Surgical treatment of hepatocellular cancer in the era of hepatic transplantation

Liver transplantation vs liver resection in HCC: promoting extensive collaborative research through a survival meta-analysis of meta-analyses

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.

Changes of long-term survival of resection and liver transplantation in hepatocellular carcinoma throughout the years: A meta-analysis

BACKGROUND

Hepatocellular Carcinoma (HCC) still is one of the most detrimental malignant diseases in the world. As two curative surgical therapies exist, the discussion whether to opt for liver resection (LR) or transplantation (LT) is ongoing, especially as novel techniques to improve outcome have emerged for both. The aim of the study was to investigate how the utilization and outcome of the respective modalities changed through time.

METHODS

We searched Medline and PubMed for relevant publications comparing LT and LR in HCC patients during the time period from 1990 to 2022, prior to March 31, 2023. A total of 63 studies involving 19,804 patients - of whom 8178 patients received a liver graft and 11,626 underwent partial hepatectomy - were included in this meta-analysis.

RESULTS

LT is associated with significantly better 5-year overall survival (OS) (64.83%) and recurrence-free survival (RFS) (70.20%) than LR (OS: 50.83%, OR: 1.79, p < 0.001; RFS: 34.46%, OR: 5.32, p < 0.001). However, these differences are not as evident in short-term intervals. Older cohorts showed comparable disparities between the outcome of the respective modalities, as did newer cohorts after 2005. This might be due to the similar improvement in survival rates that were observed for both, LT (15-23%) and LR (12-20%) during the last 30 years.

CONCLUSION

LT still outperforms LR in the therapy of HCC in terms of long-term survival rates. Yet, LR outcome has remarkably improved which is of major importance in reference to the well-known limitations that occur in LT.

An mALBI-Child-Pugh-based nomogram for predicting post-hepatectomy liver failure grade B-C in patients with huge hepatocellular carcinoma: a multi-institutional study

Objective

Post-hepatectomy liver failure (PHLF) is a severe complication in patients with hepatocellular carcinoma (HCC) who underwent hepatectomy. This study aims to develop a nomogram of PHLF grade B–C in patients with huge HCC (diameter ≥ 10 cm).

Methods

We retrospectively collected clinical information of 514 and 97 patients who underwent hepatectomy for huge HCC at two medical centers between 2016 and 2021. Univariate and multivariate analysis were carried out to screen the independent risk factors of PHLF grade B–C, which were visualized as a nomogram.

Results

Three Hundred Forty Three Thousand One Hundred Seventy One  and 97 HCC patients were included in the training cohort, internal validation cohort, and external validation cohort, with probabilities of PHLF grade B–C of 15.1%, 12.9%, and 22.7%, respectively. Pre-operative modified albumin-bilirubin (mALBI) grade (p < 0.001), Child–Pugh classification (p = 0.044), international normalized ratio (INR) (p = 0.005), cirrhosis (p = 0.019), and intraoperative blood loss (p = 0.004) were found to be independently associated with PHLF grade B–C in the training cohort. All the five independent factors were considered in the establishment of the nomogram model. In the internal validation cohort and external validation cohort, the area under receiver operating characteristic curve for the nomogram in PHLF grade B–C prediction reached 0.823 and 0.740, respectively. Divided into different risk groups according to the optimal cut-off value, patients in the high-risk group reported significantly higher frequency of PHLF grade B–C than those in the low-risk group, both in the training cohort and the validation cohort (p < 0.001).

Conclusions

The proposed noninvasive nomogram based on mALBI-Child–Pugh and three other indicators achieved optimal prediction performance of PHLF grade B–C in patients with huge HCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02672-5.

The Toronto Postliver Transplantation Hepatocellular Carcinoma Recurrence Calculator: A Machine Learning Approach

Liver transplantation (LT) listing criteria for hepatocellular carcinoma (HCC) remain controversial. To optimize the utility of limited donor organs, this study aims to leverage machine learning to develop an accurate posttransplantation HCC recurrence prediction calculator. Patients with HCC listed for LT from 2000 to 2016 were identified, with 739 patients who underwent LT used for modeling. Data included serial imaging, alpha-fetoprotein (AFP), locoregional therapies, treatment response, and posttransplantation outcomes. We compared the CoxNet (regularized Cox regression), survival random forest, survival support vector machine, and DeepSurv machine learning algorithms via the mean cross-validated concordance index. We validated the selected CoxNet model by comparing it with other currently available recurrence risk algorithms on a held-out test set (AFP, Model of Recurrence After Liver Transplant [MORAL], and Hazard Associated with liver Transplantation for Hepatocellular Carcinoma [HALT-HCC score]). The developed CoxNet-based recurrence prediction model showed a satisfying overall concordance score of 0.75 (95% confidence interval [CI], 0.64-0.84). In comparison, the recalibrated risk algorithms' concordance scores were as follows: AFP score 0.64 (outperformed by the CoxNet model, 1-sided 95% CI, >0.01; P = 0.04) and MORAL score 0.64 (outperformed by the CoxNet model 1-sided 95% CI, >0.02; P = 0.03). The recalibrated HALT-HCC score performed well with a concordance of 0.72 (95% CI, 0.63-0.81) and was not significantly outperformed (1-sided 95% CI, ≥0.05; P = 0.29). Developing a comprehensive posttransplantation HCC recurrence risk calculator using machine learning is feasible and can yield higher accuracy than other available risk scores. Further research is needed to confirm the utility of machine learning in this setting.

High pre-treatment static and dynamic alpha-fetoprotein values predict reduced overall survival in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is one of the most lethal cancers worldwide. Novel prognostic and/or predictive biomarkers are urgently needed to improve patient management. Alpha-fetoprotein is a well-established and widely used biomarker for hepatocellular carcinoma. However, diagnostic accuracy of static alpha-fetoprotein values is limited and the clinical potential is a matter of ongoing scientific discussion.

OBJECTIVE

We here evaluated the prognostic impact of pre-treatment static and dynamic alpha-fetoprotein variables on overall survival of hepatocellular carcinoma patients in a Western cohort.

METHODS

Patients with confirmed hepatocellular carcinoma (n = 809) treated at the Johannes Gutenberg-University Mainz between 1998 and 2014 and two available pre-treatment alpha-fetoprotein-values (AFP-slope) were retrospectively analysed. Clinico-pathological baseline parameters, pre-treatment static values and AFP-slope were assessed. Prognostic impact was determined by Kaplan-Meier analyses and Cox regression models.

RESULTS

High static and dynamic alpha-fetoprotein variables prior to therapy were associated with reduced survival rates of hepatocellular carcinoma patients. Several known clinical parameters such as Child-Pugh B (p < 0.01) and C stage (p < 0.001), portal vein thrombosis (p < 0.001) and extrahepatic spread (p < 0.001) were confirmed as independent predictors for overall survival. Addition of static and/or dynamic alpha-fetoprotein variable resulted in higher time-dependent area under the curves. Notably, in patients with more favourable prognosis, AFP-slope prior to therapy was a slightly stronger predictor for overall survival compared with static alpha-fetoprotein values.

CONCLUSION

Static and dynamic alpha-fetoprotein variables prior to therapy are predictive for overall survival of hepatocellular carcinoma patients. Addition of AFP-slope to established prognostic parameters might improve prognostic classification for a subgroup of hepatocellular carcinoma patients with preserved liver function and without portal vein tumour thrombosis.

Advantage of early liver transplantation whenever indicated for hepatocellular carcinoma recurrence after primary liver resection

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.

Resection or Transplant in Early Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) has an incidence of 5-10 per 100 000 persons per year in the Western world. In 20% of cases, surgical liver resection (LR) or liver transplantation (LT) can be performed. LT results in longer survival, as it involves resection not only of the tumor, but of pre - cancerous tissue as well. The optimal allocation of donor organs depends on the identification of patients for whom LR is adequate treatment. In this meta-analysis, we compare LT and LR for patients with early HCC and wellcompensated cirrhosis.

METHODS

A systematic review of the pertinent literature was followed by a subgroup analysis of the studies in which patients with early HCC and wellcompensated cirrhosis were followed up after either LR or LT. Overall survival at 1, 3, and 5 years, as well as morbidity and mortality, were compared in a random effects meta-analysis.

RESULTS

54 studies with a total of 13 794 patients were included. Among patients with early HCC, the overall survival after LT became higher than the overall survival after LR 5 years after surgery (66.67% versus 60.35%, odds ratio 0.60 [0.45; 0.78], p <0.001); there was no significant difference 1 year or 3 years after surgery. Nor was there any significant difference in morbidity or mortality between the two types of treatment in this subgroup. These findings contrast with the results obtained in all of the studies, which documented significantly better survival 3 years after LT.

CONCLUSION

Three years after surgery, the survival rates and complication rates of patients with early HCC treated with either LR or LT are comparable. Resection should therefore be the preferred form of treatment if the prerequisites for it are met. In case of recurrent tumor, these patients can still be evaluated for liver transplantation. This strategy could improve the allocation of donor organs.

Impact of local tumor lesion treatments and preoperative indicators on the survival of patients with small hepatocellular carcinomas

The prognosis for small hepatocellular carcinomas (SHCC) remains uncertain. The aim of the present study was to compare three local tumor lesion treatments and identify the prognostic factors in patients with SHCC by analyzing preoperative indicators. A retrospective study was performed using data from 206 patients with SHCC from 2006–2015. All of the patients had undergone transarterial chemoembolization (TACE) alone, TACE plus percutaneous microwave coagulation therapy (PMCT) or surgical resection (SR). The Kaplan-Meier method was used to calculate the survival rates. Multivariate analysis was conducted using Cox regression analysis. The median survival time of patients with SHCC was 27 (range, 14–49) months in the TACE group, 29.5 (range, 16–52) months in the TACE-PMCT group and 36.5 (range, 26–52) months in the SR group (P=0.091). The 1, 3 and 5-year survival rates for patients with SHCC were 82.4, 64.9 and 46.8% in the TACE group; 89.0, 72.6 and 58.3% in the TACE-PMCT group and 88.8, 72.3 and 58.6% in the SR group (P=0.181), respectively. Analysis from the Cox regression model demonstrated that preoperative α-fetoprotein (AFP; <400 ng/ml vs. ≥400 ng/ml; HR=0.548; P=0.036) was an independent predictor of the survival time of patients with SHCC. Analysis of patients with preoperative AFP levels of ≥400 ng/ml revealed that the median survival time in the SR group was 36 (range, 28.25–52) months, significantly longer than the TACE (17 months; range, 12–44 months) and TACE-PMCT group (27 months; range, 14–55 months; P=0.035). The 1, 2 and 3-year survival rates for patients with SHCC with ≥400 ng/ml AFP were: 70.8, 55.5 and 49.9% in the TACE group; 83.7, 68.0 and 60.8% in the TACE-PMCT group; and 90.9, 81.8 and 61.0% in SR group, respectively (P=0.664). However, there was no significant difference among the three groups in the survival time of patients with SHCC with <400 ng/ml preoperative AFP. The observations indicated that SR is not significantly different for overall survival time in the patients with SHCC between the two groups; this method can be employed for patients with SHCC. This was based on the median survival time of patients with ≥400 ng/ml AFP in the SR group who had a longer survival time and a higher survival rate than in the TACE and TACE-PMCT group.

Changing Paradigm in the Surgical Management of Hepatocellular Carcinoma With Salvage Transplantation

OBJECTIVE

The objective of this study was to compare the long-term outcomes of primary and salvage liver transplantation for patients with hepatocellular carcinoma (HCC).

METHOD

This was a 10-year retrospective analysis in a tertiary referral center.

RESULTS

There were 184 patients recruited (primary liver transplantation [pLT]:salvage liver transplantation [sLT], 143:41). The median follow-up time was 79 months. Operation time was shorter in the pLT group than the sLT group (661 ± 164 minutes vs 754 ± 206 minutes; P = .01) and the blood loss was 3749 mL and 3545 mL for pLT and sLT, respectively (P = .735). The reoperation rate was 5.6% and 4.9%, respectively (P = 1.0). The 5-year overall and disease-free survival rates from the time of transplantation for pLT and sLT were 84.1% versus 70.2% (P = .01) and 82.2% versus 65.8% (P = .01), respectively. The 5-year overall survival rate from the time of primary treatment for sLT was 80.3% (P = .1). Subgroup analysis of sLT showed that young age (50 vs 56 year old; P = .004) was the only factor associated with poor overall survival. Young age (P = .004) and microvascular permeation (P = .008) in the recurrent tumor were associated with HCC recurrence. Young age stands out to be the only independent factor associated with HCC recurrence.

CONCLUSION

sLT is the treatment of choice for patients with recurrent HCC in regions of graft shortage.

The preoperative globulin-to-albumin ratio, a novel inflammation-based prognostic system, predicts survival after potentially curative liver resection for patients with hepatocellular carcinoma

BACKGROUND AND OBJECTIVES

Although the globulin-to-albumin ratio (GAR) is useful for prognostication of patients with various cancers, its relationship with hepatocellular carcinoma (HCC) remains unclear. The study aims to investigate the relationship between GAR and postoperative survival among patients with HCC undergoing potentially curative liver resection (LR).

METHODS

We retrospectively reviewed 368 patients with newly diagnosed HCC who underwent initial and potentially curative LR. Univariate and multivariate analyses using the Cox proportional hazard model were performed to detect clinical characteristics that correlated with overall survival (OS). Kaplan-Meier analysis and log-rank test were used to compare OS and disease-free survival (DFS).

RESULTS

The result of multivariate analysis using 25 clinical characteristics selected by univariate analysis revealed that the GAR (≥0.918/<0.918) was significantly associated with OS (hazard ratio [HR], 2.398; 95% confidence interval [CI], 1.012-5.683; P = 0.047), as well as platelet count (<14/≥14, ×10⁴ /mm³ ) and portal vein invasion (presence/absence). Kaplan-Meier analysis and log-rank test demonstrated that the OS and DFS of patients with a high GAR (>0.918) were significantly worse than that of patients with a low GAR (≤0.918).

CONCLUSIONS

The GAR is a useful predictor of postoperative survival among patients with HCC undergoing potentially curative LR.

Serologic and molecular biomarkers for recurrence of hepatocellular carcinoma after liver transplantation: A systematic review and meta-analysis

INTRODUCTION

Recurrence after liver transplantation (LT) for hepatocellular carcinoma (HCC) is a major cause of mortality. Knowledge on biomarkers may contribute to better surveillance based on the patients' risk of recurrence. Reviewing the literature, we aimed to identify serological and molecular biomarkers for recurrence of hepatocellular carcinoma after liver transplantation.

METHODS

A literature search was performed in the databases PubMed and Scopus to identify observational studies evaluating serological or molecular biomarkers for recurrence of HCC after LT using adjusted analysis to correct for confounding.

RESULTS

Of 502 records, 69 mainly retrospective studies were included with a total of 15,213 patients. Of these, 41 studies were suitable for meta-analyses, which showed that the serum markers pre-transplant α-fetoprotein (AFP) (hazard ratio (HR) 2.69 [2.08-3.47]), pre-transplant des-gamma-carboxy prothrombin (DCP) (HR 5.99 [3.27-10.98]), and allelic imbalance in microsatellites in DNA of tumor tissue (HR 13.49 [3.17-57.30]) were related to recurrence.

CONCLUSIONS

AFP, DCP and allelic imbalance in microsatellites may be used to predict recurrence. Together with other modalities, biomarkers may be used in future transplantation criteria to optimize selection of suitable patients.

Alpha-fetoprotein Level Predicts Recurrence After Transplantation in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the leading causes of liver transplantation. In an attempt to predict their recurrence after liver transplantation, evaluation of tumor number and size, degree of histologic differentiation, and the presence of vascular invasion already have their importance established. In this context, the role of biologic markers such as alpha-fetoprotein (AFP) is still not clear. This retrospective cross-sectional study analyzed the AFP relationship with recurrence of HCC after orthotopic liver transplantation.The current study retrospectively analyzed data from 206 patients with a histopathologic confirmed HCC between 1997 and 2010.The overall survival rates at 1, 3, 5, and 14 years were 78.6%, 65.4%, 60.5%, and 38.7%, respectively. The frequency of recurrence was 15.5%, and recurrence was significantly associated with a lower survival rate (P < 0.001). No association was observed between survival and AFP level (P = 0.153). A correlation, however, was found between tumor recurrence and AFP level (P = 0.002). Univariate analysis of risk factors for recurrence revealed that an AFP level greater than 200 ng/mL, the number of tumors, the degree of cellular differentiation, and the presence of vascular invasion or satellite nodules were associated with relapse. By multivariate analysis, only an AFP level greater than 200 ng/mL remained as a risk factor.Although an elevated AFP level did not correlate with survival in HCC patients undergoing orthotopic liver transplantation, a high AFP level was associated with a 3.32-folds increase in the probability of HCC recurrence.

Outcomes of liver resection for hepatocellular carcinoma in liver transplantation era

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.

Time interval to recurrence as a predictor of overall survival in salvage liver transplantation for patients with hepatocellular carcinoma associated with hepatitis B virus

BACKGROUND

Salvage liver transplantation (SLT) has been proposed for recurrent hepatocellular carcinoma (HCC) after hepatectomy; however, it is unclear how the time interval to tumor recurrence from previous hepatectomy affects prognosis.

METHODS

We analyzed retrospectively the outcomes of 62 patients who underwent SLT in the Liver Transplantation Center of the First Affiliated Hospital of Zhejiang University between 2001 and 2012. SLT recipients were divided into 2 groups based on whether the time interval to recurrence was >1 year (L group) or <1 year (S group).

RESULTS

Baseline characteristics were similar between the 2 groups. The 1-, 3-, and 5-year overall survival rates were 81%, 45%, and 45% in the L group, which were better than in the S group, with 47%, 21%, and 21%, respectively (P = .005). The corresponding tumor-free survival rates were similar (P = .60) between 2 groups, with 71%, 51%, and 41% in the L group versus 55%, 55%, and 55% in the S group. Macrovascular invasion (hazard ratio [HR], 3.30), greatest tumor diameter (HR, 3.92), and time interval to tumor recurrence from previous hepatectomy (HR, 0.29) were independent predictors for overall survival. Furthermore, the diameter of the largest tumor was the only independent predictor of tumor-free survival (HR, 25.64).

CONCLUSION

The time interval to HCC recurrence from a previous hepatectomy is an important factor associated with survival after SLT. This finding should be helpful in guiding patient selection criteria for SLT in patients with previous hepatectomy.

Prognosis evaluation in patients with hepatocellular carcinoma after hepatectomy: comparison of BCLC, TNM and Hangzhou criteria staging systems

Purpose

This study is to evaluate the Hangzhou criteria (HC) for patients with HCC undergoing surgical resection and to identify whether this staging system is superior to other staging systems in predicting the survival of resectable HCC.

Method

774 HCC patients underwent surgical resection between 2007 and 2009 in West China Hospital were enrolled retrospectively. Predictors of survival were identified using the Kaplan–Meier method and the Cox model. The disease state was staged by the HC, as well as by the TNM and BCLC staging systems. Prognostic powers were quantified using a linear trend χ2 test, c-index, and the likelihood ratio (LHR) χ2 test and correlated using Cox's regression model adjusted using the Akaike information criterion (AIC).

Results

Serum AFP level (P = 0.02), tumor size (P<0.001), tumor number (P<0.001), portal vein invasion (P<0.001), hepatic vein invasion (P<0.001), tumor differentiation (P<0.001), and distant organ (P = 0.016) and lymph node metastasis (P<0.001) were identified as independent risk factors of survival after resection by multivariate analysis. The comparison of the different staging system results showed that BCLC had the best homogeneity (likelihood ratio χ² test 151.119, P<0.001), the TNM system had the best monotonicity of gradients (linear trend χ² test 137.523, P<0.001), and discriminatory ability was the highest for the BCLC (the AUCs for 1-year mortality were 0.759) and TNM staging systems (the AUCs for 3-, and 5-year mortality were 0.738 and 0.731, respectively). However, based on the c-index and AIC, the HC was the most informative staging system in predicting survival (c-index 0.6866, AIC 5924.4729).

Conclusions

The HC can provide important prognostic information after surgery. The HC were shown to be a promising survival predictor in a Chinese cohort of patients with resectable HCC.

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

BACKGROUND

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

DATA SOURCES

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

RESULTS

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

CONCLUSIONS

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

Salvage liver transplantation for recurrent hepatocellular carcinoma after liver resection: retrospective study of the Milan and Hangzhou criteria

Background

Salvage liver transplantation (SLT) has recently been proposed for recurrent hepatocellular carcinoma after liver resection; however, criteria for candidate assessment in SLT have not been thoroughly evaluated.

Methods and Findings

We retrospectively analyzed outcomes and factors affecting survival of 53 recipients who received SLT in the Liver Transplantation Center, The First Affiliated Hospital of Zhejiang University between 2004 and 2012. Thirty recipients fulfilled the Hangzhou criteria, of which 16 also fulfilled the Milan criteria, while the remaining 23 exceeded both criteria. The 1-year, 3-year and 5-year overall survival rates and tumor-free survival rates were both superior in patients fulfilling Milan or Hangzhou criteria compared with those exceeding the criteria. For recipients outside Milan criteria but within Hangzhou criteria, the 1-year, 3-year overall survival rates were 70.1%, 70.1%, similar to recipients within Milan criteria, with the 1-year, 3-year and 5-year overall survival of 93.8%%, 62.1% and 62.1% (P = 0.586). The tumor-free survival rates were also similar between these two subgroups, with 51.9% and 51.9% vs. 85.6%, 85.6% and 64.2% during the same time interval, respectively (P = 0.054). Cox regression analysis identified Hangzhou criteria (within vs. outside, hazard ratio (HR) 0.376) and diameter of the largest tumor (HR 3.523) to be independent predictors for overall survival. The only predictor for tumor-free survival was diameter of the largest tumor (HR 22.289).

Conclusions

Hangzhou criteria safely expanded the candidate pool and are feasible in assessment of candidates for SLT. This is helpful in donor liver allocation in transplant practice.

The role of liver cancer stem cells in donor liver allocation for patients with hepatocellular carcinoma

Previous criteria for liver transplantation in patients with hepatocellular carcinoma (HCC) has predominantly emphasized the size and number of existent tumors; however, criteria have not included tumor biology, which may comprise a critical factor for predicting patient prognosis. This issue has been recognized in the Hangzhou criteria, which take tumor histopathologic grade and pre-transplant α-fetoprotein (AFP) level into consideration. However, neither histopathologic grading nor AFP level are precise enough to adequately represent tumor biology in patients with HCC. Recent research has indicated that the development and progression of HCC are driven by a subpopulation of liver cells with stem cell features (cancer stem cells, [CSCs]). Liver CSCs with cluster of differentiation (CD)133 antigen positivity show a high tumorigenic capacity, and the increase in the percentage of CD133+ liver cancer cells is consistent with increased levels of serum AFP. In addition, the number of CD90+ cells increases with the tumorigenicity of HCC, and a positive correlation between the number of circulating CD90+ liver CSCs and disease progression has been observed. As liver CSCs can be detected using the CD profile and could more accurately represent tumor biology in HCC, we hypothesized that liver CSCs with specific phenotypes could be used for modifying the Hangzhou criteria, thereby providing valuable guidance for the development of more accurate prognosis prediction algorithms for patients with HCC being considered for liver transplantation. We provide reliable evidence supporting this hypothesis, and offer proposals for future applications in transplant practice.

Clinical significance of the thymidylate synthase, dihydropyrimidine dehydrogenase, and thymidine phosphorylase mRNA expressions in hepatocellular carcinoma patients receiving 5-fluorouracil-based transarterial chemoembolization treatment

Purpose

To determine whether 5-fluorouracil (5-FU) sensitivity is associated with the mRNA expressions of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), and thymidine phosphorylase (TP) in patients with hepatocellular carcinoma (HCC) treated with 5-FU-based transarterial chemoembolization (TACE).

Methods

Formalin-fixed, paraffin-embedded tumor specimens from 40 patients treated with 5-FU-based TACE were selected for the examination of TS, DPD, and TP expression level by a quantitative real-time reverse transcription- polymerase chain reaction (PCR) technique. Patients were categorized into high and low expression groups according to the median expression level of each enzyme. Associations between the mRNA expression levels of TS, DPD, and TP and clinical parameters including treatment efficacies, clinicopathological factors, and prognosis were assessed.

Results

High DPD expression was associated with worse treatment outcome, including intrahepatic disease progression rate (hazard ratio [HR] for high DPD versus low DPD, 2.212; 95% confidence interval [CI], 1.030–4.753; P = 0.042), extrahepatic disease progression rate (HR for high versus low DPD, 3.171; 95% CI, 1.003–10.023; P = 0.049), and progression-free survival (HR for high versus low DPD, 2.308; 95% CI, 1.102–4.836; P = 0.027). No correlation was found between the mRNA expression of TS/TP and treatment outcome.

Conclusion

DPD mRNA expression level was negatively correlated with the clinical outcomes of HCC patients treated with 5-FU-based TACE. These results provide indirect evidence that high DPD mRNA expression is a predictive marker of treatment resistance for 5-FU.

Pre-liver transplant biopsy in hepatocellular carcinoma: a potential criterion for exclusion from transplantation?

BACKGROUND

In cirrhotic patients with hepatocellular carcinoma (HCC), poor differentiation in pre-liver transplantation (LT) biopsy of the largest tumour is used as a criterion for exclusion from LT in some centres. The potential role of pre-LT biopsy at one centre was explored.

METHODS

A prospective database of patients undergoing orthotopic LT for radiologically diagnosed HCC at St James's University Hospital, Leeds during 2006-2011 was analysed.

RESULTS

A total of 60 predominantly male (85.0%) patients with viral hepatitis were identified. There were discrepancies between radiological and histopathological findings with respect to the number of tumours identified (in 27 patients, 45.0%) and their size (in 63 tumours, 64.3%). In four (6.7%) patients, the largest lesion, which would theoretically have been targeted for biopsy, was not the largest in the explant. Nine (31.0%) patients with multifocal HCC had tumours of differing grades. In two (6.9%) patients, the largest tumour was well differentiated, but smaller tumours in the explant were poorly differentiated. In one patient, the largest lesion was benign and smaller invasive tumours were confirmed histologically.

CONCLUSIONS

The need to optimize selection for LT in HCC remains. In the present series, the largest tumour was not always representative of overall tumour burden or biological aggression and its potential use to exclude patients from LT is questionable.

Liver transplantation for hepatocellular carcinoma recurrence after liver resection: why deny this chance of cure?

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.

Impact of preoperative α-fetoprotein level on disease-free survival after liver transplantation for hepatocellular carcinoma

BACKGROUND

Preoperative α-fetoprotein (AFP) levels may have an influence on disease-free survival (DFS) of patients after liver transplantation for hepatocellular carcinoma (HCC) located on a cirrhotic liver.

METHODS

Between 2000 and 2009, two groups were distinguished according to preoperative AFP level: normal-level group (<10 ng/ml) and increased-level group (>10 ng/ml). The increased-level group was further divided into three levels of preoperative AFP: 10-150, 150-500, and ≥ 500 ng/ml. DFS and recurrence rates were compared. All patients underwent transplantation using the preoperative 5/5 criteria.

RESULTS

Of the 122 patients in this study, 63 had normal and 59 had increased preoperative AFP. There were no differences between the two groups concerning perioperative or pathologic data. Those with an increased preoperative AFP level had a significantly shorter 5-year DFS, and their recurrence rate was higher than that of the normal AFP group. The 5-year DFS and recurrence rates were 71 and 4 %, respectively, for those with normal AFP; 57 and 10 %, respectively, for those with AFP 10-150 ng/ml; 46 and 24 %, respectively, for those with AFP 150-500 ng/ml; and 28 and 62 %, respectively, for those with AFP ≥ 500 ng/ml.

CONCLUSIONS

This study shows the prognostic value of preoperative AFP levels on DFS after a liver transplant for HCC in a population of patients undergoing transplantation with the same preoperative criteria.

Liver transplantation for hepatocellular carcinoma: a model including α-fetoprotein improves the performance of Milan criteria

BACKGROUND & AIMS

The aim of this study was to generate an improved prognostic model for predicting recurrence in liver transplant candidates with hepatocellular carcinoma (HCC).

METHODS

Predictors of recurrence were tested by a Cox model analysis in a training cohort of 537 patients transplanted for HCC. A prognostic score was developed and validated in a national cohort of 435 patients followed up prospectively.

RESULTS

α-Fetoprotein (AFP) independently predicted tumor recurrence and correlated with vascular invasion and differentiation. At a Cox score threshold of 0.7 (area under the receiver operating characteristic curve, 0.701; 95% confidence interval, 0.63-0.76; accuracy, 75.8%), a model combining log(10) AFP, tumor size, and number was highly predictive of tumor recurrence and death. By using a simplified version of the model, with untransformed AFP values, a cut-off value of 2 was identified. In the validation cohort, a score greater than 2 predicted a marked increase in 5-year risk of recurrence (50.6% ± 10.2% vs 8.8% ± 1.7%; P < .001) and decreased survival (47.5% ± 8.1% vs 67.8% ± 3.4%; P = .002) as compared with others. Among patients exceeding Milan criteria, a score of 2 or lower identified a subgroup of patients with AFP levels less than 100 ng/mL with a low 5-year risk of recurrence (14.4% ± 5.3% vs 47.6% ± 11.1%; P = .006). Among patients within Milan criteria, a score greater than 2 identified a subgroup of patients with AFP levels greater than 1000 ng/mL at high risk of recurrence (37.1% ± 8.9% vs 13.3% ± 2.0%; P < .001). Net reclassification improvement showed that predictability of the AFP model was superior to Milan criteria.

CONCLUSIONS

Prediction of tumor recurrence is improved significantly by a model that incorporates AFP. We propose the adoption of new selection criteria for HCC transplant candidates, taking into account AFP.

Systematic review: the prognostic role of alpha-fetoprotein following liver transplantation for hepatocellular carcinoma

BACKGROUND

Liver transplantation (LT) offers a possible cure for carefully selected patients with hepatocellular carcinoma (HCC). Studies report that preoperative alpha-fetoprotein (AFP) is a prognostic indicator that can predict survival and recurrence in these patients.

AIM

To undertake a systematic review of available literature on preoperative AFP as a predictor of survival and recurrence following LT for HCC.

METHODS

A literature search was performed using Medline, Embase, Cochrane Library, CINAHL and Google scholar databases to identify studies reporting AFP as a prognostic marker in LT for HCC. Primary outcomes of interest were overall survival and recurrence. Secondary outcomes were correlation of pre-LT AFP with vascular invasion and grade of tumour differentiation.

RESULTS

A total of 13 studies met the inclusion criteria (12,159 patients). The majority were male (9603, 78.9%). All were observational studies and only one prospective. Methodological quality was rated as poor for all studies, with selection and observer bias apparent for most cohorts. Reported survival rates and recurrence rates varied widely between the studies although overall demonstrated better outcomes for those with lower (<1000 ng/mL) pre-LT AFP levels. Similarly, rates of vascular invasion and poor tumour differentiation were higher in those with high pre-LT AFP levels.

CONCLUSIONS

A quantity of AFP >1000 ng/mL is associated with poorer outcomes from liver transplantation for hepatocellular carcinoma. The quality of studies was generally poor and precluded valid statistical meta-analysis. There is a need to improve the performance and reporting of primary prognostic studies to facilitate high quality systematic review and meta-analysis.

Hepatocellular Carcinomas and Primary Liver Tumors as Predictive Factors for Postoperative Mortality after Liver Resection: A Meta-Analysis of More than 35,000 Hepatic Resections

Liver resection is considered the therapeutic gold standard for primary and metastatic liver neoplasms. The reduction of postoperative complications and mortality has resulted in a more aggressive approach to hepatic malignancies. For the most part, results of liver surgery have been published by highly experienced institutions, but the observations of highly specialized units results may not reflect the current status of hepatic surgery, underestimating mortality and complications. The objective of this study is to evaluate morbidity and mortality as a result of liver resection for primary and metastatic lesions, analyzing a large number of studies with a meta-analytic process taking into account the overdispersion of data. An extensive literature search has been conducted, and 148 papers published between January 2000 and April 2008, including a total of 36,629 patients from both high-volume and low volume institutions, were included in the meta-analysis. A beta binomial model was used to provide a robust estimate of the summary event rate by pooling overdispersion binomial data from different studies. Overall morbidity and mortality after liver surgery were 29.32 per cent and 3.15 per cent, respectively. Significantly higher postoperative mortality was observed after liver resection for hepatocellular carcinomas and primary hepatic tumors. The application of a beta binomial model to correct for overdispersion of liver surgery data showed significantly higher postoperative mortality rates in patients with hepatocellular carcinomas or primary hepatic tumors after liver resection.

Beyond the Milan criteria: what risks for patients with hepatocellular carcinoma progression before liver transplantation?

BACKGROUND

To date the selection of the best candidates for liver transplantation (LT) owing to hepatocellular carcinoma (HCC) has been mainly based on tumor morphological characteristics (nodule diameter and number), which have resulted to be independent risk factors for short long-term survival and a high rate of tumor recurrence.

METHODS

The study cohort included 118 patients among the 166 with HCC transplanted at our unit from January 2000 to December 2007. Patients were classified according to response to locoregional treatments before LT: progressive Group A; complete Group B; partial Group C; stable Group D.

RESULTS

The 3-year and 5-year overall survival rates were 65.5% and 48.9% for Group A versus 84.8% and 74.6% for Group BCD (P = 0.01). The 3-year and 5-year disease-free survival rates were 74% and 74% for Group A and 95.7% and 93% for Group BCD (P = 0.007). HCC progression was the only independent risk factor according to Cox regression P = 0.014--odds ratio 4.4 (1.35-14.3).

CONCLUSION

After aggressive HCC treatment before LT, imaging progression while on the waiting list was a strong predictor of high HCC recurrence rate also in patients who met the Milan criteria. Lack of imaging progression can contribute toward the selection of good transplant candidates for HCC together with the Milan criteria.

Impact of tumour differentiation to select patients before liver transplantation for hepatocellular carcinoma

AIM

To generate a new score with improved accuracy compared with Milan criteria to select patients.

PATIENTS

The training cohort comprised 373 patients transplanted for hepatocellular carcinoma (HCC) between 1988 and 1998 (cohort 1). An algorithm was derived from the analysis of patient data by the proportional hazard Cox regression model. The area under the receiver operating characteristic (AUROC) was used to determine a cut-off value. The validation cohort comprised 140 patients transplanted between 1999 and 2001 (cohort 2).

RESULTS

Multivariate analysis identified three predictors of 5-year tumour-free survival: tumour differentiation (P=0.02), diameter (P<0.0001) and number of nodules (P=0.04). A cut-off value of 4 was derived from the AUROC of the final score. Five-year tumour-free survival was 60.2 ± 3.1% in patients with as score <4 and 36.4 ± 4.7% in individuals with a score ≥4, P<0.0001. In the validation cohort, 5-year tumour-free survival was 82.8 ± 3.6% (score <4) and 50.0 ± 10.7% (score ≥4), P=0.0003. In patients with a score <4, there was no significant difference in 5-year tumour-free survival between Milan+ and Milan- patients, either in cohort 1 or 2. Five-year tumour-free survival of Milan- patients was significantly better in individuals with a score <4 compared with those with a score ≥4, both in cohort 1 (61.5 ± 9.1 vs 31.4 ± 4.6%, P=0.009) and in cohort 2 (P=0.02).

CONCLUSION

A novel score taking into account tumour differentiation shows higher accuracy than Milan criteria in predicting 5-year tumour-free survival following liver transplantation for HCC. Prospective studies should validate these findings.

Role of alpha-fetoprotein in selection of patients with hepatocellular carcinoma waiting for liver transplantation: must we reconsider it?

BACKGROUND

Milan criteria (MC) represent the most commonly adopted criteria for the selection of patients with hepatocellular carcinoma (HCC) waiting for liver transplantation (LT). However, MC are exclusively based on morphological aspects. The aim of the present study was to evaluate pre-LT-detectable biological parameters, to compare them with morphological ones in terms of tumor recurrence prediction and patient survival.

METHODS

A cohort of 153 consecutive adult patients who underwent LT for HCC on cirrhosis from January 1999 to March 2009 was retrospectively analyzed.

RESULTS

HCC recurrence was observed in 12 patients (7.8%). At multivariate logistic regression analysis, serum alpha-fetoprotein (AFP) was the unique independent negative risk factor for the development of HCC recurrence (odds ratio 2.0, p=0.03). Adopting a cutoff value of 210 ng/mL, patients who presented serum AFP =210 ng/mL showed a 5-year survival rate of 23.3% versus 76.2% observed in patients with pre-LT serum AFP <210 ng/mL (log-rank test: <0.0001).

CONCLUSIONS

In our experience, AFP was the strongest predictor of HCC recurrence, stronger than tumor morphology. AFP could ameliorate the selection of LT candidates. Further studies to evaluate the combination of morphological and biological criteria are needed.

Current management of hepatocellular cancer

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, being the fifth most frequent cancer worldwide. It usually occurs in the setting of chronic liver disease and has a poor prognosis if untreated. Following the diagnosis, this disease requires multidisciplinary management. Orthotopic liver transplantation is theoretically the best treatment for early, unresectable HCC. However, the major practical obstacle is the extreme shortage of organs, which makes this a practical option only in selected patients. In this report we describe new advancements in diagnosis, classification, and treatment that have emerged in the field of HCC in recent years.

Progression of alphafetoprotein before liver transplantation for hepatocellular carcinoma in cirrhotic patients: a critical factor

Liver transplantation (LT) for cirrhotic/Hepatocellular carcinoma (HCC) is associated with reduced survival in patients with poor histological features. Preoperative levels of alphafetoprotein (AFP) could predict negative biological features. AFP progression could be more relevant than static AFP levels in predicting LT outcomes. A total of 252 cirrhotic/HCC patients transplanted between 1985 and 2005 were reviewed. One hundred fifty-three patients were analyzed, 99 excluded (for nonsecreting tumors and/or salvage transplantation). Using receiver operating characteristics analysis for recurrence after LT, 'progression' of AFP was defined by >15 microg/L per month before LT. A total of 127 (83%) were transplanted under and 26 (16%) over this threshold. After 45 months of follow-up (median), 5-year overall survival (OS) and recurrence free-survival (RFS) were 72% and 69%, respectively. Five-year survival in the progression group was lower than the nonprogression group (OS 54% vs. 77%; RFS 47% vs. 74%). Multivariate analysis showed progression of AFP>15 microg/L per month and preoperative nodules>3 were associated with decreased OS. Progression group and age>60 years were associated with decreased RFS. Male gender, progression of AFP and size of tumor>30 mm were associated with satellite nodules and/or vascular invasion. In conclusion, increasing AFP>15 microg/L/month while waiting for LT is the most relevant preoperative prognostic factor for low OS/DFS. AFP progression could be a pathological preoperative marker of tumor aggressiveness.

Liver transplantation, liver resection, and transarterial chemoembolization for hepatocellular carcinoma in cirrhosis: which is the best oncological approach?

The aim of the study was to evaluate our institutional experience with monotherapies for hepatocellular carcinoma (HCC) in the setting of cirrhosis. A retrospective cohort study was carried out at the tertiary care academic referral center and involved 185 consecutive HCC patients with cirrhosis and no previous treatment who underwent resection (n = 61), transarterial chemoembolization (TACE) (n = 64), or liver transplantation (LT) (n = 60). Long-term survival and survival according to the Milan criteria were the main outcomes measured. Median survival after resection, TACE, and LT was 11, 14, and 23 months, respectively. Five-year cumulative survival after resection, TACE, and LT was 23, 10, and 59%, respectively (P = 0.001). Five-year cumulative disease-free survival after resection and LT was 15% and 77%, respectively (P = 0.002). The presence of complications in the resection group (P = 0.004), MELD score (P = 0.0003), and maximum tumor diameter (P = 0.05) in the TACE group, and tumor grade (P = 0.01) and complications (P = 0.004) in the LT group were found to be independent predictors of survival. Five-year survival for patients within the Milan criteria after resection, TACE, and LT was 26, 37, and 66%, respectively. Five-year survival for patients outside the Milan criteria for patients undergoing LT was 53%. The results suggest that LT represents the best oncological treatment option for patients with HCC in the setting of cirrhosis, even for those beyond the Milan criteria. Considering the scarcity of available organs, liver resection remains the best alternative option. TACE remains a potential therapy in patients within the Milan criteria, where it may be more beneficial than resection.

Liver transplantation for hepatocellular carcinoma: the Baylor experience

BACKGROUND

Liver transplantation (LTX) is indicated in selected patients with hepatocellular carcinoma (HCC) and cirrhosis.

METHODS

We compared the outcome of LTX for patients with and without HCC in 5-year time periods between 1987 and 2007 to reflect the implementation of the Milan tumor selection criteria in 1997 and of the model for end-stage liver disease (MELD) score-based liver allocation in 2002.

RESULTS

Of 2350 patients who underwent primary LTX, 330 had HCC. Five-year patient survival for HCC patients was 28.6% in 1987-1992 and 42.3% in 1992-1997, which was 41.4-31.4% lower than that in non-HCC patients (P < 0.0001). After 1997, 5-year survival was 76% for HCC patients, similar to the survival for non-HCC patients (P = 0.8784). Five-year tumor recurrence dropped from 52.9% (1987-1992) and 48.2% (1992-1997) to 11.4% (1997-2002) and 8.4% (2002-2007) (P < 0.0001). Multivariate analysis for tumor recurrence showed the following significant factors: tumor size >6 cm [hazard ratio (HR) 3.67], >or=5 nodules (HR 3.441), vascular invasion (HR 3.18), transplant in 1987-1992 (HR 6.772), and transplant in 1992-1997 (HR 3.059). MELD-based liver allocation reduced median waiting time for LTX for HCC versus non-HCC (35 vs. 111 days; P = 0.005) without compromise in patient outcome.

CONCLUSIONS

The results of LTX for HCC continue to improve and are equal to results in patients without HCC.

Current management strategy of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) still remains a considerable challenge for surgeons. Surgery, including liver transplantation, is the most important therapeutic approach for patients with this disease. HCC is frequently diagnosed at advanced stages and has a poor prognosis with a high mortality rate even when surgical resection has been considered potentially curative. This brief report summarizes the current status of the management of this malignancy and includes a short description of new pharmacological approaches in HCC treatment.

Improved results of transplantation for hepatocellular carcinoma: a report from the International Registry of Hepatic Tumors in Liver Transplantation

Improved outcome after liver transplantation (LTX) for hepatocellular carcinoma (HCC) made LTX a legitimate treatment of the disease. We analyzed trends of LTX for HCC with tumors known before transplantation in 902 patients in a large international registry across 3 periods: 1983-1990, 1991-1996, and 1997-2005. Patient survival improved gradually across eras, with 5-year survival rates of 25.3%, 44.4%, and 67.8%, respectively (P < 0.0001), and the 5-year tumor recurrence rate declined from 59% to 41.3% and 15%, respectively (P < 0.0001). The number of HCC nodules and tumor size decreased over time, and there were fewer moderately or poorly differentiated tumors. Tumors > 5 cm decreased from 54.5% to 31.7% and 11.7%, respectively (P < 0.0001), and LTX with >or=4 nodules decreased from 38.9% to 23.5% and 15.1%, respectively (P = 0.0044). Poorly differentiated tumors decreased from 37.2% to 31.8% and 20.3%, respectively (P = 0.0005). Tumor microvascular invasion remained at 21.2% to 23.8% despite changes in patient selection over time (P = 0.7124). Stepwise Cox regression analysis (n = 502) showed significant risk for tumor recurrence and patient survival for transplants before 1997 [hazard ratio (HR), 1.82 and 1.88, respectively], tumor size > 6 cm (HR, 2.09 and 1.76), microvascular invasion (HR, 1.75 and 1.69, respectively), and alpha-fetoprotein > 200 (HR, 2.45 and 2.32, respectively). In conclusion, outcome after LTX for HCC has improved continuously over the past 20 years. Improved perioperative care and better patient selection may partially explain the improved outcome after LTX for HCC.

The role of mTOR inhibitors in the management of posttransplant malignancy

Organ transplant recipients given mammalian target of rapamycin inhibitor (mTORi) have reduced incidence of de novo posttransplant malignancies (dNPTMs). Posttransplant Kaposi's sarcoma and nonmelanotic skin malignancies (NMSC) frequently undergo remission/regression after conversion to mTORi immunosuppression (IS), especially early, small, and low-grade lesions, whereas larger, aggressive, and metastatic skin tumors are less likely to respond. mTORi-based IS is effective and well tolerated in orthotopic liver transplant patients with hepatocellular carcinoma (HCC) achieving excellent survival and disease-free intervals, particularly with extended criteria tumors, although the evidence that mTORi prevents HCC recurrence after orthotopic liver transplantation is only suggestive. Regression of metastatic HCC and other tumors and various forms of posttransplant lymphoproliferative disease have occurred after mTOR conversion. Documentation of regression/remission of other solid-organ dNPTM (colon, stomach, breast, etc.) after mTORi conversion is essentially absent with only anecdotal reports lacking follow-up data. Unfortunately, there is not a single reported prospective clinical trial powered for looking at the effect of mTORi IS in transplant recipients. Nevertheless, reduced incidence of all of dNPTMs and remission/regression of the commonest posttransplant tumors with mTOR therapy are strong reasons to expand the use of mTORi.

Liver transplantation for hepatocellular carcinoma without preoperative tumor biopsy

BACKGROUND

Progress in liver imaging has made pretransplantation tumor biopsy no longer systematic in patients with hepatocellular carcinoma (HCC).

OBJECTIVES

Our aim was to evaluate the accuracy of a preoperative diagnosis of HCC based on clinical and radiological findings in 102 cirrhotics qualified for liver transplantation (LT) between January 1995 and August 2003 at our institution.

METHODS

The diagnostic accuracy of our policy was assessed by comparing pretransplant diagnosis with the pathologic report of explanted livers.

RESULTS

Sensitivity, specificity, positive, and negative predictive values for the preoperative clinical and radiological diagnosis of HCC were 89%, 94.3%, 77%, and 93.3%, respectively. A false-positive preoperative diagnosis was made in 20 of 102 patients (19.6%) (dysplastic nodules [n=9], regenerative nodules [n=5] cholangiocellular carcinoma [n=1], hemangioma [n=1], and no lesion [n=4]). All tumors larger than 3 cm were correctly diagnosed, irrespective of serum alpha-fetoprotein (sAFP) levels. The risk of overestimating the diagnosis of HCC in the subgroup of patients with tumors less than 3 cm was conversely correlated with preliver transplantation sAFP (sAFP<or=100 ng/L: 28%; sAFP>100: 11%; sAFP>200: 0%).

CONCLUSION

In cirrhotics with nodules larger than 3 cm irrespective of sAFP or nodules less than 3 cm with sAFP greater than 200 ng/L, the pretransplant diagnosis of HCC can be made without performing biopsy. In other cases (i.e., nodules less than 3 cm and sAFP lower than 200 ng/L), histologic confirmation of HCC or a close follow-up imaging should be considered.

The timing of liver transplantation after primary hepatectomy for hepatocellular carcinoma: a special reference to recurrence pattern and Milan criteria

INTRODUCTION

Hepatic resection (HR) is commonly applied as first-line treatment of hepatocellular carcinoma (HCC) even in the era of liver transplantation (LT).

METHODS

Outcomes and detailed recurrence pattern of 80 patients, who underwent curative HR for HCC were examined referring to Milan criteria.

RESULTS

(I) After HR for HCCs exceeding Milan criteria (n=41), recurrence within the criteria was observed in 13 patients (group-A) and recurrence not-meeting the criteria was observed in 22 patients (group-B). group-A showed better 3-year recurrence-free survival rate than group-B (85.7% vs. 23.9%, P<0.05). Tumor size more than or equal to 6 cm was identified as the significant factor for having recurrence as in group-A pattern (P<0.05). Among the patients in group-A, re-recurrence after treating recurrent HCC was observed in eight patients (61.5%) with increased rate of extra-Milan criteria recurrence at 12 months from the initial recurrence. (II) After HR for HCCs meeting Milan criteria (n=39), recurrences within the criteria was observed in 15 patients (group-C) and recurrence not-meeting the criteria was observed in five patients (group-D). The 3-year recurrence-free survival rate was 62.8% in group-C and 40.0% in group-D (P<0.05). Increased rate of extra-Milan re-recurrence was observed later than 12 months from the recurrence in group-C.

CONCLUSIONS

For HCCs not meeting Milan criteria, secondary LT after primary HR could be applied for a proportion of cases with less aggressiveness. For those meeting Milan criteria, primary LT should be the first therapeutic option. However, secondary LT could be offered for those with re-recurrence within criteria after primary HR.

Liver transplantation for hepatocellular carcinoma: Hangzhou experiences

INTRODUCTION

Liver transplantation (LT) has been the treatment of choice for patients with hepatocellular carcinoma (HCC). This study was designed to summarize our experience in LT for HCC patients and establish a new set of criteria for patient selection and prognosis prediction.

MATERIALS AND METHODS

Data of 195 patients with HCC were retrospectively analyzed and various clinical and pathological factors for survival and tumor-free survival were examined by univariate and multivariate analyses.

RESULTS

Macrovascular invasion, preoperative serum alpha fetoprotein (AFP) level, tumor size, multifocality, histopathologic grading, distribution, and cirrhosis background were significant factors for survival and tumor-free survival by univariate analysis. Multivariate analysis identified macrovascular invasion, tumor size, preoperative AFP level, and histopathologic grading were prognostic factors independently associated with patient survival or tumor-free survival (RR=1.688-2.779, P=0.000-0.034). Based on the prognostic stratification of different risk groups of patients without macrovascular invasion, Hangzhou criteria was established, containing one of the two following items: (a) Total tumor diameter less than or equal to 8 cm; (b) total tumor diameter more than 8 cm, with histopathologic grade I or II and preoperative AFP level less than or equal to 400 ng/mL, simultaneously. The difference between survival curves of patients fulfilling Milan criteria (n=72) and patients fulfilling Hangzhou criteria (n=99) did not achieve statistical significance (5-year survival rates: 78.3% vs. 72.3%, P>0.05). Of the patients exceeding Milan criteria (n=123), those who fulfilled Hangzhou criteria (n=26) also had better prognosis than the others (n=97) (P=0.000).

CONCLUSION

The results of this study show a reliable and feasible candidates selection and prognostic criteria of LT in HCC patients.

Development of a survival evaluation model for liver transplant recipients with hepatocellular carcinoma secondary to hepatitis B

AIM

To develop a model using easily obtainable, objective, verifiable preoperative parameters, to help evaluate post transplant survival probability for hepatocellular carcinoma (HCC) patients with hepatitis B.

METHODS

We retrospectively examined a cohort of 150 consecutive primary cadaveric liver transplants with HCC in our center over 6 years. Thirteen preoperative biochemical parameters and six tumor-related factors were analyzed to identify their correlation with post transplant survival using the Cox proportional-hazards regression model. The predictive power of a new model and the model for end stage liver disease was compared by the receiver operating characteristic curve.

RESULTS

In univariate analysis, the factors significantly associated with post transplant survival were serum concentrations of albumin, total bilirubin, alkaline phosphatase, alpha-fetoprotein, gamma-glutamyltransferase, aspartate aminotransferase, sodium, tumor diameter and the number of tumor nodules. Multivariate analysis showed alpha-fetoprotein, serum sodium, alkaline phosphatase and the number of tumor nodules were significantly associated with the post transplant outcome. Based on the four variables, we established a new model with a c-statistic of 0.72 which was significantly greater than 0.50 (P = 0.001), and the c-statistic of MELD was 0.59 (P = 0.146).

CONCLUSION

The new model based on four objective tumor-related parameters has the capacity to evaluate the risk of post transplant mortality for HCC patients with hepatitis B.

Outcome of patients with hepatocellular carcinoma referred to a tertiary centre with availability of multiple treatment options including cadaveric liver transplantation

Hepatocellular carcinoma (HCC) is a primary cancer of the liver with an established causal link to viral hepatitis and other forms of chronic liver disease.

AIMS

The aim of this study was to analyse the determinants of outcome in patients with HCC referred to a tertiary centre for management.

METHOD

Two hundred and thirty-five prospective patients with HCC and minimum 12-month follow-up were studied.

RESULTS

The cohort was heterogeneous, with 52% Caucasian, 40% Asian and 5% of Middle-Eastern origin. Independent predictors of outcome included tumour size and number, the presence of ascites or portal vein thrombosis, alpha-foetoprotein >50 U/L and an impaired performance status. Treatment was determined on an individual case basis by a multidisciplinary tumour team. Surgical resection was primary treatment in 43 patients, liver transplantation in 40 patients, local ablation (percutaneous radiofrequency ablation or alcohol injection) in 33 patients, transarterial chemoembolisation in 33 patients, chemotherapy or other systemic therapy in 30 patients and no treatment in 56 patients. After adjustment for significant covariates, both liver transplantation (P<0.001) and surgical resection (P=0.029) had a significant effect on patient survival compared with no treatment, but local ablation (P=0.410) and chemoembolisation (P=0.831) did not. Liver transplantation resulted in superior overall and, in particular, disease-free survival compared with surgical resection (disease-free survival 84 vs 15% at 5 years).

CONCLUSION

In conclusion, both surgical resection and liver transplantation significantly improve the survival of patients with HCC, but improvements need to be made to the delivery of loco-regional therapy to enhance its effectiveness.

Genetic polymorphisms in the methylenetetrahydrofolate reductase and thymidylate synthase genes and risk of hepatocellular carcinoma

Methylenetetrahydrofolate reductase (MTHFR) and thymidylate synthase (TYMS) are known to play a role in DNA methylation, synthesis, and repair. The genetic mutations in MTHFR and TYMS genes may have influences on their respective enzyme activities. Data on the association studies of the MTHFR and TYMS genetic polymorphisms and risk of hepatocellular carcinoma (HCC) are sparse. MTHFR and TYMS genotypes were determined on 365 HCC cases and 457 healthy control subjects among Hispanic and non-Hispanic whites and African-Americans in Los Angeles County, California, and among Chinese in the city of Nanning, Guangxi, China. Relative to the high-activity genotype, each low-activity genotype of MTHFR was associated with a statistically nonsignificant 30% to 50% reduction in risk of HCC. Relative to the TYMS3'UTR +6/+6 genotype, individuals with 1 or 2 copies of the deletion allele had a statistically significant 50% reduction in risk of HCC. When we examined HCC risk by the total number of mutant alleles in the 3 polymorphic loci of MTHFR/TYMS (range, 0-4), there was a monotonic decrease in risk with increasing number of mutant alleles (P for trend = 0.003). Individuals possessing the maximum number of mutant alleles (i.e., 4) had an odds ratio of 0.46 (95% confidence interval = 0.23-0.93) for HCC compared with those with no or only 1 mutant allele.

CONCLUSION

This study supports the hypothesis that reduced MTHFR activity and enhanced TYMS activity, both of which are essential elements in minimizing uracil misincorporation into DNA, may protect against the development of HCC.

Large hepatocellular carcinoma: time to stop preoperative biopsy

BACKGROUND

In Western countries, hepatocellular carcinoma (HCC) often presents at a large size, which is seen as a contraindication to transplantation and often resection. Although diagnosis by imaging and alpha-fetoprotein is usually straightforward, nonspecialist units continue to use biopsy to prove the diagnosis before transfer for specialist surgical opinion. We have looked at the impact of this on our practice.

STUDY DESIGN

We retrospectively analyzed all large HCCs resected in our unit during the last 12 years. Survival data were calculated according to size and univariate and multivariate analyses were carried out to determine impact of preoperative, operative, and histologic factors affecting outcomes.

RESULTS

We identified 85 large HCCs (> 3 cm) and classified 42 as giant (> 10 cm). Overall survival at 1, 3, and 5 years was 76%, 54%, and 51%. Size did not influence survival, although more complex surgical techniques were required for giant tumors. Predictors of poorer disease-free survival were positive resection margin (p < 0.001), multiple tumors (p = 0.003), macroscopic vascular invasion (p = 0.015), and preoperative lesion biopsy (p = 0.027).

CONCLUSIONS

Our data shows excellent outcomes after resection for large HCC. This supports the management of such patients in large-volume units that are fully equipped and experienced in the management of these patients. Preoperative biopsy should be avoided, as this unnecessary maneuver appears to have worsened our longterm results.