in the primary LDLT group tended to show better survival. However, when stratified by the presence or absence of microscopic vascular invasion, no significant group difference was found for overall or disease-free survival among those without versus with microscopic vascular invasion. CONCLUSIONS Five-year overall survival after primary versus salvage LDLT were similar when differences in tumor pathologic features, such as microscopic vascular invasion, were taken into account. Multivariate analysis showed that the treatment itself was not a significant prognostic factor for survival.
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Affiliation(s)
- J I Moon
- Department of Surgery, Konyang University Hospital, Konyang University School of Medicine, Daejeon, Korea
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Puneet P, Perera MTPR, Mirza DF. Current opinion on the role of resection and liver transplantation for hepatocellular cancer. Indian J Gastroenterol 2012; 31:89-99. [PMID: 22711364 DOI: 10.1007/s12664-012-0200-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 05/25/2012] [Indexed: 02/04/2023]
Abstract
Hepatocellular carcinoma (HCC) represents one of the most common cancers worldwide with rising incidence in developed countries. The best treatment options with curative intent for patients with HCC are liver resection or transplantation, although the role of hepatic ablative therapies has also been recognized. Surgical resection has emerged as the primary treatment in carefully selected patients of HCC. With the advances in surgical and radiological techniques, the perioperative mortality has been reduced to less than 5 % depending on the extent of resection and hepatic reserve. The role of liver transplantation (LT) as the mainstay of treatment for the majority of patients with HCC has evolved in the last few decades. Historically, the Milan criteria have been considered the gold standard for selecting patients; more expanded selection criteria to include those with more advanced tumors have been implemented in recent years. Living donor liver transplantation (LDLT) has emerged as a way to expand the donor pool and has influenced the role of transplantation for HCC, especially in communities with little access to cadaveric transplantation. Salvage transplantation is an alternative option as it allows a window for the biologically less favorable lesions to declare tumor behavior. Salvage transplantation also decreases the burden on transplant resources. Sirolimus, a novel immunosuppressant drug with anti-tumor effect, may have a role in limiting the severity of recurrent disease after transplantation for HCC, and play an important role in the future management of transplant recipients. This article examines the literature on current status of management of HCC.
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Affiliation(s)
- P Puneet
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH, UK
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Hu Z, Zhou J, Xu X, Li Z, Zhou L, Wu J, Zhang M, Zheng S. Salvage liver transplantation is a reasonable option for selected patients who have recurrent hepatocellular carcinoma after liver resection. PLoS One 2012; 7:e36587. [PMID: 22574187 PMCID: PMC3344909 DOI: 10.1371/journal.pone.0036587] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 04/03/2012] [Indexed: 12/14/2022] Open
Abstract
Background Salvage liver transplantation (SLT) has been reported as being feasible for patients who develop recurrent hepatocellular carcinoma (HCC) after primary liver resection, but this finding remains controversial. We retrospectively studied the clinical characteristics of SLT recipients and conducted a comparison between SLT recipients and primary liver transplantation (PLT) recipients. Methodology and Principal Findings A retrospective study examined data from the China Liver Transplant Registry (CLTR) for 6,975 transplants performed from January 1999 to December 2009. A total of 6,087 patients underwent PLT and 888 patients underwent SLT for recurrence. Living donor liver transplantation (LDLT) was performed in 389 patients, while 6,586 patients underwent deceased donor liver transplantation (DDLT). Kaplan-Meier curves were used to compare survival rates. The 1-year, 3-year, and 5-year overall survival of SLT recipients was similar to that of PLT recipients: 73.00%, 51.77%, and 45.84% vs. 74.49%, 55.10%, and 48.81%, respectively (P = 0.260). The 1-year, 3-year and 5-year disease-free survival of SLT recipients was inferior to that of PLT recipients: 64.79%, 45.57%, and 37.78% vs. 66.39%, 50.39%, and 43.50%, respectively (P = 0.048). Similar survival results were observed for SLT and PLT within both the LDLT and DDLT recipients. Within the SLT group, the 1-year, 3-year, and 5-year overall survival for LDLT and DDLT recipients was similar: 93.33%, 74.67%, and 74.67% vs. 80.13%, 62.10%, and 54.18% (P = 0.281), as was the disease-free survival: 84.85%, 62.85%, and 62.85% vs. 70.54%, 53.94%, and 43.57% (P = 0.462). Conclusions Our study demonstrates that for selected patients, SLT has similar survival to that of PLT, indicating that SLT is acceptable for patients with recurrent HCC after liver resection. Given the limited organ donor pool, salvage LDLT might be considered as a possible treatment.
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Affiliation(s)
- Zhenhua Hu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jie Zhou
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaofeng Xu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhiwei Li
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lin Zhou
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Wu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Min Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- * E-mail:
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