MR‐guided percutaneous ethanol ablation of hepatocellular carcinomas before liver transplantation

Histological findings in non-tumoral liver and tumor after chemoembolization with drug-eluting beads

Purpose: To evaluate the histological findings in both tumor and surrounding non-tumoral liver parenchyma after trans-arterial chemoembolization with drug-eluting beads (DEB-TACE) for hepatocellular carcinoma (HCC) in patients who subsequently underwent hepatectomy.Material and methods: This study included six patients with an HCC (size 15-61 mm). DEB-TACE was performed using polyvinyl alcohol-based hydrogel microspheres loaded with epirubicin. Radiological tumor response was evaluated after DEB-TACE and before hepatectomy, according to the Modified Response Evaluation Criteria in Solid Tumors. Surgical specimens were histologically evaluated with hematoxylin and eosin, and elastic Van Gieson's staining.Results: Segmental, sub-segmental, or partial hepatectomy were performed 14-58 days after DEB-TACE. There was no remarkable destructive change and minimal to absent inflammatory cell infiltration in the surrounding non-tumoral liver parenchyma. There was no evidence of biliary tract or arterial wall impairment. Complete and partial histological tumor necrosis were found in three cases, respectively, in agreement with the complete and partial responses seen during the radiological evaluation.Conclusion: Histological examination of resected liver specimens after DEB-TACE showed substantial tumor necrosis without any severe inflammatory or destructive changes in the non-tumoral liver parenchyma.

Therapies for patients with hepatocellular carcinoma awaiting liver transplantation: A systematic review and meta-analysis

Patients with hepatocellular carcinoma (HCC) who are listed for liver transplantation (LT) are often treated while on the waiting list with locoregional therapy (LRT), which is aimed at either preventing progression of HCC or reducing the measurable disease burden of HCC in order to receive increased allocation priority. We aimed to synthesize evidence regarding the effectiveness of LRT in the management of patients with HCC who were on the LT waitlist. We conducted a comprehensive search of multiple databases from 1996 to April 25, 2016, for studies that enrolled adults with cirrhosis awaiting LT and treated with bridging or down-staging therapies before LT. Therapies included transcatheter arterial chemoembolization, transarterial radioembolization, ablation, and radiotherapy. We included both comparative and noncomparative studies. There were no randomized controlled trials identified. For adults with T1 HCC and waiting for LT, there were only two nonrandomized comparative studies, both with a high risk of bias, which reported the outcome of interest. In one series, the rate of dropout from all causes at 6 months in T1 HCC patients who underwent LRT was 5.3%, while in the other series of T1 HCC patients who did not receive LRT, the dropout rate at median follow-up of 2.4 years and the progression rate to T2 HCC were 30% and 88%, respectively. For adults with T2 HCC awaiting LT, transplant with any bridging therapy showed a nonsignificant reduction in the risk of waitlist dropout due to progression (relative risk [RR], 0.32; 95% confidence interval [CI], 0.06-1.85; I² = 0%) and of waitlist dropout from all causes (RR, 0.38; 95% CI, 0.060-2.370; I² = 85.7%) compared to no therapy based on three comparative studies. The quality of evidence is very low due to high risk of bias, imprecision, and inconsistency. There were five comparative studies which reported on posttransplant survival rates and 10 comparative studies which reported on posttransplant recurrence, and there was no significant difference seen in either of these endpoints. For adults initially with stage T3 HCC who received LRT, there were three studies reporting on transplant with any down-staging therapy versus no downstaging, and this showed a significant increase in 1-year (two studies, RR, 1.11; 95% CI, 1.01-1.23) and 5-year (1 study, RR, 1.17; 95% CI, 1.03-1.32) post-LT survival rates for patients who received LRT. The quality of evidence is very low due to serious risk of bias and imprecision.

CONCLUSION

In patients with HCC listed for LT, the use of LRT is associated with a nonsignificant trend toward improved waitlist and posttransplant outcomes, though there is a high risk of selection bias in the available evidence. (Hepatology 2018;67:381-400).