Liver transplantation for hepatocellular carcinoma

A comprehensive analysis of GAS2 family members identifies that GAS2L1 is a novel biomarker and promotes the proliferation of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common primary liver cancer with a high incidence and mortality. Members of the growth-arresting-specific 2 (GAS2) family are involved in various biological processes in human malignancies. To date, there is only a limited amount of information available about the expression profile and clinical importance of GAS2 family in HCC. In this study, we found that GAS2L1 and GAS2L3 were distinctly upregulated in HCC specimens compared to non-tumor specimens. Pan-cancer assays indicated that GAS2L1 and GAS2L3 were highly expressed in most cancers. The Pearson's correlation revealed that the expressions of GAS2, GAS2L1 and GAS2L2 were negatively associated with methylation levels. Survival assays indicated that GAS2L1 and GAS2L3 were independent prognostic factors for HCC patients. Immune cell infiltration analysis revealed that GAS2, GAS2L1 and GAS2L3 were associated with several immune cells. Finally, we confirmed that GAS2L1 was highly expressed in HCC cells and its knockdown suppressed the proliferation of HCC cells. Taken together, our findings suggested the expression patterns and prognostic values of GAS2 members in HCC, providing insights for further study of the GAS2 family as sensitive diagnostic and prognostic markers for HCC.

Suboptimal performance of LI-RADS v2018 on gadoxetic acid-enhanced MRI for detecting hepatocellular carcinoma in liver transplant candidates

OBJECTIVES

To evaluate the diagnostic performance for hepatocellular carcinoma (HCC) detection of the Liver Imaging Reporting and Data System (LI-RADS) version 2018 on gadoxetic acid-enhanced MRI, comparing liver transplant candidates (LT group) with patients who underwent surgical resection (SR group), and to determine significant clinical factors for diagnostic performance of LI-RADS v2018.

METHODS

Patients who underwent gadoxetic acid-enhanced MRI and subsequent SR or LT for HCC were retrospectively included between January 2019 and December 2020. The sensitivity and specificity of LI-RADS LR-5 for HCC were compared between the two groups using generalized estimating equations. The accuracy of patient allocation according to the Milan criteria was calculated for the LT group. Univariable and multivariable logistic regression analyses were performed to determine significant clinical factors associated with the sensitivity of LI-RADS.

RESULTS

Of the 281 patients, 237 were assigned to the SR group, and 44 were assigned to the LT group. The LT group showed significantly lower per-patient (48.5% vs. 79.6%, p < .001) and per-lesion sensitivity (31.0% vs. 75.9%, p < .001) than the SR group, whereas no significant difference in both per-patient (100.0% vs. 91.7%, p > .99) and per-lesion specificities (100.0% vs. 94.1%, p > .99). The accuracy of patient allocation was 50.0%. Sensitivity was significantly lower in patients with a smaller lesion size (p < .001), a larger lesion number (p = .002), and a higher Child-Pugh score (p = .009).

CONCLUSION

LI-RADS v2018 on gadoxetic acid-enhanced MRI might be insufficient in liver transplant candidates and other diagnostic imaging tests should be considered in patients with these significant clinical factors.

CLINICAL RELEVANCE STATEMENT

In liver transplant candidates with a smaller lesion size, a larger lesion number, and a higher Child-Pugh score, imaging tests other than gadoxetic acid-enhanced MRI may be clinically useful to determine the transplant eligibility.

KEY POINTS

• The sensitivity of the Liver Imaging Reporting and Data System (LI-RADS) was lower in liver transplant candidates than in those who underwent surgical resection. • With the use of gadoxetic acid-enhanced MRI, the accuracy of patient allocation for liver transplantation on the basis of the Milan criteria was suboptimal. • The sensitivity of LI-RADS v2018 was significantly associated with lesion size, lesion number, and Child-Pugh classification.

A decline in functional status while awaiting liver transplantation is predictive of increased post-transplantation mortality

BACKGROUND

Functional status (FS) is dynamic and changes over time. We examined how changes in FS while awaiting liver transplantation influence post-transplant outcomes.

METHODS

Data on adult liver transplants performed in the United States during the MELD era were obtained through September 2020. Patient and graft survival were compared between groups with no change or improved FS, and those with worsening FS.

RESULTS

Of the 90,210 transplant recipients included in the analysis, 39,193 (43%) had worsening FS, which was associated with longer waiting-list time (187 vs. 329 days, p < 0.001) and worse patient survival after liver transplant (1858 vs. 1727 days, p < 0.001). A consistent and dose-dependent relationship was observed for each 10-point decrease in Karnofsky Performance Score and post-transplant survival. Multivariable regression analysis confirmed that a decline in FS was associated with worse patient survival (HR 1.15, p < 0.001). Similar findings were observed for graft survival.

CONCLUSION

A decline in FS on the waiting-list is associated with significantly greater post-liver transplant mortality in recipients. These results should be taken into consideration when allocating organs and determining transplant candidacy. Strategies to optimize FS prior to transplantation should be prioritized as even subtle decreases in FS are associated with inferior post-transplantation outcomes.

New approach for hepatocellular carcinoma treatment

Hepatocellular carcinoma (HCC) is the fifth most common cancer, with an increasing incidence in recent years. The prognosis is unfavorable, representing the third most frequent cause of cancer-related death worldwide. This is because it generally develops in patients with pre-existing liver pathology, thus limiting therapeutic options. The role of ablative therapies is well-established in nodules smaller than 3 cm, but for nodules from 3 to 5 cm, the best therapeutic management is not well defined. Recent studies reported that combining minimally invasive procedures like transarterial chemoembolization (TACE) with microwave ablation (MWA) or radiofrequency ablation is superior to each alone. However, there is no consensus regarding the timing and the order in which each procedure should be performed. We report a case of an 86 years old male with HCV-related compensated hepatic cirrhosis and multiple cardiac comorbidities diagnosed with a 47/50 mm HCC. Pre-surgical evaluation of the associated pathologies determined that the risk for the surgical approach outweighs the benefits, so the committee decided to treat it in a less invasive manner. We performed MWA and TACE in a single session with technical success according to the modified Response Evaluation Criteria in Solid Tumors (m-RECIST). This case illustrates the first case of simultaneous MWA and TACE performed in our center. This new approach of hepatocellular carcinoma appears to be a good alternative to more invasive methods, with good results even in older people that are unfit for surgery.

Alpha-fetoprotein-adjusted-to-HCC-size criteria are associated with favourable survival after liver transplantation for hepatocellular carcinoma

Background

The Milan criteria are recommended to select hepatocellular carcinoma (HCC) patients for liver transplantation (LT). The utility of other selection criteria, such as the alpha‐fetoprotein‐adjusted‐to‐HCC‐size (AFP‐UTS) criteria, is still unclear.

Objective

We investigated, in HCC patients who underwent LT, the survival and the recurrence after LT according to AFP‐UTS and Milan criteria, the impact of early recurrence and the correlation between radiological and pathological staging.

Methods

Adult HCC patients undergoing deceased donor LT at the Medical University of Vienna between 1997 and 2014 were retrospectively analysed.

Results

Among 166 patients included, the number of patients who fulfilled Milan or AFP‐UTS criteria was the same (139 [84%] each), although not all of them were the same individuals; 127 patients (77%) fulfilled both Milan and AFP‐UTS criteria. Median overall survival of patients within AFP‐UTS was 126.9 versus 34.2 months outside AFP‐UTS (5‐year survival rate 71% vs. 43%; p = 0.104). The 5‐year recurrence rate was significantly lower in patients fulfilling the AFP‐UTS criteria (18%) than in those exceeding AFP‐UTS (64%; p < 0.001). Of the 139 patients within Milan criteria on imaging, 24 (17%) had microvascular invasion and 47 (34%) were outside Milan according to explant histology. Early recurrence correlated with AFP‐UTS and was associated with dismal survival (median overall survival 17.2 vs. 122.1 months, p = 0.002).

Conclusions

The overall survival of patients within AFP‐UTS criteria was favourable with a 5‐year survival rate above 70%. Early recurrence is associated with worse survival after LT. The AFP‐UTS criteria may be more suitable to exclude patients at high risk of (early) recurrence than Milan criteria.

Downstaging treatment for patients with hepatocelluar carcinoma before transplantation

Liver transplantation (LT), one of the radical methods of treating liver cancer, has brought new hope for the treatment of unresectable liver cancer. Currently, patients who meet transplant criteria can achieve a favorable prognosis, but those who exceed transplant criteria tend not to have very satisfactory outcomes. For patients whose tumor burden exceeds the transplant criteria, downstaging treatment is a promising method to reduce tumor burden to within the transplant criteria that may lead to good posttransplant survival. Multiple treatments, such as transcatheter arterial chemoembolization (TACE), transarterial radioembolization (TARE), percutaneous ethanol injection (PEI), and radiofrequency ablation (RFA), have been used as downstaging treatments. However, there are still some issues that limit the effectiveness of downstaging treatments, such as the inclusion criteria for downstaging, which the choice of downstaging treatment method, and the endpoint of downstaging, all of which are worthy of further discussion. Based on the published literature, this review discusses these issues.

Is Portal Vein Embolization Followed by Hepatectomy for Hepatocellular Carcinoma Justified in Patients with Impaired Liver Function?

BACKGROUND

Portal vein embolization (PVE) was developed for patients with insufficient future liver remnant volume and function and has gained relevant support worldwide before major hepatectomy. However, the efficacy of preoperative PVE for hepatocellular carcinoma (HCC) patients with impaired liver function remains uncertain.

PATIENTS AND METHODS

Ninety-seven HCC patients who were scheduled for PVE followed by hepatectomy were enrolled in this study. Their short- and long-term outcomes were investigated, according to the liver damage classification defined by the Liver Cancer Study Group of Japan.

RESULTS

Of 97 patients who underwent preoperative PVE, 30 (32.4%) could not undergo subsequent hepatectomy. Dropout rate from treatment strategy was significantly higher in patients with liver damage B (n = 13, 61.5%) than in those with liver damage A (n = 84, 26.2%) (P = 0.014). Among the 67 patients who underwent planned hepatectomy after PVE, 53 were categorized to liver damage A, and 14 were categorized to liver damage B at the point of hepatectomy. Although major complication and mortality rates were comparable between the two groups, the cumulative overall survival (OS) and disease-free survival (DFS) after hepatectomy were markedly worse in patients with liver damage B than in those with liver damage A (5-year OS rate: 23.1% vs 74.6%, P = 0.014, 5-year DFS rate: 7.8% vs 33.5%, P = 0.054, respectively).

CONCLUSIONS

The treatment strategy of PVE followed by hepatectomy might be a contraindication for HCC patients with impaired liver function categorized as liver damage B because of the higher dropout rate and poorer long-term outcomes after hepatectomy.

Evolving thresholds for liver transplantation in hepatocellular carcinoma: A Western experience

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related deaths worldwide. Once considered an experimental treatment with dismal survival rates, liver transplantation for HCC entered a new era with the establishment of the Milan criteria over 20 years ago. In the modern post-Milan-criteria era, 5-year survival outcomes are now upwards of 70% in select patients. Liver transplantation (LT) is now considered the optimal treatment for patients with moderate to severe cirrhosis and HCC, and the rates of transplantation in the United States are continuing to rise. Several expanded selection criteria have been proposed for determining which patients with HCC should be candidates for undergoing LT with similar overall and recurrence-free survival rates to patients within the Milan criteria. There is also a growing experience with downstaging of patients who fall outside conventional LT criteria at the time of HCC diagnosis with the goal of tumor shrinkage via locoregional therapies to become a candidate for transplantation. The aim of this review article is to characterize the various patient selection criteria for LT, discuss balancing organ stewardship with outcome measures in HCC patients, present evidence on the role of downstaging for large tumors, and explore future directions of LT for HCC.

C-reactive protein is an independent predictor for hepatocellular carcinoma recurrence after liver transplantation

BACKGROUND

Serum C-reactive protein (CRP) is a prognostic factor for overall survival (OS) and recurrence of hepatocellular carcinoma (HCC) in patients treated with resection or non-surgical treatment. Here, we investigated the association of elevated CRP (≥1 vs. <1 mg/dL) with (i) recurrence of HCC and (ii) OS after liver transplantation (LT).

METHODS

Adult HCC patients undergoing orthotopic deceased donor LT at the Medical University of Vienna between 1997 and 2014 were retrospectively analysed.

RESULTS

Among 216 patients included, 132 (61.1%) were transplanted within the Milan criteria and forty-two patients (19.4%) had microvascular invasion on explant histology. Seventy patients (32.4%) showed elevated CRP (≥ 1 mg/dL). On multivariate analysis, a CRP ≥ 1 mg/dL was an independent risk factor for HCC recurrence with a 5-year recurrence rate of 27.4% vs. 16.4% (HR 2.33; 95% CI 1.13-4.83; p = 0.022). OS was similar in patients with normal vs. elevated CRP levels.

CONCLUSIONS

Elevated serum CRP is associated with HCC recurrence after LT and may be a marker for more aggressive tumor biology. Future studies should evaluate whether patients with elevated pre-transplant CRP levels benefit from closer monitoring for HCC recurrence.

Optimal criteria for hepatocellular carcinoma diagnosis using CT in patients undergoing liver transplantation

OBJECTIVE

To compare the diagnostic performance of various guidelines for hepatocellular carcinoma (HCC) diagnosis using computed tomography (CT) in patients undergoing liver transplantation (LT).

METHODS

In total, 216 patients who underwent preoperative CT and subsequent LT were included. Two radiologists retrospectively evaluated focal hepatic lesions independently according to various guidelines and allocated patients according to the Milan criteria. The diagnostic performance of the guidelines was compared using alternative free-response receiver-operating characteristics (AFROC) analysis with bootstrapping. Comparisons of sensitivity, specificity, and accuracy of patient allocation based on the Milan criteria between guidelines were performed using logistic regression with generalized estimating equations (GEE).

RESULTS

Fifty-two of 216 patients had 87 HCCs. The reader-averaged figure of merit obtained using AFROC analysis was 0.738 for the AASLD/EASL or KLCSG-NCC guidelines and 0.728 for the LI-RADS v2014 or OPTN/UNOS (bootstrapping, p = 0.005). The per-lesion sensitivity for HCCs (all and 1-2-cm lesions) was significantly higher with the AASLD/EASL (37.9-41.4% and 30.8-41.0%) than with LI-RADS (28.7% and 15.4-18.0%) (logistic regression with GEE, p = 0.008 and 0.030 for reader 1 and p = 0.005 for reader 2). The per-patient specificity (98.8-99.4%) was the same for all guidelines. The accuracy of the Milan criteria was 81.5-83.3% without significant differences among the four guidelines (logistic regression with GEE, p > 0.05).

CONCLUSION

AASLD/EASL showed higher diagnostic performance and sensitivity, particularly for 1-2-cm HCCs, and the same specificity with LI-RADS. All guidelines are comparable for patient allocation based on the Milan criteria for LT.

KEY POINTS

• The overall diagnostic performance of CT for HCC diagnosis was highest with AASLD/EASL. • AASLD/EASL showed higher sensitivity for diagnosis of 1-2-cm HCCs than LI-RADS. • The accuracy of the Milan criteria using CT was comparable among the four guidelines.

Is disease progression a contraindication for the strategy of portal vein embolization followed by hepatectomy for hepatocellular carcinoma?

BACKGROUND

Portal vein embolization has been used worldwide to induce hypertrophy of the future liver remnant and to reduce the risk of hepatic insufficiency and death after major hepatectomy. However, whether disease progression after portal vein embolization can affect long-term oncologic outcomes in patients with hepatocellular carcinoma is uncertain.

METHODS

From a total of 107 patients who underwent portal vein embolization and subsequent hepatectomy between 2000 and 2016, 57 patients with hepatocellular carcinoma were enrolled. We evaluated their long-term oncologic outcomes and investigated whether the disease progression between portal vein embolization and subsequent hepatectomy affected survival.

RESULTS

The 5-year overall survival and disease-free survival after hepatectomy were 74.5% and 31.7%, respectively. Multivariate analyses revealed that tumor number before hepatectomy ≥3 (hazard ratio 3.59, P = .019), des-γ-carboxy prothrombin >200 mAU/mL (hazard ratio 3.36, P = .045), and red blood cell transfusion (hazard ratio 11.03, P = .0008) were independent prognostic factors for overall survival. Male sex (hazard ratio 3.74, P = .029), bilobar tumor distribution (hazard ratio 3.65, P = .004), and red blood cell transfusion (hazard ratio 6.22, P = .0026) were independent prognostic factors for disease-free survival. Disease progressions after portal vein embolization, including increases in tumor size, tumor number, α-fetoprotein, lens culinaris agglutinin-reactive fraction of α-fetoprotein, and des-γ-carboxy prothrombin, were observed in 22.8%, 14.0%, 29.8%, 19.3%, and 47.4% of patients, respectively. Only an increase of tumor number significantly decreased the disease-free survival rate after hepatectomy in a univariate analysis, and none of the variables affected overall survival.

CONCLUSION

Disease progression after portal vein embolization did not affect long-term survival in patients with hepatocellular carcinoma if the planned subsequent hepatectomy could be completed.

Conversion therapy and suitable timing for subsequent salvage surgery for initially unresectable hepatocellular carcinoma: What is new?

AIM

To review the conversion therapy for initially unresectable hepatocellular carcinoma (HCC) patients and the suitable timing for subsequent salvage surgery.

METHODS

A PubMed search was undertaken from 1987 to 2017 to identify articles using the keywords including “unresectable” “hepatocellular carcinoma”, ”hepatectomy”, ”conversion therapy”, “resection”, “salvage surgery” and “downstaging”. Additional studies were investigated through a manual search of the references from the articles. The exclusion criteria were duplicates, case reports, case series, videos, contents unrelated to the topic, comments, and editorial essays. The main and widely used conversion therapies and the suitable timing for subsequent salvage surgery were discussed in detail. Two members of our group independently performed the literature search and data extraction.

RESULTS

Liver volume measurements [future liver remnant (FLR)/total liver volume or residual liver volume/bodyweight ratio] and function tests (scoring systems and liver stiffness) were often performed in order to justify whether patients were suitable candidates for surgery. Successful conversion therapy was usually defined as downstaging the tumor, increasing FLR and providing subsequent salvage surgery, without increasing complications, morbidity or mortality. The requirements for performing salvage surgery after transcatheter arterial chemoembolization were the achievement of a partial remission in radiology, the disappearance of the portal vein thrombosis, and the lack of extrahepatic metastasis. Patients with a standardized FLR (sFLR) > 20% were good candidates for surgery after portal vein embolization, while other predictive parameters like growth rate, kinetic growth rate were treated as an effective supplementary. There was probably not enough evidence to provide a standard operation time after associating liver partition and portal vein ligation for staged hepatectomy or yttrium-90 microsphere radioembolization. The indications of any combinations of conversion therapies and the subsequent salvage surgery time still need to be carefully and comprehensively evaluated.

CONCLUSION

Conversion therapy is recommended for the treatment of initially unresectable HCC, and the suitable subsequent salvage surgery time should be reappraised and is closely related to its previous therapeutic effect.

Surgical treatment strategy for hepatocellular carcinoma in patients with impaired liver function: hepatic resection or radiofrequency ablation?

BACKGROUND

To compare the survival impacts of radiofrequency ablation (RFA) as an initial treatment for hepatocellular carcinoma (HCC) in patients with impaired liver functional reserve compared to those of hepatic resection (HR).

METHODS

In total, 104 patients with liver damage B as defined by the Liver Cancer Study Group of Japan underwent RFA (n = 33) or HR (n = 71) as an initial treatment for hepatocellular carcinoma. The overall survival (OS) and disease-free survival (DFS) rates were compared, and independent prognostic factors were identified.

RESULTS

The OS tended to be better in the RFA group than in the HR group. There was no significant difference in the DFS rate between the two groups. Independent poor prognostic factors for OS were tumor size >3 cm and red blood cell transfusion, and those for DFS were aspartate aminotransferase level >35 IU/L and multiple tumors. Subgroup analyses revealed that the OS with RFA was significantly better in patients with aspartate aminotransferase >35 IU/L, serum albumin <3.5 g/dL, and ^99mTc-galactosyl human serum albumin <0.85.

CONCLUSIONS

RFA offers comparable results with HR and may be preferable for HCC in the particular setting of liver damage B, especially in those with poorer liver functional reserve.

FAM83D associates with high tumor recurrence after liver transplantation involving expansion of CD44+ carcinoma stem cells

To investigate the potential oncogene promoting recurrence of hepatocellular carcinoma (HCC) following liver transplantation (LT), throughput RNA sequencing was performed in a subgroup of HCC patients. The up-regulated FAM83D in HCC tissues was found and further verified in 150 patients by real-time PCR and immunohistochemistry. FAM83D overexpression significantly correlated with high HCC recurrence rate following LT and poor HCC characteristics such as high AFP, poor differentiation. Of cancer stem cells (CSCs) markers, CD44 expression was effectively suppressed when FAM83D was knocked down by siRNA. Meanwhile, the siRNA transfected cells suppressed formation of sphere and ability of self-renew. In a xenograft tumorigenesis model, FAM83D knockdown apparently inhibited tumor growth and metastasis. Microarray assays revealed that FAM83D promotes CD44 expression via activating the MAPK, TGF-β and Hippo signaling pathways. Furthermore, CD44 knockdown presented reverse effect on above signaling pathways, which suggested that FAM83D was a key activator of loop between CD44 and above signaling pathways. In conclusion, FAM83D promotes HCC recurrence by promoting CD44 expression and CD44⁺ CSCs malignancy. FAM83D provides a novel therapeutic approach against HCC recurrence after LT.

Is the Hong Kong Liver Cancer staging system the best guide for hepatitis B virus-related hepatocellular carcinoma patients with multiple tumors?

It still must be confirmed whether the newly developed Hong Kong Liver Cancer Staging (HKLC) system can effectively stratify patients with multiple tumors and identify patients who could obtain a survival benefit with radical resection. In this study, we retrospectively compared survival rates of surgery versus transcatheter arterial chemoembolization for hepatitis B virus-related hepatocellular carcinoma patients with multiple tumors by using the propensity score method. In addition, the prognostic roles of tumor size, number and thrombus status together with other covariates on postoperative survival were analyzed by multivariate analysis. In matched cohorts, surgical treatment could significantly reduce patient mortality in patients within or outside HKLC criteria (odds ratio (OR) = 0.5, P < 0.001, OR = 0.6, P = 0.001, respectively). In 941 patients undergoing radical resection, the state of tumor thrombus demonstrated a significant interaction with tumor size on postoperative survival (P for interaction = 0.041). Tumor number was not a predictor of postoperative survival in patients with multiple tumors (adjusted OR = 1.1, P = 0.202). In patients without tumor thrombus, tumor size > 5 cm was an independent risk factor of postoperative survival (OR = 1.7, P < 0.001). In patients without tumor thrombus, patient survival was mainly influenced by tumor location (OR = 2.1, P < 0.001). In summary, patients with multiple tumors could obtain a survival benefit from radical surgery based on the more aggressive HKLC staging system. However, parameters in this staging system still need further adjustments.

Comparison of treatment outcome between living donor liver transplantation and sorafenib for patients with hepatocellular carcinoma beyond the Milan criteria

For patients with advanced hepatocellular carcinoma (HCC), sorafenib is the only systemic treatment recommended by international guidelines. We recently reported that HCC patients with a low MoRAL (model to predict tumor recurrence after LDLT) score (≤ 314.8) have excellent treatment outcomes after living-donor liver transplantation (LDLT), even though they are beyond the Milan criteria. In the present study, we investigated whether LDLT offers a better treatment outcome than sorafenib for patients with HCC beyond the Milan criteria according to the MoRAL score. A retrospective cohort study of 325 consecutive patients who were treated with either LDLT (n = 122) or sorafenib (n = 203) for HCC beyond the Milan criteria from 2005 to 2014 at a tertiary hospital was performed. The primary and secondary endpoints were overall survival (OS) and time-to-progression. When baseline characteristics were balanced using inverse probability weighting, OS was significantly longer in the LDLT group than in the sorafenib group (5-year OS rate, 71.9% vs. 4.9%; HR=0.1; P < 0.001). The LDLT group exhibited a significantly lower risk of tumor progression (5-year recurrence rate, 34.7% vs. 96%; HR=0.14; P < 0.001) than the sorafenib group. The increase in OS with LDLT was predominantly among patients with a low MoRAL score (5-year OS rate, 81.1% vs. 5.8%; HR=0.06; P < 0.001) compared with those with a high MoRAL score (5-year OS rate, 28.3% vs. 4.3%; HR = 0.42; P = 0.047). Patients with a low MoRAL score and without extrahepatic metastasis or hepatic vein invasion might be good candidates for LDLT instead of sorafenib treatment if there is a willing living related donor.

Outcome of Living-Donor Liver Transplant for Hepatocellular Carcinoma: 15-Year Single-Center Experience in Egypt

OBJECTIVES

Liver transplant performed for hepatocellular carcinoma must adhere to criteria for the size and number of focal hepatic lesions to lower the incidence of recurrence and achieve survival rates comparable to patients transplanted for other indications. Since the Milan criteria were established in 1996, there have been many less restrictive criteria yielding similar results. Our aim was to identify the prognostic factors for patient survival and for recurrence of hepatocellular carcinoma for patients within and beyond the Milan criteria.

MATERIALS AND METHODS

This retrospective and prospective analysis was conducted in 60 adult patients who underwent right lobe living-donor liver transplant for cirrhosis complicated by hepatocellular carcinoma at Dar Al Fouad Hospital, 6th of October City, Egypt, between August 2001 and June 2012. The median follow-up was 39.5 months.

RESULTS

Overall 1-, 3-, and 5-year survival rates were 98.3%, 93.5%, and 71.4%. Overall disease-free survival rates at 1, 3, and 5 years were 96.6%, 93.5%, and 64.2%. There was no statistically significant difference in overall survival time between patients within and beyond the Milan criteria. Factors affecting recurrence were the tumor grade, lobar distribution, size of the largest nodule, and the total tumor burden in the explanted liver. Recurrence adversely affected survival.

CONCLUSIONS

Using our criteria of a single tumor ≤ 6 cm, or 2 to 3 tumors with the largest ≤ 4.5 cm, or 4 to 5 tumors with the largest ≤ 3 cm and total tumor size ≤ 8 cm resulted in overall survival comparable to patients within the Milan criteria.

Bridging locoregional therapy: Longitudinal trends and outcomes in patients with hepatocellular carcinoma

The purpose of this article is to analyze longitudinal trends in locoregional therapy (LRT) use and review locoregional therapy's role in the management of hepatocellular carcinoma prior to orthotropic liver transplantation Porrett et al. (2006) . LRT has a role in both bridge to transplantation and downstaging of patients not initially meeting Milan or UCSF Criteria. Due to the lack of randomized controlled trials, no specific bridging LRT modality is recommended over another for treating patients on the waiting list, however each modality has unique and patient-specific advantages. Pre-transplant LRT use in the United States has increased dramatically over the last two decades with more than 50% of the currently listed patients receiving LRT Freeman et al. (2008) . Despite these national trends, significant differences in LRT utilization, referral patterns, recurrence rates and survival have been observed among UNOS regions, socioeconomic levels and races. The use of LRT as a biologic selection tool based on response to treatment has shown promising results in its ability to predict successful post-transplant outcomes.

Prognosis for recipients with hepatocellular carcinoma of salvage liver transplantation versus those of primary liver transplantation: a retrospective single-center study

PURPOSE

The prognosis for recipients with hepatocellular carcinoma (HCC) of salvage liver transplantation (SLT) versus those of primary liver transplantation (PLT) remains controversial. The objective of this study was to evaluate the clinical features and survival rate of SLT recipients.

METHODS

Three hundred seventy-one patients with HCC transplanted at Shanghai General Hospital, China, between October 2001 and October 2011 were separated into PLT (n = 295) and SLT (n = 76) groups. Patient characteristics and survival curves were studied by univariate and multivariate analysis. A Milan criteria-stratified survival analysis was conducted.

RESULTS

The proportions of reoperation (11.8 vs. 5.4 %, P = 0.047) and early postoperative mortality (11.8 vs. 4.7 %, P = 0.032) were higher in the SLT group than in the PLT group. Recurrence free survival (RFS) rate and overall survival (OS) rate had no statistically significant differences after stratification using Milan criteria between the PLT group and SLT group. Alphafetoprotein >400 ng/mL (P = 0.011), microscopic vascular invasion (MVI) (P < 0.001), tumor node metastasis (TNM) staging (P = 0.006), and out of Milan criteria (P < 0.001) were independent risk factors for RFS, while MVI (P < 0.001), TNM staging (P = 0.009), and out of Milan criteria (P = 0.003) were factors for OS. In the multivariate logistic regression analysis, HCC recurrence was associated with MVI (OR = 4.196 [2.538-6.936], P < 0.001), and out of Milan criteria (OR = 2.704 [1.643-4.451], P < 0.001).

CONCLUSIONS

Our retrospective, single-center study demonstrated that SLT increases surgical difficulty; however, it has good post-transplantation OS and is a feasible alternative after HCC recurrence within Milan criteria.

Indications for living donor liver transplantation in patients with hepatocellular carcinoma

Liver transplantation is the optimal radical therapy for patients with cirrhosis and hepatocellular carcinoma (HCC). The Milan criteria are widely applied for deceased donor liver transplantation (DDLT) in the western countries. Living donor liver transplantation (LDLT), however, prevails in Asian countries due to the extreme shortage of deceased donor organs. In contrast to DDLT, the feasibility of LDLT is not restricted by the national allocation system, and therefore the indications for LDLT in patients with HCC depend on institutional policies that consider both the operative risk to the donor and the survival benefit for the recipient. The results of a nationwide survey as well as the experiences of individual centers demonstrate similar outcomes for patients whose tumors fall within the Milan criteria and those whose tumors extend beyond the Milan criteria.

Identification of Imaging Predictors Discriminating Different Primary Liver Tumours in Patients with Chronic Liver Disease on Gadoxetic Acid-enhanced MRI: a Classification Tree Analysis

OBJECTIVES

To identify predictors for the discrimination of intrahepatic cholangiocarcinoma (IMCC) and combined hepatocellular-cholangiocarcinoma (CHC) from hepatocellular carcinoma (HCC) for primary liver cancers on gadoxetic acid-enhanced MRI among high-risk chronic liver disease (CLD) patients using classification tree analysis (CTA).

METHODS

A total of 152 patients with histopathologically proven IMCC (n = 40), CHC (n = 24) and HCC (n = 91) were enrolled. Tumour marker and MRI variables including morphologic features, signal intensity, and enhancement pattern were used to identify tumours suspicious for IMCC and CHC using CTA.

RESULTS

On CTA, arterial rim enhancement (ARE) was the initial splitting predictor for assessing the probability of tumours being IMCC or CHC. Of 43 tumours that were classified in a subgroup on CTA based on the presence of ARE, non-intralesional fat, and non-globular shape, 41 (95.3 %) were IMCCs (n = 29) or CHCs (n = 12). All 24 tumours showing fat on MRI were HCCs. The CTA model demonstrated sensitivity of 84.4 %, specificity of 97.8 %, and accuracy of 92.3 % for discriminating IMCCs and CHCs from HCCs.

CONCLUSIONS

We established a simple CTA model for classifying a high-risk group of CLD patients with IMCC and CHC. This model may be useful for guiding diagnosis for primary liver cancers in patients with CLD.

KEY POINTS

• Arterial rim enhancement was the initial splitting predictor on CTA. • CTA model achieved high sensitivity, specificity, and accuracy for discrimination of tumours. • This model may be useful for guiding diagnosis of primary liver cancers.

Impact of age on the prognosis after liver transplantation for patients with hepatocellular carcinoma: a single-center experience

BACKGROUND

Liver transplantation (LT) offers the most effective treatment for hepatocellular carcinoma patients. Various preoperative variables are correlated with survival after LT, but the prognostic role of aging on LT remains controversial.

METHODS

Between January 2001 and December 2011, 290 consecutive transplants for patients with hepatocellular carcinoma performed in Shanghai First People's Hospital (People's Republic of China) were analyzed retrospectively. We compared patient characteristics and survival curves between a younger group (less than 49 years, n=135) and an aged group (50 years or older, n=155). We then performed Cox multivariate regression analysis of the risk factors for survival in aged and younger patients.

RESULTS

Younger age was associated with higher alpha-fetoprotein (P=0.014), larger tumor size (P=0.038), poorer differentiation (P=0.025), portal lymph node metastasis (P=0.001), and higher recurrence rate (P=0.038). Aged patients had significantly longer recurrence-free survival and overall survival (P=0.020 and P=0.014, respectively); however, there were no significant differences between the younger and aged patients who met the Milan criteria (P>0.05). The 1-, 3-, and 5-year recurrence-free survival rates were 59.7%, 44.5%, and 37.3%, respectively, in the younger group, and 67.9%, 55.3%, and 53.8%, respectively, in the aged group. The 1-, 3-, and 5-year overall survival rates were 68.4%, 45.5%, and 38.9%, respectively, in the younger group, and 76.1%, 59.7%, and 53.9%, respectively, in the aged group. Alpha-fetoprotein ≥400 ng/mL, microvascular invasion, and tumor size >5 cm were independent risk factors for prognosis in both groups.

CONCLUSION

Younger patients in our center tended to present with more aggressive tumors and have a higher risk of recurrence. Our single-center experience suggests that younger patients should be assessed more rigorously before LT, while aged patients should be actively considered for LT after appropriate selection.

Validation of models in patients with hepatocellular carcinoma: comparison of Hong Kong Liver Cancer with Barcelona Clinic Liver Cancer staging system in a Chinese cohort

OBJECTIVE

Accurate staging information is necessary to determine the prognosis of patients with hepatocellular carcinoma (HCC) and to guide subsequent patient management. This study aims to investigate the prognostic performance of the Hong Kong Liver Cancer (HKLC) classification in a Chinese cohort of HCC patients.

METHODS

A total of 668 HCC patients between 2003 and 2012 were included. Performances of the HKLC and the Barcelona Clinic Liver Cancer (BCLC) system were compared using Akaike information criterion (AIC), concordance-index (c-index), and area under the receiver operating characteristic curve (AUC). Independent prognostic factors of survival were identified using univariate and multivariate analyses.

RESULTS

Independent predictors of survival were Child-Pugh grade (P=0.009), lactate dehydrogenase (P<0.001) and albumin (P=0.001) levels, tumor location (P=0.032), tumor number (P<0.001), tumor size (P<0.001), and vascular invasion (P<0.001). Discriminatory ability was shown to be better for HKLC (AUC at 1, 3, and 5 years were 0.740, 0.695, and 0.615, respectively) than BCLC (AUC at 1, 3, and 5 years were 0.622, 0.569, and 0.548, respectively). On the basis of AIC and c-index, HKLC had a higher predictive power for survival (AIC=4709.480, c-index=0.805) than BCLC (AIC=4852.708, c-index=0.717).

CONCLUSION

In our selected patient population, whose main etiology was hepatitis B, the HKLC system was more suitable for predicting prognosis in a Chinese cohort of HCC patients than the BCLC classification.

Impact of current staging systems on treatment strategy for HBV-related hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second leading cause of cancer-related death worldwide. HCC incidence has increased over the last few years, with more than half of HCC cases being reported in China, where hepatitis B virus (HBV) infection is the main etiologic factor. The heterogeneity in HCC's worldwide distribution and the differences in its etiology in different locations may result in prognosis estimation and therapeutic decision making being more complicated for HCC patients. In the past decade, several clinical staging systems have been developed based on relevant prognostic factors. Among them, the Barcelona Clinic Liver Cancer (BCLC) and Hong Kong Liver Cancer (HKLC) staging systems are the only two classification systems that link prognostic classification to treatment indications. In this review, we mainly focus on the use of the BCLC and HKLC staging systems for guiding therapeutic decision making for HCC, the respective advantages and disadvantages of each classification system, and future perspectives for the improvement of the HKLC model.

Salvage treatment for local recurrence of hepatocellular carcinoma after local ablation therapy

AIM

Local recurrence of hepatocellular carcinoma (HCC) after local ablation therapy (LAT) is a serious problem; however, the optimal treatment strategy remains unclear.

METHODS

A retrospective analysis was conducted of 50 patients with local recurrence of HCC after LAT that underwent either salvage hepatectomy (n = 23) or radiofrequency ablation (RFA; n = 27). Their background characteristics, intraoperative data, and postoperative short- and long-term outcome were analyzed.

RESULTS

The RFA group was found to be significantly associated with an impaired liver functional reserve, smaller number and size of tumors. The hepatectomy group showed a significantly longer operation time, greater intraoperative blood loss and more frequent red blood cell transfusion. In-hospital stay mortality and morbidity rate did not significantly differ. The disease-free and overall survival showed no significant difference between the groups. Although local recurrence after salvage treatment was found in zero (0%) for hepatectomy and in seven (25.9%) for RFA, that did not affect the overall survival. The tumor size at the prior LAT was identified as an independent prognostic factor for disease-free survival and serum albumin for overall survival.

CONCLUSION

Whereas salvage hepatectomy for local recurrent HCC is recommended for selected patients in terms of its good local control effect, salvage RFA is also acceptable because it is less invasive and also has a reasonable long-term outcome.

Diagnostic performance of gadoxetic acid-enhanced liver MR imaging in the detection of HCCs and allocation of transplant recipients on the basis of the Milan criteria and UNOS guidelines: correlation with histopathologic findings

PURPOSE

To determine whether hepatobiliary phase ( HBP hepatobiliary phase ) imaging can improve the diagnostic performance of gadoxetic acid-enhanced liver magnetic resonance (MR) imaging in the detection of hepatocellular carcinomas ( HCC hepatocellular carcinoma s) and to investigate the accuracy of gadoxetic acid-enhanced MR imaging in the allocation of transplant recipients on the basis of the Milan criteria and United Network for Organ Sharing ( UNOS United Network for Organ Sharing ) guidelines.

MATERIALS AND METHODS

This retrospective study had institutional review board approval; the requirement for informed consent was waived. Between June 2008 and June 2011, 63 patients who underwent liver transplantation (LT) were included. All patients underwent a gadoxetic acid-enhanced 3.0-T MR imaging examination of the liver that included HBP hepatobiliary phase images obtained 20 minutes after contrast material administration. Two abdominal radiologists independently assessed two MR imaging data sets to detect HCC hepatocellular carcinoma s: Set 1 included unenhanced and gadoxetic acid-enhanced dynamic images, and set 2 also included HBP hepatobiliary phase images. Patients were allocated into three groups: Those who did not meet the Milan criteria, those who did meet the Milan criteria with additional priority according to UNOS United Network for Organ Sharing guidelines, and those who did meet the Milan criteria without additional priority. Diagnostic performance of each data set in depicting HCC hepatocellular carcinoma s was compared by using jackknife alternative free-response receiver operating characteristics ( JAFROC jackknife alternative free-response receiver operating characteristic s). Sensitivity and accuracy of patient allocation were compared by using generalized estimating equations.

RESULTS

Sixty-three HCC hepatocellular carcinoma s were found in 36 of 63 patients. Eight patients were classified as not meeting Milan criteria, 12 as meeting Milan criteria with additional priority, and 43 as meeting Milan criteria without additional priority. For the detection of HCC hepatocellular carcinoma s, reader-averaged figures of merit estimated with JAFROC jackknife alternative free-response receiver operating characteristic s were 0.761 for set 1 and 0.791 for set 2 (P < .001). Addition of HBP hepatobiliary phase images significantly improved sensitivity for the detection of HCC hepatocellular carcinoma s, particularly 1-2-cm HCC hepatocellular carcinoma s (six [20.7%] vs 13 [44.8%] of 29 [P = .008] for reader 1 and eight [27.6%] vs 12 [41.4%] of 29 [P = .041] for reader 2). Accuracy of patient allocation was 88.9% for set 1 and 92.1% for set 2 (P = .151).

CONCLUSION

Addition of HBP hepatobiliary phase images can significantly improve the diagnostic performance of gadoxetic acid-enhanced liver MR imaging in the detection of 1-2-cm HCC hepatocellular carcinoma s in liver transplantation candidates. In addition, gadoxetic acid-enhanced MR imaging showed 92.1% accuracy in patient allocation on the basis of the Milan criteria and UNOS United Network for Organ Sharing guidelines.

An evaluation of the sensitivity of MRI at detecting hepatocellular carcinoma in cirrhotic patients utilizing an explant reference standard

OBJECTIVE

To evaluate the sensitivity of magnetic resonance imaging (MRI) at detecting hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

MRIs performed within 120 days of transplant, and pathology, were reviewed.

RESULTS

Of the 87 patients included in the final analysis, 58 had HCC at explant (106 total HCCs). The per-patient and per-lesion sensitivity was 74.1% (43/58) and 81.1% (86/106), respectively. The sensitivity based on size <1cm, 1-2 cm, and >2 cm was 80.0% (28/35), 77.2% (44/57), and 100% (14/14).

CONCLUSION

MRI accurately detects HCC, including HCCs <2 cm. In our study population, the imaging disease staging was concordant with pathological staging in 80% of patients.

The Indian National Association for Study of the Liver (INASL) Consensus on Prevention, Diagnosis and Management of Hepatocellular Carcinoma in India: The Puri Recommendations

Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality and healthcare expenditure in patients with chronic liver disease. There are no consensus guidelines on diagnosis and management of HCC in India. The Indian National Association for Study of the Liver (INASL) set up a Task-Force on HCC in 2011, with a mandate to develop consensus guidelines for diagnosis and management of HCC, relevant to disease patterns and clinical practices in India. The Task-Force first identified various contentious issues on various aspects of HCC and these issues were allotted to individual members of the Task-Force who reviewed them in detail. The Task-Force used the Oxford Center for Evidence Based Medicine-Levels of Evidence of 2009 for developing an evidence-based approach. A 2-day round table discussion was held on 9th and 10th February, 2013 at Puri, Odisha, to discuss, debate, and finalize the consensus statements. The members of the Task-Force reviewed and discussed the existing literature at this meeting and formulated the INASL consensus statements for each of the issues. We present here the INASL consensus guidelines (The Puri Recommendations) on prevention, diagnosis and management of HCC in India.

Living Donor Liver Transplantation Outcomes for Hepatocellular Carcinoma Beyond Milan or UCSF Criteria

Liver transplantation (LT) is the most effective treatment for hepatocellular carcinoma (HCC) that arises from cirrhosis. The Milan and the University of California, San Francisco (UCSF) selection criteria have resulted in major improvements in patient survival. We assessed our outcomes for patients with HCC that were beyond the Milan and UCSF criteria after living donor liver transplantation. We reviewed the data for 109 patients with cirrhosis and HCC who underwent living donor right lobe liver transplantation (living donor liver transplantation; LDLT) during the period from July 2004 to July 2012. Sixteen (14.7 %) patients had HCC recurrences during a mean follow-up of 35.4 ± 26.2 months (range 4-100 months). The mean time to recurrence was 11 ± 9.4 months (range 4-26 months). Survival rates were not significantly different between patients with HCC that met and were beyond the Milan and UCSF criteria (p = 0.761 and p = 0.861, respectively). The Milan and UCSF criteria were not independent risk factors for HCC recurrence or patient survival. Only poorly differentiated tumors were associated with a lower survival rate (OR = 8.656, 95 % confidence interval (CI) 2.01-37.16; p = 0.004). Survival rates for patients with HCC that were beyond conventional selection criteria should encourage reconsidering the acceptable thresholds of these criteria so that more HCC patients may undergo LT without affecting outcomes.

Nephrogenic systemic fibrosis risk and liver disease

Objective. Evaluate the incidence of nephrogenic systemic fibrosis (NSF) in patients with liver disease in the peritransplant period. Materials and Methods. This IRB approved study retrospectively reviewed patients requiring transplantation for cirrhosis, hepatocellular carcinoma (HCC), or both from 2003 to 2013. Records were reviewed identifying those having gadolinium enhanced MRI within 1 year of posttransplantation to document degree of liver disease, renal disease, and evidence for NSF. Results. Gadolinium-enhanced MRI was performed on 312 of 837 patients, including 23 with severe renal failure (GFR < 30 mL/min/1.73 cm(2)) and 289 with GFR > 30. Two of 23 patients with renal failure developed NSF compared to zero NSF cases in 289 patients with GFR > 30 (0/289; P < 0.003). High dose gadodiamide was used in the two NSF cases. There was no increased incidence of NSF with severe liver disease (1/71) compared to nonsevere liver disease (1/241; P = 0.412). Conclusion. Renal disease is a risk factor for NSF, but in our small sample our evidence suggests liver disease is not an additional risk factor, especially if a low-risk gadolinium agent is used. Noting that not all patients received high-risk gadolinium, a larger study focusing on patients receiving high-risk gadolinium is needed to further evaluate NSF risk in liver disease in the peritransplant period.

Role of overexpression of MACC1 and/or FAK in predicting prognosis of hepatocellular carcinoma after liver transplantation

BACKGROUND

Metastasis-associated in colon cancer-1 (MACC1) acts as a promoter of tumor metastasis; however, the predictive value of MACC1 for hepatocellular carcinoma (HCC) after liver transplantation (LT) remains unclear.

METHODS

We examined the expression of MACC1 and its target genes MET and FAK by quantitative PCR in 160 patients with HCC that was undergone LT.

RESULTS

The patients with MACC1(high) or FAK(high) in HCCs showed a significantly shorter overall survival and higher cumulative recurrence rates after liver transplantation (LT), compared with MACC1(low) or FAK(low) group. Multivariate analysis indicated that MACC1 alone or combination of MACC1/FAK was an independent prognostic factor for overall survival and cumulative recurrence.

CONCLUSIONS

MACC1 or combination of MACC1/FAK could serve as a novel biomarker in predicting the prognosis of HCC after LT.

Sorafenib treatment is save and may affect survival of recurrent hepatocellular carcinoma after liver transplantation

INTRODUCTION

Recurrent hepatocellular carcinoma (HCC) after liver transplantation (LT) is a rare but challenging condition. In most cases, the recurrent tumor is presented with extrahepatic spread. Therefore, systemic treatment with sorafenib has to be assessed. Because of a plethora of possible drug interactions, e.g., with immunosuppressant or anti-infective therapy, safety and feasibility of sorafenib treatment requires special attention.

MATERIALS AND METHODS

We retrospectively analyzed 18 patients who suffered from recurrent advanced HCC after LT between January 2002 and December 2010 at the University Hospital Heidelberg regarding safety of sorafenib treatment and survival.

RESULTS

Results showed that 8 patients were eligible for treatment with sorafenib showing a median time to progression (TTP) of 4.5 months and an overall survival of 9 months. Most common side effects were grades I and II diarrhea and hand-foot syndrome (HFS) which could be managed by sorafenib dose reduction. No grade III or IV adverse events (AEs) were noticed. No patient had to discontinue treatment due to AEs. The ten patients not amenable for sorafenib treatment, due to initial poor performance status or its deterioration after first line treatment, were treated with surgical resection (n = 3), locoregional therapies (n = 1), or palliative radiation therapy (n = 1). They showed a median overall survival of 2.3 months.

CONCLUSION

Sorafenib may represent a therapeutic option for recurrent HCC after LT with manageable side effects. The clinical benefit of sorafenib in this setting is promising but needs to be confirmed in a prospective randomized trial.

Role of FNA and Core Biopsy of Primary and Metastatic Liver Disease

Objective. To examine our experience with cytology and histology biopsy of the liver and to define methods for improvement of diagnosis of primary liver tumors. Methods. This include retrospective study of 189 biopsies of 185 liver masses for cytological or histological analysis. Patients were subdivided into two groups. Group 1 consisted of 124 suspected metastasis. Group 2 consisted of 61 suspected primary neoplasms. Biopsies were considered positive or equivocal. In equivocal cases, special stains were performed. In Group 2, cases were classified by contrast CT or MRI as to (I) classic HCC, (II) infiltrated HCC, or (Ill) equivocal. Results. Definitive diagnosis was obtained in 117/124 masses (94%) in Group 1, 48/61 masses (79%) in Group 2, and (Ill) equivocal 13 cases in Group II. In two equivocal cases in which special stains were performed, they were reclassified as HCC. In 8/13 cases, CT findings were consistent with HCC. Conclusion. Liver biopsies are useful in obtaining a definitive diagnosis of suspected metastatic liver disease. Biopsy results are less reliable in patients with suspected primary liver tumors. In these situations, strategies can include basing treatment on imaging criteria or use of newer special pathological stains. Advances in Knowledge. Use of newer special immunological stains improves accuracy in definitive diagnosis of primary liver tumors.

New concepts and best practices for management of pre- and post-transplantation cancer

Solid-organ transplant recipients are at increased risk of developing cancer compared with the general population. Tumours can arise de novo, as a recurrence of a preexisting malignancy, or from the donated organ. The ATOS (Aula sobre Trasplantes de Órganos Sólidos; the Solid-Organ Transplantation Working Group) group, integrated by Spanish transplant experts, meets annually to discuss current advances in the field. In 2011, the 11th edition covered a range of new topics on cancer and transplantation. In this review we have highlighted the new concepts and best practices for managing cancer in the pre-transplant and post-transplant settings that were presented at the ATOS meeting. Immunosuppression plays a major role in oncogenesis in the transplant recipient, both through impaired immunosurveillance and through direct oncogenic activity. It is possible to transplant organs obtained from donors with a history of cancer as long as an effective minimization of malignancy transmission strategy is followed. Tumour-specific wait-periods have been proposed for the increased number of transplantation candidates with a history of malignancy; however, the patient's individual risk of death from organ failure must be taken into consideration. It is important to actively prevent tumour recurrence, especially the recurrence of hepatocellular carcinoma in liver transplant recipients. To effectively manage post-transplant malignancies, it is essential to proactively monitor patients, with long-term intensive screening programs showing a reduced incidence of cancer post-transplantation. Proposed management strategies for post-transplantation malignancies include viral monitoring and prophylaxis to decrease infection-related cancer, immunosuppression modulation with lower doses of calcineurin inhibitors, and addition of or conversion to inhibitors of the mammalian target of rapamycin.

Identification of recurrence-related microRNAs in hepatocellular carcinoma following liver transplantation

Tumor recurrence-related microRNAs (miRNAs) in hepatocellular carcinoma (HCC) following orthotopic liver transplantation (OLT) are not clear yet. This study was designed to determine whether altered miRNA expression is associated with HCC recurrence and prognosis following OLT. 18 miRNAs, including 6 up-regulated and 12 down-regulated miRNAs were identified by microarray in primary HCC samples of patients who had developed HCC recurrence (n = 5) compared to those with non-recurrence (n = 5) following OLT by using p < 0.05 as cutoff value. The six most significantly altered miRNAs (fold change ≥ 2: miR-19a, miR-886-5p, miR-126, miR-223, miR-24 and miR-147) were further confirmed by qRT-PCR in the remaining 105 HCC samples. In receiver-operating characteristic curve analysis, this six miRNAs were of high sensitivity and specificity in predicting HCC recurrence. Using Cox regression and risk score analysis, we built a six-miRNA signature based on their qRT-PCR readings for the prediction of outcome of HCC following OLT. Kaplan-Meier and Cox proportional regression revealed this six-miRNA signature was a significant independent predictor of overall survival (log-rank p = 0.020) and recurrence-free survival (log-rank p < 0.001). Finally, the data were further reconfirmed in an independent cohort of 50 patients from another transplant center. In addition, bioinformatics Gene Ontology and pathway analysis were also performed to better understand the critical roles of these miRNAs in HCC recurrence. Our study, in addition to suggesting a different miRNA expression pattern between HCC samples of patients with recurrence and those with non-recurrence, proposes that this six-miRNA signature may serve as biomarker for prognosis of HCC patients following OLT.

Saudi guidelines for the diagnosis and management of hepatocellular carcinoma: technical review and practice guidelines

Recognizing the significant prevalence of hepatocellular carcinoma (HCC) in Saudi Arabia, and the difficulties often faced in early and accurate diagnoses, evidence-based management, and the need for appropriate referral of HCC patients, the Saudi Association for the Study of Liver diseases and Transplantation (SASLT) formed a multi-disciplinary task force to evaluate and update the previously published guidelines by the Saudi Gastroenterology Association. These guidelines were later reviewed, adopted and endorsed by the Saudi Oncology Society (SOS) as its official HCC guidelines as well. The committee assigned to revise the Saudi HCC guidelines was composed of hepatologists, oncologists, liver surgeons, transplant surgeons, and interventional radiologists. Two members of the task force served as guidelines editors. A wide based search on all published reports on all aspects of the epidemiology, natural history, risk factors, diagnosis, and management of HCC was performed. All available literature was critically examined and available evidence was then classified according to its strength. The whole document and the recommendations were then discussed in detail by members and consensus was obtained. All recommendations in these guidelines were based on the best available evidence, but were tailored to the patients treated in Saudi Arabia. We hope that these guidelines will improve HCC patient care and enhance the multidisciplinary care needed for these patients.

Up-regulation of microRNA-155 promotes cancer cell invasion and predicts poor survival of hepatocellular carcinoma following liver transplantation

PURPOSE

MicroRNAs play important roles in cancer development, progression, and metastasis. The aim of this study was to determine whether altered microRNA-155 expression is associated with hepatocellular carcinoma (HCC) recurrence and prognosis following orthotopic liver transplantation (OLT).

METHODS

Tissue specimens from 100 HCC patients following OLT were recruited. MicroRNA-155 expression levels were detected using quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Kaplan-Meier and Cox proportional regression analyses were utilized to determine the association of microRNA-155 expression with survival of patients. MicroRNA-155 expression levels of two HCC cell lines (HepG2 and SMMC-7721) and normal liver tissue were quantified using qRT-PCR. The potential function of miR-155 on invasiveness was evaluated in the above HCC cell lines.

RESULTS

We found that microRNA-155 expression levels were high in tumor tissues in patients with post-OLT HCC recurrence (n = 45) compared with those in patients with non-recurrence (n = 55) (P = 0.001) and correlated with micro-vascular invasion of HCC tissue samples (P = 0.001). Patients with higher miR-155 expression had significantly poorer recurrence-free survival (RFS, log rank P < 0.001) and overall survival (OS, log rank P < 0.001). Multivariate analysis revealed that high miR-155 expression was an independent predictor of poor prognosis (HR 2.748, P = 0.001 for RFS; HR 5.752, P < 0.001 for OS). In addition, the invasiveness of HCC cells was significantly increased by higher microRNA-155 expression.

CONCLUSIONS

MicroRNA-155 is a candidate oncogenic microRNA and plays an important role in promoting HCC cells invasion. Our findings suggest that microRNA-155 may serve as a novel biomarker for tumor recurrence and survival of HCC patients following OLT.

Living donor liver transplantation for hepatocellular carcinoma: the Japanese experience

Treatment strategies against hepatocellular carcinoma have progressed remarkably over the past decade. In Asia, evidence-based guidelines for the management of hepatocellular carcinoma have evolved, including the option of liver transplantation. Due to severe organ shortage, however, living donor liver transplantation has become mainstream in Japan. Unlike deceased donor transplantation, living donor transplantation is not limited by the restrictions imposed by the nationwide allocation system. The decision for transplantation often depends on institutional or case-by-case considerations, balancing the will of the donor, the operative risk, and the overall survival benefit for the recipient. Cumulative data from the national multicenter registry analysis as well as individual center experience suggest that expansion of the Milan criteria is warranted.

Up-regulation of microRNA-155 promotes cancer cell invasion and predicts poor survival of hepatocellular carcinoma following liver transplantation

PURPOSE

MicroRNAs play important roles in cancer development, progression, and metastasis. The aim of this study was to determine whether altered microRNA-155 expression is associated with hepatocellular carcinoma (HCC) recurrence and prognosis following orthotopic liver transplantation (OLT).

METHODS

Tissue specimens from 100 HCC patients following OLT were recruited. MicroRNA-155 expression levels were detected using quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Kaplan-Meier and Cox proportional regression analyses were utilized to determine the association of microRNA-155 expression with survival of patients. MicroRNA-155 expression levels of two HCC cell lines (HepG2 and SMMC-7721) and normal liver tissue were quantified using qRT-PCR. The potential function of miR-155 on invasiveness was evaluated in the above HCC cell lines.

RESULTS

We found that microRNA-155 expression levels were high in tumor tissues in patients with post-OLT HCC recurrence (n = 45) compared with those in patients with non-recurrence (n = 55) (P = 0.001) and correlated with micro-vascular invasion of HCC tissue samples (P = 0.001). Patients with higher miR-155 expression had significantly poorer recurrence-free survival (RFS, log rank P < 0.001) and overall survival (OS, log rank P < 0.001). Multivariate analysis revealed that high miR-155 expression was an independent predictor of poor prognosis (HR 2.748, P = 0.001 for RFS; HR 5.752, P < 0.001 for OS). In addition, the invasiveness of HCC cells was significantly increased by higher microRNA-155 expression.

CONCLUSIONS

MicroRNA-155 is a candidate oncogenic microRNA and plays an important role in promoting HCC cells invasion. Our findings suggest that microRNA-155 may serve as a novel biomarker for tumor recurrence and survival of HCC patients following OLT.

The metabolic and toxicological considerations for mTOR inhibitors in the treatment of hepatocarcinoma

INTRODUCTION

Hepatocellular carcinoma (HCC) is a major health problem worldwide. Several molecular pathways involved in HCC growth and progression have recently been identified. Rapamycin analogs are able to inhibit one of the most active oncogenic molecular pathways in HCC cells: the mammalian target of rapamycin (mTOR) pathway.

AREAS COVERED

In this review, the authors analyze the principal molecular features of the mTOR pathway and the use of rapamycin analogs in the treatment of hepatocarcinoma. The article also looks at the reoccurrence of HCC following liver transplantation as well as after the treatment of de novo neoplasms. Finally, the authors discuss the advantage of using a combined HCC pharmacological therapy to obtain a synergistic effect on tumor mass.

EXPERT OPINION

Among the available options for the treatment of advanced-stage HCC, mTOR pathway inhibitors show great promise. Once these agents have their safety and efficacy confirmed, in the treatment of liver disease, their use should be considered in patients affected by HCC. This should especially be the case for those who have had liver transplants or suffered with de novo tumors. Moreover, the authors believe that mTOR inhibitors could be used in a combined pharmacological approach to improve HCC molecular-targeted therapy by producing a multiple-level block of tumor intracellular signaling.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Significance of tumor necrosis for outcome of patients with hepatocellular carcinoma receiving locoregional therapy prior to liver transplantation

BACKGROUND

Locoregional therapy has been advocated as an effective treatment for patients with unresectable hepatocellular carcinoma (HCC), and the majority of patients with HCC receive locoregional therapy prior to liver transplantation (LT). We herein aim to determine the prognostic factors affecting the outcome in patients who receive pretransplantation therapy.

METHODS

We conducted a retrospective study of the prospective data of patients who received locoregional therapy before undergoing LT for HCC. The clinicopathologic features of the patients were studied using univariate and multivariate analysis to determine prognostic factors.

RESULTS

Univariate and multivariate analysis of clinicopathologic features identified mean tumor necrosis (TN) ≥60% as the sole independent factor associated with lower HCC recurrence following LT. Further, the groups of patients with mean TN ≥60% who were within the University of California, San Francisco (UCSF) criteria and whose tumors beyond UCSF criteria were downstaged by TN following locoregional therapy had significantly better survival rates than the opposite groups. In-depth exploration of treatment modalities and pathological features indicated that HCC showed marked TN, while tumor nodules were well treated by locoregional therapy, and no viable tumors could be detected on radiological examination.

CONCLUSIONS

Mean TN ≥60% of tumor by locoregional therapy could offer better outcomes for patients with HCC undergoing LT. Therefore, locoregional therapy should be considered for patients with HCC awaiting LT or potential candidates for LT in order to induce TN as well as leading to diminished viable tumor burden and reducing the odds of HCC recurrence following LT.

Overexpression of long non-coding RNA HOTAIR predicts tumor recurrence in hepatocellular carcinoma patients following liver transplantation

BACKGROUND

The long noncoding RNA HOTAIR has been reported as a poor prognostic biomarker in patients with breast cancer. The aim of the present study is to examine the expression pattern of HOTAIR in hepatocellular carcinoma (HCC) and its clinical significance as well as its biological role in tumor progression.

MATERIALS AND METHODS

We examined the expression of HOTAIR in 110 HCC samples using real-time reverse transcription-polymerase chain reaction and analyzed its correlation with clinical parameters and prognosis in 60 HCC patients that have undergone liver transplantation (LT). Suppression of HOTAIR using siRNA was performed to explore its roles in tumor progression.

RESULTS

The expression level of HOTAIR in cancer tissues was higher than in adjacent noncancerous tissues. High expression level of HOTAIR was an independent prognostic factor for predicting HCC recurrence in LT patients (P = .001, hazard ratio, 3.564). Furthermore, in patients exceeding the Milan criteria, those with a high expression level of HOTAIR revealed a significantly shorter recurrence-free survival. Moreover, siRNA suppression of HOTAIR in a liver cancer cell line reduced cell viability and cell invasion, sensitized TNF-α induced apoptosis, and increased the chemotherapeutic sensitivity of cancer cells to cisplatin and doxorubicin.

CONCLUSIONS

The high expression level of HOTAIR in HCC could be a candidate biomarker for predicting tumor recurrence in HCC patients who have undergone liver transplant therapy and might be a potential therapeutic target.