Liver transplantation and recurrent hepatocellular carcinoma: predictive value of nodule size in a retrospective and explant study

SIMAP500: A novel risk score to identify recipients at higher risk of hepatocellular carcinoma recurrence following liver transplantation

BACKGROUND

Recurrence of hepatocellular carcinoma (HCC) following liver transplantation (LT) has a devastating influence on recipients’ survival; however, the risk of recurrence is not routinely stratified. Risk stratification is vital with a long LT waiting time, as that could influence the recurrence despite strict listing criteria.

AIM

This study aims to identify predictors of recurrence and develop a novel risk prediction score to forecast HCC recurrence following LT.

METHODS

A retrospective review of LT for HCC recipients at University Hospitals Birmingham between July 2011 and February 2020. Univariate and multivariate analyses were performed to identify recurrence predictors, based on which the novel SIMAP500 (satellite nodules, increase in size, microvascular invasion, AFP > 500, poor differentiation) risk score was proposed.

RESULTS

234 LTs for HCC were performed with a median follow-up of 5.3 years. Recurrence developed in 25 patients (10.7%). On univariate analyses, RETREAT score > 3, α-fetoprotein (AFP) at listing 100-500 and > 500, bridging, increased tumour size between imaging at the listing time and explant histology, increase in the size of viable tumour between listing and explant, presence of satellite nodules, micro- and macrovascular invasion on explant and poor differentiation of tumours were significantly associated with recurrence, based on which, the SIMAP500 risk score is proposed. The SIMAP500 demonstrated an excellent predictive ability (c-index = 0.803) and outperformed the RETREAT score (c-index = 0.73). SIMAP500 is indicative of the time to disease recurrence.

CONCLUSION

SIMAP500 risk score identifies the LT recipients at risk of HCC recurrence. Risk stratification allows patient-centric post-transplant surveillance programs. Further validation of the score is recommended.

Combined transarterial chemoembolization and thermal ablation in candidates to liver transplantation with hepatocellular carcinoma: pathological findings and post-transplant outcome

OBJECTIVES

Evaluating the pathological response and the survival outcomes of combined thermal ablation (TA) and transarterial chemoembolization (TACE) as a bridge or downstaging for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) > 3 cm.

MATERIALS AND METHODS

A retrospective review encompassed 36 consecutive patients who underwent combined TA-TACE as bridging or downstaging before LT. Primary objectives included necrosis of the target lesion at explant pathology, post-LT overall survival (OS) and post-LT recurrence-free survival (RFS). For OS and RFS, a comparison with 170 patients subjected to TA alone for nodules <3 cm in size was also made.

RESULTS

Out of the 36 patients, 63.9% underwent TA-TACE as bridging, while 36.1% required downstaging. The average node size was 4.25 cm. All cases were discussed in a multidisciplinary tumor board to assess the best treatment for each patient. Half received radiofrequency (RF), and the other half underwent microwave (MW). All nodes underwent drug-eluting beads (DEB) TACE with epirubicin. The mean necrosis percentage was 65.9% in the RF+TACE group and 83.3% in the MW+TACE group (p-value = 0.099). OS was 100% at 1 year, 100% at 3 years and 94.7% at 5 years. RFS was 97.2% at 1 year, 94.4% at 3 years and 90% at 5 years. Despite the different sizes of the lesions, OS and RFS did not show significant differences with the cohort of patients subjected to TA alone.

CONCLUSIONS

The study highlights the effectiveness of combined TA-TACE for HCC>3 cm, particularly for bridging and downstaging to LT, achieving OS and RFS rates significantly exceeding 80% at 1, 3 and 5 years.

SNHG16 promotes hepatocellular carcinoma development via activating ECM receptor interaction pathway

BACKGROUND

Accumulating data have suggested that long non-coding RNAs (lncRNAs) play important roles in regulating tumor cell growth. This study was designed to investigate the role of SNHG16 in hepatocellular carcinoma (HCC).

METHODS

SNHG16 expression was detected with real-time polymerase chain reaction (PCR). The cutoff value of SNHG16 for tumor-free survival (TFS) was determined with receiver operating characteristic curve analysis. Small interfering RNA was used to inhibit the expression of SNHG16 in HCC cell lines. The biologic behavior of HCC cell was determined with cell viability assay and Transwell assay in vitro. The potential predictive value of SNHG16 on prognosis was analyzed by Kaplan-Meier curves and Cox proportional hazards regression model.

RESULTS

SNHG16 expression was upregulated in tumor tissues and HCC cell lines. High expression of SNHG16 was associated with tumor recurrence and poor prognosis after surgery. Multivariate analysis revealed that SNHG16 was an independent prognostic factor for poor recurrence-free survival. Moreover, inhibition of SNHG16 in HepG2, Hep3B, and BEL-7402 cells significantly reduced cell invasiveness and proliferation. Mechanistic analyses indicated that the ECM-receptor interaction pathway was remarkably activated by SNHG16.

CONCLUSIONS

SNHG16 might be a promising biomarker for predicting tumor recurrence in HCC patients after surgery and a potential therapeutic target for HCC.

The Multiple Function of lncRNA MALAT1 in Cancer Occurrence and Progression

Long non-coding RNAs (lncRNAs) have received particular attention in the last decade due to its engaging in carcinogenesis and tumorigenesis. Metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) is a lncRNA that plays physiological and pathological roles in many aspects of genome function as well as biological processes involved in cell development, differentiation, proliferation, invasion, and migration. In this article, we will review the effects of lncRNA MALAT1 on the progression of six prevalent human cancers by focusing on MALAT1 ability to regulate post-transcriptional modification and signaling pathways.

Hepatocellular Carcinoma Staging: Differences Between Radiologic and Pathologic Systems and Relevance to Patient Selection and Outcomes in Liver Transplantation

Liver transplant is indicated with curative intent for patients with early-stage hepatocellular carcinoma (HCC). The radiologic T category is used to determine candidacy and priority of patients on the waiting list. After transplant, the explant liver pathologic TNM stage is used as a predictor of postoperative outcomes and overall prognosis. Although the comparison of radiologic and pathologic T categories for concordance is often considered to be straightforward, the staging conventions significantly differ. Not accounting for these differences is in part the reason for the high rates of radiologic-pathologic discordance reported in the literature, with inconsistent terminology being an additional source of confusion when evaluating concordance. These factors may affect the understanding of important radiopathologic phenotypes of disease and the adequate investigation of their prognostic capabilities. The aims of this article are to provide an overview of the pathologic and radiologic TNM staging systems for HCC while describing staging procedures, emphasize the differences between these staging systems to highlight the limitations of radiologic-pathologic stage correlation, present a review of the literature on the prognostic value of individual features used for HCC staging; and signal significant aspects of preoperative risk stratification that could be improved to positively impact posttransplant outcomes.

Number of hepatocellular carcinoma nodules in patients listed for liver transplantation within alpha-fetoprotein score: a new prognostic risk factor

In France, the listing for liver transplantation (LT) for hepatocellular carcinoma (HCC) requires an AFP score ≤2. This study evaluates whether the number of nodules assessed immediately before LT has a prognostic value among patients already listed within AFP score. Among 143 recipients transplanted with an AFP score ≤2 between 2013 and 2017 in our center, the number of nodules was considered at listing on the waiting list and at last imaging before LT. We compared the overall survival (OS) and disease-free survival (DFS) post-LT of patients with ≤3 and >3 nodules (current classification), and aimed to propose a new criteria to exclude patients on list at high risk of recurrence. The 3-year OS of patients with ≤3 HCC vs. >3 HCC at listing was of 90.3% vs. 67.3%, respectively (P = 0.04). At last imaging, eight listed patients presented ≥5 HCC nodules and had a significantly lower OS than <5 nodules patients (5-year OS: 24.4% vs. 78.1%; P = 0.01). Although the current AFP score offers satisfactory outcomes, we highlight the poorer outcomes when ≥5 nodules persist or appear after listing. A modification of the AFP score is mandatory to consider exclusion of high-risk patients already listed for LT program.

Outcomes of Liver Transplantation for Hepatocellular Carcinoma Beyond the University of California San Francisco Criteria: A Single-center Experience

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common primary malignant liver tumor. Currently, liver transplantation may be the optimal treatment for HCC in cirrhotic patients. Patient selection is currently based on tumor size. We developed a program to offer liver transplantation to selected patients with HCC outside of traditional criteria.

METHODS

Retrospective review for patients transplanted with HCC between April 2008 and June 2017. Patients were grouped by tumor size according to Milan, University of California San Francisco (UCSF), and outside UCSF criteria. Patient demographics, laboratory values, and outcomes were compared. Patients radiographically outside Milan criteria were selected based on tumor control with locoregional therapy (LRT) and 9 months of stability from LRT. α-fetoprotein values were not exclusionary.

RESULTS

Two hundred twenty HCC patients were transplanted, 138 inside Milan, 23 inside UCSF, and 59 beyond UCSF criteria. Patient survival was equivalent at 1, 3, or 5 years despite pathologic tumor size. Waiting time to transplantation was not significantly different at an average of 344 days. In patients outside UCSF, tumor recurrence was equivalent to Milan and UCSF criteria recipients who waited >9 months from LRT. Although tumor recurrence was more likely in outside of UCSF patients (3% versus 9% versus 15%; P = 0.02), recurrence-free survival only trended toward significance among the groups (P = 0.053).

CONCLUSIONS

Selective patients outside of traditional size criteria can be effectively transplanted with equivalent survival to patients with smaller tumors, even when pathologic tumor burden is considered. Tumor stability over time can be used to help select patients for transplantation.

Interreader Variability in Semantic Annotation of Microvascular Invasion in Hepatocellular Carcinoma on Contrast-enhanced Triphasic CT Images

Purpose

To evaluate interreader agreement in annotating semantic features on preoperative CT images to predict microvascular invasion (MVI) in patients with hepatocellular carcinoma (HCC).

Materials and Methods

Preoperative, contrast material-enhanced triphasic CT studies from 89 patients (median age, 64 years; age range, 36-85 years; 70 men) who underwent hepatic resection between 2008 and 2017 for a solitary HCC were reviewed. Three radiologists annotated CT images obtained during the arterial and portal venous phases, independently and in consensus, with features associated with MVI reported by other investigators. The assessed factors were the presence or absence of discrete internal arteries, hypoattenuating halo, tumor-liver difference, peritumoral enhancement, and tumor margin. Testing also included previously proposed MVI signatures: radiogenomic venous invasion (RVI) and two-trait predictor of venous invasion (TTPVI), using single-reader and consensus annotations. Cohen (two-reader) and Fleiss (three-reader) κ and the bootstrap method were used to analyze interreader agreement and differences in model performance, respectively.

Results

Of HCCs assessed, 32.6% (29 of 89) had MVI at histopathologic findings. Two-reader agreement, as assessed by pairwise Cohen κ statistics, varied as a function of feature and imaging phase, ranging from 0.02 to 0.6; three-reader Fleiss κ varied from -0.17 to 0.56. For RVI and TTPVI, the best single-reader performance had sensitivity and specificity of 52% and 77% and 67% and 74%, respectively. In consensus, the sensitivity and specificity for the RVI and TTPVI signatures were 59% and 67% and 70% and 62%, respectively.

Conclusion

Interreader variability in semantic feature annotation remains a challenge and affects the reproducibility of predictive models for preoperative detection of MVI in HCC.Supplemental material is available for this article.© RSNA, 2020.

A New Prognostic Model Based on Albumin-Bilirubin Grade for Hepatocellular Carcinoma Beyond the Milan Criteria

BACKGROUND

The survival of patients with advanced hepatocellular carcinoma (HCC) is highly variable due to heterogeneous tumoral characteristics. We proposed and validated an albumin-bilirubin (ALBI)-based model for HCC beyond Milan criteria, the ALBI-HOME, for these patients.

METHODS

A total of 2186 patients were enrolled and randomly assigned to the derivation cohort (n = 1093) and validation cohort (n = 1093). Multivariate Cox proportional hazards model was used to determine significant prognostic factors in the derivation cohort. The performance of ALBI-HOME was evaluated in the validation cohort.

RESULTS

In the Cox model, six factors were identified as independent predictors of poor survival: ALBI grade 2 [hazard ratio (HR) 1.848, 95% confidence incidence (CI) 1.556-2.195, p < 0.001], ALBI grade 3 (HR 3.266, 95% CI 2.531-4.215, p < 0.001), serum AFP ≥ 100 ng/ml (HR 1.482, 95% CI 1.279-1.717, p < 0.001), total tumor volume ≥ 250 cm³ (HR 1.503, 95% CI 1.294-1.746, p < 0.001), ascites (HR 1.400, 95% CI 1.187-1.561, p < 0.001), performance status 0-1 (HR 1.756, 95% CI 1.485-2.076 p < 0.001), and vascular invasion or metastasis (HR 2.110, 95% CI 1.809-2.0, p < 0.001). The ALBI-HOME is based on these six parameters, and the score ranges from 0 to 7. This model was associated with the best prognostic ability among different HCC staging systems to predict survival in patients beyond Milan criteria; its ability remained consistently stable in different treatment subgroups and viral etiologies.

CONCLUSIONS

The proposed ALBI-HOME is a simple and feasible predictive model for HCC beyond Milan criteria. It demonstrates superior prognostic performance among the currently used staging systems and may help identify at-risk patients to undergo more aggressive treatments.

A nomogram based on bi-regional radiomics features from multimodal magnetic resonance imaging for preoperative prediction of microvascular invasion in hepatocellular carcinoma

Background

We aimed to develop and validate a nomogram combining bi-regional radiomics features from multimodal magnetic resonance imaging (MRI) and clinicoradiological characteristics to preoperatively predict microvascular invasion (MVI) of hepatocellular carcinoma (HCC).

Methods

A total of 267 HCC patients were divided into training (n=194) and validation (n=73) cohorts according to MRI data. Bi-regional features were extracted from whole tumors and peritumoral regions in multimodal MRI. The minimum redundancy maximum relevance (mRMR) algorithm was applied to select features and build signatures. The predictive performance of the optimal radiomics signature was further evaluated within subgroups defined by tumor size and alpha fetoprotein (AFP) level. Then, a radiomics nomogram including the optimal radiomics signature, radiographic descriptors, and clinical variables was developed using multivariable regression. The nomogram performance was evaluated based on its discrimination, calibration, and clinical utility.

Results

The fusion radiomics signature derived from triphasic dynamic contrast-enhanced (DCE) MR images can effectively classify MVI and non-MVI HCC patients, with an AUC of 0.784 (95% CI: 0.719-0.840) in the training cohort and 0.820 (95% CI: 0.713-0.900) in the validation cohort. The fusion radiomics signature also performed well in the subgroups defined by the two risk factors, respectively. The nomogram, consisting of the fusion radiomics signature, arterial peritumoral enhancement, and AFP level, outperformed the clinicoradiological prediction model in the validation cohort (AUCs: 0.858 vs. 0.729; P=0.022), fitting well in the calibration curves (P>0.05). Decision curves confirmed the clinical utility of the nomogram.

Conclusions

The radiomics nomogram can serve as a visual predictive tool for MVI in HCCs, and thus assist clinicians in selecting optimal treatment strategies to improve clinical outcomes.

Noninvasive radiomics signature based on quantitative analysis of computed tomography images as a surrogate for microvascular invasion in hepatocellular carcinoma: a pilot study

We explore noninvasive biomarkers of microvascular invasion (mVI) in patients with hepatocellular carcinoma (HCC) using quantitative and semantic image features extracted from contrast-enhanced, triphasic computed tomography (CT). Under institutional review board approval, we selected 28 treatment-naive HCC patients who underwent surgical resection. Four radiologists independently selected and delineated tumor margins on three axial CT images and extracted computational features capturing tumor shape, image intensities, and texture. We also computed two types of "delta features," defined as the absolute difference and the ratio computed from all pairs of imaging phases for each feature. 717 arterial, portal-venous, delayed single-phase, and delta-phase features were robust against interreader variability ([Formula: see text]). An enhanced cross-validation analysis showed that combining robust single-phase and delta features in the arterial and venous phases identified mVI (AUC [Formula: see text]). Compared to a previously reported semantic feature signature (AUC 0.47 to 0.58), these features in our cohort showed only slight to moderate agreement (Cohen's kappa range: 0.03 to 0.59). Though preliminary, quantitative analysis of image features in arterial and venous phases may be potential surrogate biomarkers for mVI in HCC. Further study in a larger cohort is warranted.

Liver transplantation for intermediate hepatocellular carcinoma: An adaptive approach

Hepatocellular carcinoma is becoming an increasing indication for liver transplantation, but selection and allocation of patients are challenging because of organ shortages. Conventional Milan criteria are the reference for the selection of patients worldwide, but many expanded criteria, like University of California San Francisco criteria and up-to-7 criteria, have demonstrated that survival and recurrence results are lower than those for restricted indications. Correct staging is crucial and should include surrogate markers of biological aggressiveness (α-fetoprotein, response to loco-regional treatments). Successful down-staging can select between patients with tumor burden initially beyond transplantation criteria those with a more favorable biology, provided a 3-mo stability in meeting the transplantation criteria. Allocation rules are constantly adjusted to minimize the imbalance between the priorities of candidates with and without hepatocellular carcinoma, and take into account local donor rate and waitlist dynamics. Recently, Mazzaferro et al proposed a benefit-oriented “adaptive approach”, in which the selection and allocation of patients are based on their response to non-transplantation treatments: low priority for transplantation in case of complete response, high priority in case of partial response or recurrence, and no listing in case of progression beyond transplantation criteria.

Alpha-fetoprotein and (18)F-FDG positron emission tomography predict tumor recurrence better than Milan criteria in living donor liver transplantation

BACKGROUND & AIMS

Given the organ shortage for liver transplantation (LT) and the limitations of the current morphology-based selection criteria, improved criteria are needed to achieve the maximum benefit of LT for hepatocellular carcinoma (HCC). We hypothesized that a combination of biological markers may better predict the prognosis than the Milan criteria.

METHODS

HCC patients (n=123) with preoperative data on serum alpha-fetoprotein (AFP) levels and (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) positivity underwent live-donor LT between January 2003 and December 2009. The cut-off values for serum AFP levels (200 ng/ml) and (18)F-FDG PET positivity (1.10) for tumor recurrence were determined by c-statistics using receiver operating characteristic curves. Univariate and multivariate analyses with preoperative variables were performed to find pre-transplant prognostic factors. Disease-free survival rates and overall survival rates were analysed with regard to serum AFP levels and (18)F-FDG PET positivity.

RESULTS

The 5-year disease-free survival rates and overall survival rates were 80.3% and 81.6% respectively. (18)F-FDG PET positivity (hazard ratio (HR) 9.766, 95% CI 3.557-26.816; p<0.001) and serum AFP level (HR 6.234, 95% CI 2.643-14.707; p<0.001) were the only significant pre-transplant prognostic factors in the multivariate analysis; tumor number and size were not significant. A combination of criteria showed that the biologically high-risk group (AFP level ⩾200 ng/ml and PET-positive) had an HR of 29.069 (95% CI 8.797-96.053; p<0.001) compared with the double-negative group. Use of the Milan criteria yielded an HR of 1.351 (95% CI 0.500-3.652; p=0.553).

CONCLUSIONS

The combination of the serum AFP level and (18)F-FDG PET data predicted better outcomes than those using the Milan criteria, improving objectivity when adult-to-adult living donor LT is contemplated.

Outcome of Hepatitis B Virus Infection After Living-Donor Liver Transplant: A Single-center Experience Over 20 Years

OBJECTIVES

Despite living-donor liver transplant being a life-saving therapy for patients with hepatitis B virus with or without hepatocellular carcinoma, outcomes for patients with these diseases are worse. Hepatitis B virus recurrence or relapse of hepatocellular carcinoma can result in subsequent graft loss or patient death. In this study, we discuss the postoperative outcomes of patients with hepatitis B virus infection after living-donor liver transplant.

MATERIALS AND METHODS

We retrospectively analyzed 125 patients with hepatitis B virus-related end-stage liver disease, comparing results with 1228 control patients who had other pathologies, including hepatitis C virus, combined hepatitis B virus and hepatitis C virus, and neither virus.

RESULTS

Survival rates of patients with hepatitis B virus did not differ from the control groups (P > .05). Patients with concurrent hepatitis B virus and hepatocellular carcinoma were significantly older (P < .0001), had critical status (P < .0001), had chronic underlying pathology (P = .001), lower graft-to-recipient body weight ratio (P = .047), needed more intraoperative plasma transfusion, and experienced more rejection episodes than those without hepatocellular carcinoma. Of interest, in 5 patients who had hepatitis B virus recurrence after living-donor liver transplant, Model for End-Stage Liver Disease score was significantly higher than those who did not have recurrence (P = .015). In addition, 2 patients had hepatocellular carcinoma recurrence in the form of peritoneal metastasis, with both patients having high preoperative alpha-fetoprotein levels.

CONCLUSIONS

Our study provides details on long-term outcomes of patients with hepatitis B virus infection who had undergone living-donor liver transplant. Based on our results, we suggest that prolonged antiviral prophylactic therapy in the form of hepatitis B immunoglobulin with either lamivudine or entecavir be considered for patients who associated with risk factors to prevent postoperative recurrence.

Validation of a criteria-specific long-term survival prediction model for hepatocellular carcinoma patients after liver transplantation

The aim of this study was to validate a criteria-specific long-term survival prediction model (MHCAT) in a large cohort of hepatocellular carcinoma (HCC) patients after liver transplantation (LT) in China. Independent risk factors in MHCAT were retrospectively analysed for HCC patients recorded in the China Liver Transplant Registry. Survival predictions for each patient were calculated using MHCAT scores and the Metroticket formula separately, and the prediction efficacy of MHCAT and Metroticket was compared using the area under ROC curve (c-statistic). A total of 1371 LTs for HCC were analysed in the study, with a median follow-up of 22.2 months (IQR 6.1–72.4 months). The proportions meeting the Milan, UCSF, Fudan and Hangzhou criteria were 34.4%, 39.7%, 44.2% and 51.9%, respectively. The c-statistics for MHCAT predictions of 3- and 5-year survival rates of HCC recipients were 0.712–0.727 and 0.726–0.741, respectively. Among these patients, 1298 LTs for HCC were ultimately selected for the comparison analysis for prediction efficacy. The c-statistic of MHCAT for predictions of 3-year survival with reference to the Milan, UCSF and Fudan criteria was significantly increased compared with that for Metroticket (p < 0.05). In conclusion, MHCAT can effectively predict long-term survival for HCC recipients after LT.

Poor prognosis for hepatocellular carcinoma with transarterial chemoembolization pre-transplantation: Retrospective analysis

AIM: To investigate whether transarterial chemoembolization (TACE) before liver transplantation (LT) improves long-term survival in hepatocellular carcinoma (HCC) patients.

METHODS: A retrospective study was conducted among 204 patients with HCC who received LT from January 2002 to December 2010 in PLA General Hospital. Among them, 88 patients received TACE before LT. Prognostic factors of serum α-fetoprotein (AFP), intraoperative blood loss, intraoperative blood transfusion, disease-free survival time, survival time with tumor, number of tumor nodules, tumor size, tumor number, presence of blood vessels and bile duct invasion, lymph node metastasis, degree of tumor differentiation, and preoperative liver function were determined in accordance with the Child-Turcotte-Pugh (Child) classification and model for end-stage liver disease. We also determined time of TACE before transplant surgery and tumor recurrence and metastasis according to different organs. Cumulative survival rate and disease-free survival rate curves were prepared using the Kaplan-Meier method, and the log-rank and χ² tests were used for comparisons.

RESULTS: In patients with and without TACE before LT, the 1, 3 and 5-year cumulative survival rate was 70.5% ± 4.9% vs 91.4% ± 2.6%, 53.3% ± 6.0% vs 83.1% ± 3.9%, and 46.2% ± 7.0% vs 80.8% ± 4.5%, respectively. The median survival time of patients with and without TACE was 51.857 ± 5.042 mo vs 80.930 ± 3.308 mo (χ² = 22.547, P < 0.001, P < 0.05). The 1, 3 and 5-year disease-free survival rates for patients with and without TACE before LT were 62.3% ± 5.2% vs 98.9% ± 3.0%, 48.7% ± 6.7% vs 82.1% ± 4.1%, and 48.7% ± 6.7% vs 82.1% ± 4.1%, respectively. The median survival time of patients with and without TACE before LT was 50.386 ± 4.901 mo vs 80.281 ± 3.216 mo (χ² = 22.063, P < 0.001, P < 0.05). TACE before LT can easily lead to pulmonary or distant metastasis of the primary tumor. Although there was no significant difference between the two groups, the chance of metastasis of the primary tumor in the group with TACE was significantly higher than that of the group without TACE.

CONCLUSION: TACE pre-LT for HCC patients increased the chances of pulmonary or distant metastasis of the primary tumor, thus reducing the long-term survival rate.

Peritoneal recurrence of initially controlled hepatocellular carcinoma after living donor liver transplantation

It is well known that the presence of end-stage liver disease increases the risk of developing hepatocellular carcinoma (HCC). Liver transplantation (LT) for patients within the Milan criteria has become a standard treatment for HCC in most developed centers worldwide. However, a major cause of death in cirrhotic patients with HCC after transplantation is tumor recurrence, including peritoneal recurrences, which develops rarely but presents a significant problem with regard to their management. Our experience includes two cases with HCC within the Milan criteria of peritoneal recurrences after living donor LT. Both patients had interventions for HCC in their medical history before LT, and we propose that these might have been a possible cause of the HCC peritoneal recurrence.

The effectiveness of ultrasound surveillance for hepatocellular carcinoma in a Canadian centre and determinants of its success

BACKGROUND

The effectiveness of surveillance for hepatocellular carcinoma (HCC) using ultrasound (US) in North America has been questioned due to the predominance of patients of Caucasian ethnicity and larger body habitus.

OBJECTIVE

To determine the effectiveness of US surveillance for HCC in a Canadian hepatobiliary centre and to identify independent variables associated with early detection of tumour(s).

METHODS

A retrospective review of patients with first HCC in a US surveillance population at the authors' hospital yielded 201 patients (over a 10.5-year period). Patients were categorized into three groups: regular surveillance (frequency of surveillance ≤12 months [n=109]); irregular surveillance (frequency of surveillance >12 months [n=38]); or first surveillance (tumour detected on first scan [n=54]). The Milan criteria for transplantation and Barcelona Clinic Liver Cancer (BCLC) staging system were used as outcome measures. Effective surveillance was defined as tumour detection within Milan criteria or curative BCLC stages 0 and A; its association with multiple patient- and disease-related variables was tested.

RESULTS

When using the Milan criteria as outcome, 84 of 109 (77%) regular surveillance patients, 23 of 38 (61%) irregular surveillance patients and 40 of 54 (74%) first surveillance patients had tumours meeting the transplantation criteria. The difference between regular and irregular surveillance was statistically significant (P=0.03). When using the BCLC staging system, 87 of 109 (80%) regular surveillance patients, 26 of 38 (68%) irregular surveillance patients and 41 of 54 (76%) first surveillance patients had their tumours detected in BCLC curative stages (0 and A; P=0.11). Regular surveillance was the only variable significantly associated with detection of tumour(s) within the Milan criteria (OR 2.76 [95% CI 1.10 to 6.88]). Tumours detected more recently were more likely to be <2 cm in size (BCLC stage 0; OR 2.38 [95% CI 1.07 to 5.31]).

CONCLUSION

A high rate of HCC surveillance success was achieved using US alone when performed regularly in a specialized hepatobiliary centre.

Review article: liver transplantation for hepatocellular carcinoma - a critical appraisal of the current worldwide listing criteria

BACKGROUND

Liver transplantation (LT) plays an important role in the management of patients with hepatocellular carcinoma (HCC). Although early results following LT for HCC were poor, since the introduction of the Milan criteria in 1996 morphological criteria have since been well established. Thereafter, various expansions of the Milan criteria were introduced worldwide. Listing criteria for LT for HCC in the United Kingdom (UK) initially conformed to the Milan criteria but were re-defined in 2009 by expansion of the Milan criteria.

AIMS

To look at the evidence in literature on listing criteria and management of HCC worldwide in comparison with the UK. Secondly, we aim to review worldwide vs. UK literature on prioritisation models, loco-regional therapy protocols and role of alpha-fetoprotein (AFP) in LT for HCC.

METHODS

An electronic literature search with Medline was carried out to identify articles related to LT for HCC.

RESULTS

Although various expansions of the Milan criteria have been described, they remain the gold standard against which other criteria are measured. The UK criteria are an expansion of the Milan criteria that go beyond Milan and University of California, San Francisco (UCSF) criteria. The current UK listing criteria for LT for HCC when compared to the worldwide criteria have a worse survival benefit (projected 5-year survival between 35-50%) when plotted on the metroticket calculator.

CONCLUSIONS

In keeping with most transplant centres worldwide, the UK have adopted expansions to Milan to allow more patients to benefit from LT. However, currently, as it stands the UK criteria when plotted in the modification of the Metroticket model project worse survival that would seem unjustified.

Post liver transplant presentation of needle-track metastasis of hepatocellular carcinoma following percutaneous liver biopsy

Hepatocellular carcinoma (HCC) is one of the few malignant tumours often treated without prior histological confirmation (in the patient with cirrhosis). Contrast-enhanced cross-sectional imaging is frequently diagnostic of HCC with a high degree of accuracy. However, on occasion, a liver biopsy is required, a complication of which can be needle-track metastasis. We present the case of a 57-year-old man who had previously undergone a liver transplant; he was found to have abdominal wall metastasis at the site of a prior percutaneous biopsy. This is the second case until now date of needle-track metastasis that presented following liver transplantation.

Total tumor volume is a better marker of tumor burden in hepatocellular carcinoma defined by the Milan criteria

BACKGROUND

The Milan criteria are used to define small hepatocellular carcinoma (HCC) and to select patients for curative treatments. Total tumor volume (TTV) is an alternative parameter for tumor burden. We aimed to evaluate whether TTV is a feasible prognostic marker in HCC patients with upper boundary TTV of 65.5 cm(3), which is equivalent to a single 5 cm tumor nodule defined by the Milan criteria.

METHODS

A total of 774 HCC patients with TTV <65.5 cm(3) receiving surgical resection, liver transplantation, or radiofrequency ablation (RFA) as the primary treatment were retrospectively analyzed.

RESULTS

Of these patients, 50 (6.5 %) did not fulfill the Milan criteria. Patients beyond the Milan criteria more often had larger tumor size and TTV, as well as more tumor nodules (p values all <0.01). There was no significant survival difference between patients within and beyond the Milan criteria (p = 0.205). Patients with TTV >15 cm(3) had a significantly poorer survival than patients with TTV <15 cm(3) (p = 0.007). There was no survival difference between patients receiving surgical treatments versus RFA (p = 0.932). In the Cox proportional hazards model, TTV >15 cm(3) [risk ratio (RR): 1.474, p = 0.005], serum bilirubin ≥ 1.5 mg/dL (RR: 1.663, p = 0.003), serum sodium <135 mmol/L (RR: 2.016, p = 0.01), and α-fetoprotein (AFP) ≥ 100 ng/mL (RR: 1.37, p = 0.033) were independent predictors of poor prognosis.

CONCLUSIONS

Total tumor volume, is an independent and better prognostic marker than the Milan criteria to indicate tumor burden in HCC patients who had tumor volume defined by the Milan criteria and underwent curative therapies.

Living donor liver transplantation for hepatocellular carcinoma

Liver transplantation (LT) may be the best curative treatment that offers a chance of cure for the tumor and the underlying cirrhosis by complete extirpation of both. In Asia, where the supply of cadaveric grafts remains scarce and the incidence of HCC combined with chronic hepatitis B virus (HBV)- and hepatitis C virus (HCV)-related liver disease is high, adult living donor liver transplantation (LDLT) has been settled upon as a practical alternative to deceased-donor liver transplantation (DDLT). Even in Western countries, where adequate access to DDLT is feasible for HCC patients satisfying the Milan criteria, the necessity for LDLT is well established in particular for more advanced HCC patients who are disadvantaged by current allocation algorithms for grafts from deceased donors due to organ shortage, increasing waiting lists, and the expectation that many patients listed for LT will die while awaiting a suitable organ. In the field of LDLT in Asia, numerous technical innovations were achieved to secure donor safety, as well as to ensure patient survival. The experience with LDLT for HCC has been progressively increasing in many Asian countries to date. Although there are questions regarding the higher recurrence of HCC after LDLT than after DDLT, the application of the Milan and UCSF criteria to LDLT in high-volume multicenter cohorts from Japan and Korea has resulted in patient survival outcomes very similar to those following DDLT. Recently, inclusion of biologic tumor markers such as alpha fetoprotein (AFP), protein induced by vitamin K antagonist II (PIVKA II), and positive positron emission tomography (PET) in addition to parameters of tumor morphology might be the key to establishing the best criteria for LDLT for HCC. As pretransplant treatments, most LDLT centers in Asia cannot adopt the strategy of bridging therapy under scarcity of cadaveric organ donation but have to use those multi-modality treatments as a salvage intending for primary curative treatment or a downstaging therapy before LDLT. After LDLT, basically there is no difference in the management strategy for HCC recurrence between DDLD and LDLT.

Treatment of recurrent hepatocellular carcinoma after liver transplantation

AIM

Liver transplantation (LT) is a curative treatment for localized hepatocellular carcinoma (HCC), but the recurrence rate after LT is about 10-20%, with a dismal prognosis. Little data exist as to the natural history, treatment outcome and optimal treatment of recurrent HCC after LT. We reviewed various treatment modalities given to patients with recurrent HCC after LT.

METHODS

Among 132 patients who underwent LT for localized HCC, we retrospectively reviewed medical records of 39 of the 132 patients who developed recurrent HCC after LT. We analyzed the clinical outcome of various treatment modalities and treatment-related adverse events.

RESULTS

A total of 39 (29%) of the original 132 patients had recurrent HCC, most recurrences (82%) having occurred within 1 year after LT and involved extrahepatic lesions. Only seven patients had recurrent disease limited to the liver. The median overall survival from the initial treatment of all relapsed patients was 6.9 months. There were various initial treatment modalities, namely palliative systemic chemotherapy, trans-catheter arterial chemo-embolization/infusion (TACE/I), radiation therapy (RT), surgical resection and no treatment. The median overall survival was 9.5 months for first-line chemotherapy, including those who had prior local therapy, 6.3 months TACE/I and 6.9 months for RT.

CONCLUSION

Various clinical approaches have been used to treat patients with recurrent HCC after LT in a clinical setting. More effective strategies and clinical guidelines for recurrent HCC following LT must be established.

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.

Liver transplantation for hepatocellular carcinoma on cirrhosis: Strategies to avoid tumor recurrence

Hepatocellular carcinoma (HCC) is one of the most frequent neoplasms worldwide and in most cases it is associated with chronic liver disease. Liver transplantation (LT) is potentially the optimal treatment for those patients with HCC who have a poor functional hepatic reserve due to their underlying chronic liver disease. However, due to the limited availability of donors, only those patients whose oncologic profile is favorable can be considered for LT. Despite the careful selection of candidates based on strict rules, 10 to 20% of liver transplant recipients who have HCC in the native cirrhotic liver develop tumor recurrence after transplantation. The selection criteria presently employed to minimize the risk of recurrence are based on gross tumor characteristics defined by imaging techniques; unfortunately, the accuracy of imaging is far from being optimal. Furthermore, microscopic tumor features that are strictly linked with prognosis can not be assessed prior to transplantation. Pre-transplantation tumor downstaging may allow transplantation in patients initially outside the selection criteria and seems to improve the prognosis; it also provides information on tumor biology. The main peculiarity of the transplantation setting, when this is compared with other modalities of treatment, is the need for pharmacological immunosuppression: this is based on drugs that have been demonstrated to increase the risk of tumor development. As HCC is an aggressive malignancy, immunosuppression has to be handled carefully in patients who have HCC at the time of transplantation and new categories of immunosuppressive agents should be considered. Adjuvant chemotherapy following transplantation has failed to show any significant advantage. The aim of the present study is to review the possible strategies to avoid recurrence of HCC after liver transplantation based on the current clinical evidence and the more recent developments and to discuss possible future directions.

Long non-coding RNA MALAT-1 overexpression predicts tumor recurrence of hepatocellular carcinoma after liver transplantation

Metastasis-associated lung adenocarcinoma transcript 1(MALAT1), a long non-coding RNA (lncRNA), is up-regulated in many solid tumors and associated with cancer metastasis and recurrence. However, its role in hepatocellular carcinoma (HCC) remains poorly understood. In the present study, we evaluated the expression of MALAT1 by quantitative real-time PCR in 9 liver cancer cell lines and 112 HCC cases including 60 cases who received liver transplantation (LT) with complete follow-up data. Moreover, small interfering RNA (siRNA) was used to inhibit MALAT1 expression to investigate its biological role in tumor progression. We found that MALAT1 was up-regulated in both cell lines and clinical tissue samples. Patients with high expression level of MALAT1 had a significantly increased risk of tumor recurrence after LT, particularly in patients who exceeded the Milan criteria. On multivariate analysis, MALAT1 was an independent prognostic factor for predicting HCC recurrence (hazard ratio, 3.280, P = 0.003).In addition, inhibition of MALAT1 in HepG2 cells could effectively reduce cell viability, motility, invasiveness, and increase the sensitivity to apoptosis. Our data suggest that lncRNA MALAT1 play an important role in tumor progression and could be a novel biomarker for predicting tumor recurrence after LT and serve as a promising therapeutic target.

Long non-coding RNA MALAT-1 overexpression predicts tumor recurrence of hepatocellular carcinoma after liver transplantation

Metastasis-associated lung adenocarcinoma transcript 1(MALAT1), a long non-coding RNA (lncRNA), is up-regulated in many solid tumors and associated with cancer metastasis and recurrence. However, its role in hepatocellular carcinoma (HCC) remains poorly understood. In the present study, we evaluated the expression of MALAT1 by quantitative real-time PCR in 9 liver cancer cell lines and 112 HCC cases including 60 cases who received liver transplantation (LT) with complete follow-up data. Moreover, small interfering RNA (siRNA) was used to inhibit MALAT1 expression to investigate its biological role in tumor progression. We found that MALAT1 was up-regulated in both cell lines and clinical tissue samples. Patients with high expression level of MALAT1 had a significantly increased risk of tumor recurrence after LT, particularly in patients who exceeded the Milan criteria. On multivariate analysis, MALAT1 was an independent prognostic factor for predicting HCC recurrence (hazard ratio, 3.280, P = 0.003).In addition, inhibition of MALAT1 in HepG2 cells could effectively reduce cell viability, motility, invasiveness, and increase the sensitivity to apoptosis. Our data suggest that lncRNA MALAT1 play an important role in tumor progression and could be a novel biomarker for predicting tumor recurrence after LT and serve as a promising therapeutic target.

[Surgical treatment of liver cancer: experience of the A Coruña UHC (Spain)]

INTRODUCTION

Liver cancer (LC) is one of the most frequent tumours, in which the potentially curative treatment is surgery: partial surgical resection or liver transplant.

OBJECTIVES

To determine the morbidity and mortality, survival, and their associated factors in patients with LC, according to the type of surgical treatment: partial surgical resection or liver transplant.

MATERIAL AND METHODS

A retrospective, observational follow-up study of LC patients diagnosed and treated from June 1994 to December 2007. A descriptive analysis of the variables was performed, as well as a Kaplan- Meier survival analysis and Cox regression.

RESULTS

The incidence of tumour recurrence in the 150 transplant patients was 13.3%, with a survival at 1, 3, and 5 years of 89.3%, 73.1% and 61.4%, respectively. The multivariate analysis showed that only the histological grade/differentiation was an independent risk factor. In the 33 patients with partial surgical resection, the incidence of tumour was 51.5%, with a survival at 1, 3, and 5 years of 90.9%, 60.2%, and 38.6%, respectively. A significantly higher mortality was observed in patients with higher tumour and TNM staging.

CONCLUSIONS

The survival throughout follow-up was higher in liver transplant, and tumour recurrence was more frequent in patients with partial surgical resection. The survival results in transplanted patients are consistent with the Spanish and European Liver Transplant Register and with the United Network for Organ Sharing register.

Prognostic and developmental factors in patients receiving liver transplant due to hepatocellular carcinoma: one center's experience in the north of Spain

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most frequent types of tumor. The aim of this study was to determine the survival of patients who had received liver transplants as a result of the disease.

METHODS

This observational follow-up study included 150 patients who received liver transplantations from June 1994 to December 2007. The study considered epidemiological and staging variables, tumor descriptions, and follow-up variables. We employed Kaplan-Meier methodology together with a Cox multivariate regression analysis.

RESULTS

The incidence of tumor relapse was 13.3%, with survival rates at 1, 3, and 5 years of 89.3%, 73.1%, and 61.4%, respectively. Variables that showed an independent effect to predict mortality were the degree of histological differentiation and of macrovascular invasion. Patients with poorly differentiated HCC had a 4.03 fold (95% confidence interval [CI]: 1.61-10.06) greater possibility of dying. Macrovascular involvement increased the risk of death (relative risk = 2.23), an effect that was at the limit of significance (95% CI 0.99-5.04).

CONCLUSIONS

The survival rate was consistent with the literature. Poor tumor differentiation and macrovascular involvement were independent predictors of mortality.

Current controversies surrounding liver transplantation for hepatocellular carcinoma

Liver transplantation (LT) for hepatocellular carcinoma (HCC) has progressed rapidly over the last decade from a futile therapy to the first choice therapy for suitable patients. Excellent outcomes of LT for HCC can be largely attributed to the use of the Milan Criteria, which have restricted LT to patients with early stage tumors. These criteria may be conservative, and it is likely that a subset of patients with tumors beyond these criteria can have acceptable outcomes. However, there is currently insufficient data to accept more liberal criteria as a standard of care, and a higher quality evidence base must be achieved to prevent poor utilization of valuable donor liver resources. In the future, it is probable that more sophisticated selection criteria will emerge incorporating aspects of tumor biology beyond tumor size and number. Dropout from the waiting list due to tumor progression remains a clinical challenge particularly in regions with prolonged waiting times. Priority allocation using HCC MELD points is a practical and transparent solution that has successfully reduced waitlist dropout for HCC patients. Further refinements of the HCC MELD point system are required to ensure equity of access to LT for non-HCC patients and prioritization of HCC patients with the highest risk of dropout. Improving the evidence base for pre-LT locoregional therapy to prevent waitlist dropout is an urgent and difficult challenge for the LT community. In the interim transplant clinicians must restrict the use of these therapies to those patients who are most likely to benefit from them.

Hepatocellular carcinoma: CT for tumor response after transarterial chemoembolization in patients exceeding Milan criteria--selection parameter for liver transplantation

PURPOSE

To retrospectively evaluate the clinical outcome of patients with hepatocellular carcinoma (HCC) who exceeded the Milan criteria, who underwent transarterial chemoembolization (TACE) before orthotopic liver transplantation (OLT), to determine the value of computed tomography (CT)-based tumor response to TACE as a preoperative selection criterion for OLT.

MATERIALS AND METHODS

The study included 33 patients with HCC who exceeded the Milan criteria and underwent OLT after TACE. Informed written consent was obtained before TACE and OLT. Institutional review board approval was not required. Tumor response to TACE was evaluated at 1 month with CT according to amended Response Evaluation Criteria in Solid Tumours (RECIST) guidelines. In the explanted liver, degree of tumor necrosis (> or = 90%, 50%-89%, or < 50%), residual tumor stage and grade, and presence of microvascular invasion were assessed. Follow-up after OLT ranged from 1 to 143 months.

RESULTS

After TACE, CT showed complete tumor response (CR) in 18 (55%) patients. On the explanted liver, tumor necrosis was rated 90% or greater in 20 (61%) patients, with a good correlation with CT. Microvascular invasion was observed in nine (27%) of 33 patients; none of them were reported to have a CR at CT. The 5-year cumulative survival rate after OLT was 72.5%; it was significantly (P = .003) higher in patients with a CR (94.4%) compared with patients with a partial response (PR) (45.4%) and stable disease (50%). The 5-year cumulative recurrence-free rate after OLT was 74.4%; it was not affected by the tumor nodule size and number, whereas it was significantly (P = .008) higher in patients with a CR (94.4%) compared with patients with a PR (46.7%) and stable disease (50%).

CONCLUSION

In patients with HCC who exceeded the Milan criteria, a CR after TACE, on the basis of amended RECIST guidelines, is associated with excellent posttransplantation outcomes. Therefore, 1-month response to TACE assessed at CT may represent a valid selection criterion for OLT.

Beyond Milan criteria--chances and risks of expanding transplantation criteria for HCC patients with liver cirrhosis

Orthotopic liver transplantation (OLT) is, apart from resection, one important curative treatment for hepatocellular carcinoma (HCC) in liver cirrhosis, and especially attractive because it eliminates both the tumor and the underlying liver disease. The application of restrictive inclusion criteria for OLT in HCC patients resulted in favorable long-term recurrence-free survival. These criteria, however, exclude a subgroup of patients which, despite advanced tumor size, demonstrate an acceptable outcome. As a consequence, expansion of the strict Milan criteria has been discussed. However, this will also deteriorate the average outcome of OLT in HCC patients. Considering that we run short of donor organs, more sophisticated prediction models for survival after OLT for HCC patients are needed to identify patients who benefit best from OLT. Neoadjuvant treatment that is frequently applied as a bridging technique for patients on the waiting list for OLT could provide useful information on tumor behavior to better predict the risk of post-OLT tumor recurrence. This might also allow expansion of the Milan criteria to patients with good response to downstaging methods without negatively affecting post-OLT survival. Furthermore, alternative scoring systems have been suggested to identify HCC patients that might still benefit from resection instead of OLT, and molecular tools are being explored to provide predictive information on HCC biology. This review discusses the advantages and risks of extended inclusion criteria for OLT and the currently available data on alternative prediction models and bridging methods in HCC patients.

Postoperative surveillance with monthly serum tumor markers after living-donor liver transplantation for hepatocellular carcinoma

AIM

Recurrence of hepatocellular carcinoma (HCC) after liver transplantation decreases patient survival. The usefulness of post-transplant surveillance with tumor markers, however, is not clear. We evaluated our cumulative experience with recurrent HCC detected during post-transplant surveillance.

METHODS

We analyzed 100 patients with HCC detected in the explanted liver. Monthly to bimonthly measurement of tumor markers and yearly computed tomography were scheduled postoperatively.

RESULTS

Preoperatively, 82 met the Milan criteria. The histological findings indicated that 61 fulfilled the Milan criteria. In nine patients, HCC recurred 10 months (2-29) after liver transplantation in the graft (n = 1), lung (n = 2), bone (n = 3) and multiple organs (n = 3). In all nine recipients, HCC was first suspected based on an increase in tumor marker levels. Recurrent HCC was confirmed by computed tomography (n = 7) or magnetic resonance imaging (n = 2) within 4 months (0-6) after first identifying an increase in the tumor marker levels. Six cases were treated surgically, two of which achieved prolonged survival of 16 and 38 months.

CONCLUSION

Frequent measurement of alpha-fetoprotein and des-gamma carboxy prothrombin was useful for detecting recurrent HCC and may be useful long-term follow-up markers for post-transplant surveillance.

Effect of different immunosuppressive schedules on recurrence-free survival after liver transplantation for hepatocellular carcinoma

BACKGROUND

Tumor recurrence represents the main limitation of liver transplantation in patients with hepatocellular carcinoma (HCC) and can be favored by exposure to calcineurin inhibitors.

METHODS

We investigated the effect of an immunosuppressant schedule that minimizes the exposure to calcineurin inhibitors on patients transplanted for HCC to ascertain whether this can reduce the tumor recurrence rate. For this purpose, we conducted a matched-cohort study: 31 patients with HCC transplanted between 2004 and 2007 who received sirolimus as part of their immunosuppression (group A) were compared with a control group of 31 patients (group B) transplanted in the same period who had the same prognostic factors but were given standard immunosuppression based on tacrolimus.

RESULTS

Three-year recurrence-free survival was 86% in group A and 56% in group B (P=0.04). Although the prevalence of microvascular invasion G3-G4 grading and alpha-fetoprotein more than 200 ng/mL was identical in the two groups, exposure to tacrolimus was significantly higher in patients of group B (median, 8.54; range, 5.5-13.5) in comparison with those of group A (median, 4.6; range, 1.8-9.1) (P=0.0001).

CONCLUSIONS

By using sirolimus, exposure to calcineurin inhibitors can be minimized, reducing the risk of HCC recurrence.

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.

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.

Transarterial injection of (131)I-lipiodol, compared with chemoembolization, in the treatment of unresectable hepatocellular cancer

Transarterial chemoembolization (TACE) improves survival in patients with hepatocellular carcinoma (HCC) in whom curative therapies are not suitable. The aim of this study was to assess survival differences in patients with hepatic cirrhosis and unresectable HCC treated by (131)I-lipiodol versus TACE or transarterial embolization (TAE).

METHODS

A retrospective study was performed on a cohort of 124 patients undergoing treatment for unresectable HCC between 1997 and 2006. A total of 50 patients (44 men; mean age, 59 y) received (131)I-lipiodol (mean sessions per patient, 1.7), and 74 patients (63 men; mean age, 61 y) received TACE/TAE (mean sessions per patient, 1.8). Although no significant difference between the 2 treatment groups with respect to HCC size and clinical staging was observed, a higher proportion of patients with portal vein thrombosis (PVT) was treated with (131)I-lipiodol than with TACE/TAE (28% vs. 8%, P = 0.003).

RESULTS

Actuarial survival was not significantly different between patients treated with (131)I-lipiodol and patients treated with TACE/TAE. Survival at 6 mo, 1 y, 2 y, and 3 y was 86%, 69%, 54%, and 45%, respectively, after (131)I-lipiodol, compared with 77%, 62%, 47%, and 43%, respectively, after TACE/TAE. However, patients with PVT survived a mean of 454 d after (131)I-lipiodol, compared with a mean of 171 d after TACE/TAE (P = 0.025). In addition, patients with more advanced disease (Barcelona Clinic Liver Cancer stage D) lived on average 363 d after (131)I-lipiodol, compared with 36 d after TACE/TAE (P = 0.014).

CONCLUSION

In patients with unresectable HCC, there was no difference in survival between (131)I-lipiodol therapy and TACE/TAE treatment. However, in the patients with advanced clinical staging or PVT, there was a significant survival advantage for those treated with (131)I-lipiodol.

The estimated number of patients with hepatocellular carcinoma selected for liver transplantation using expanded selection criteria

Recently, several groups have introduced expanded criteria for selection of patients with hepatocellular carcinoma (HCC) prior to transplant, but the exact number of potential newly recruited patients remains unclear. This registry-based study assessed 270 patients diagnosed with HCC. The potential number of transplant candidates was based on age (< or =65 years), absence of metastases and macro-vascular invasion, and on 12 previously published, expanded selection criteria. A wide range of increase in the number of transplant candidates was observed (12-63% when compared with the number of such candidates who would have been selected solely based on the Milan criteria). The most conservative criteria were Seoul (Kwon, 2007; increase of 12%), Valencia (Silva, 2008; 16%), total tumor volume/alpha-fetoprotein (Toso, 2009; 20%) and UCSF (Yao, 2007; 20%). This data will assist Centers and policy agencies in predicting the need for resources linked to an expansion of criteria.

Reassessing selection criteria prior to liver transplantation for hepatocellular carcinoma utilizing the Scientific Registry of Transplant Recipients database

The current model of liver graft allocation in place in the United States favors transplantation of patients with small hepatocellular carcinomas (HCCs) within the Milan criteria (a single tumor up to 5 cm in diameter or up to three lesions, none larger than 3 cm). Although several reports have suggested that these criteria could be extended, there is currently no agreement on new selection tools. In this study, we performed an overview of 6478 adult recipients of an isolated first liver transplant registered in the Scientific Registry of Transplant Recipients (SRTR) database. From March 2002 to January 2008, increasing numbers of patients outside Milan criteria (P <or= 0.001) have been registered for a transplant, but they still represent less than 5% of the transplants performed for HCC. Of all the tested variables (tumor number, largest tumor size, and Milan and University of California San Francisco criteria), only total tumor volume (TTV; P <or= 0.05) and alpha fetoprotein (AFP; P <or= 0.001) could predict patient survival. While these two parameters demonstrated independent behaviors (no patient demonstrated an increase in both values), a composite score was defined, with patients with a TTV > 115 cm(3) or an AFP > 400 ng/mL being outside criteria. The combined TTV/AFP score efficiently predicted posttransplant survival (hazard ratio = 2, 95% confidence interval = 1.7-2.4, P <or= 0.001); patients not meeting these criteria had a survival below 50% at 3 years.

CONCLUSION

According to the present SRTR data, Milan criteria are too restrictive, and patients with larger TTV can enjoy satisfactory posttransplant survivals. A composite patient selection score combining TTV and AFP was the most effective of all tested staging criteria for the prediction of posttransplant patient survival for candidates with HCC.

TACE versus TAE as therapy for hepatocellular carcinoma

Transarterial chemoembolization (TACE) improves survival in cirrhotic patients with hepatocellular carcinoma (HCC). The optimal schedule, best anticancer agent and best technique are still unclear. TACE may not be better than transarterial embolization (TAE). HCC is very chemoresistant, thus embolization may be more important than chemotherapy. Lipiodol cannot be considered as an embolic agent and there are no data to show that it can release chemotherapeutic agents slowly. It can mask residual vascularity on CT imaging and its use is not recommended. Both TACE and TAE result in hypoxia, which stimulates angiogenesis, promoting tumor growth; thus combination of TACE with antiangiogenic agents may improve current results. To date, there is no evidence that TACE pre-liver transplantation or resection helps to expand current selection criteria for patients with HCC, nor results in less recurrence after surgery. Combination with other techniques, such as radiofrequency ablation and drugs, may enhance the effect of TACE. New trials are being conducted to clarify these issues.

Capn4 overexpression underlies tumor invasion and metastasis after liver transplantation for hepatocellular carcinoma

Liver transplantation (LT) is one of the best therapeutic options for nonresectable hepatocellular carcinoma (HCC). Unfortunately, some HCC patients succumb to the disease after LT, which reduces long- and medium-term survival. To identify the proteins associated with HCC invasion and metastasis, HCC patients undergoing LT with complete follow-up data were included in this study and were categorized into recurrence and nonrecurrence groups. We extracted the total protein from the acquired homogeneous tumor cells and applied a cleavable isotope-coded affinity tag technology to quantitate relative changes in protein levels between the two groups. We identified a total of 149 proteins with two-dimensional liquid chromatography coupled with tandem mass spectrometry, including 52 differentially expressed proteins by at least two-fold. Among them, calpain small subunit 1 (Capn4), a protein with relevant interactions with many migration-invasion-related proteins, has attracted more attention. First, Capn4 overexpression in the recurrence group was confirmed via real-time polymerase chain reaction and western blotting in another cohort of 40 HCC patients undergoing LT. Second, Capn4 was associated with enhanced invasiveness in vitro. The small interfering RNA-mediated knockdown expression of Capn4 in HCC cell lines significantly inhibited its mobile and invasive ability. Tissue microarray in a further 192 cases revealed that Capn4 significantly correlated with invasive phenotype of HCC, and univariate and multivariate analyses indicated that Capn4 is an independent prognostic factor for recurrence and survival of HCC patients.

CONCLUSION

Our study revealed that Capn4 overexpression underlies invasion and metastasis after LT for HCC and might be a candidate biomarker for future diagnosis and a target for therapy.

Multicentric occurrence and spread of hepatocellular carcinoma in whole explanted end-stage liver

AIM

Hepatocellular carcinoma (HCC) arising from the end stages of liver cirrhosis is a fair indication for liver transplantation (LT). To pathologically investigate the multicentric occurrence of relatively early staged HCC in cirrhosis, we studied whole explanted livers.

METHODS

Fourteen explanted livers from patients undergoing living donor LT (LDLT) were examined. The stage of the HCCs was judged to be within the Milan criteria (M-C; a single HCC less than 5 cm or three HCCs less than 3 cm). Histological examination was performed using serially sectioned specimens 5-7 mm in width. Characterization of preoperatively detectable and undetectable lesions was also performed.

RESULTS

In nine patients (64.3%), a total of 34 nodules were found after whole liver histological examination (WLHE). In five patients (31%), the results exceeded the M-C. The characteristics of undetectable HCCs included a minute (median size 6 mm), well-differentiated appearance (80%), with indistinct margins (85.3%) and without vascular invasion (94%). There was no recurrence in any patients at the time of follow up (median follow-up period, 30.1 months).

CONCLUSION

A multicentric occurrence of HCCs was demonstrated in cirrhotic livers with HCCs within the M-C. Undetectable HCCs in cirrhotic livers may have no impact on recurrence after LT.

Predicting survival after liver transplantation in patients with hepatocellular carcinoma beyond the Milan criteria: a retrospective, exploratory analysis

BACKGROUND

Patients undergoing liver transplantation for hepatocellular carcinoma within the Milan criteria (single tumour </=5 cm in size or </=3 tumours each </=3 cm in size, and no macrovascular invasion) have an excellent outcome. However, survival for patients with cancers that exceed these criteria remains unpredictable and access to transplantation is a balance of maximising patients' chances of cure and organ availability. The aim of this study was to explore the survival of patients with tumours that exceed the Milan criteria, to assess whether the criteria could be less restrictive, enabling more patients to qualify as transplant candidates, and to derive a prognostic model based on objective tumour characteristics, to see whether the Milan criteria could be expanded.

METHODS

Data on patients who underwent transplantation for hepatocellular carcinoma despite exceeding Milan criteria at different centres were recorded via a web-based survey completed by specialists from each centre. The survival of these patients was correlated retrospectively with the size of the largest tumour nodule, number of nodules, and presence or absence of microvascular invasion detected at pathology. Contoured multivariable regression Cox models produced survival estimates by means of different combinations of the covariates. The primary aim of this study was to derive a prognostic model of overall survival based on tumour characteristics, according to the main parameters used in the Tumour Node Metastasis classification. The secondary aim was the identification of a subgroup of patients with hepatocellular carcinoma exceeding the Milan criteria, who achieved a 5-year overall survival of at least 70%-ie, similar to the outcome expected for patients who meet the Milan criteria.

FINDINGS

Over a 10-month period, between June 25, 2006, and April 3, 2007, data for 1556 patients who underwent transplantation for hepatocellular carcinoma were entered on the database by 36 centres. 1112 patients had hepatocellular carcinoma exceeding Milan criteria and 444 patients had hepatocellular carcinoma shown not to exceed Milan criteria at post-transplant pathology review. In the group of patients with hepatocellular carcinomas exceeding the criteria, the median size of the largest nodule was 40 mm (range 4-200) and the median number of nodules was four (1-20). 454 of 1112 patients (41%) had microvascular invasion and, for those transplanted outside the Milan criteria, 5-year overall survival was 53.6% (95% CI 50.1-57.0), compared with 73.3% (68.2-77.7) for those that met the criteria. Hazard ratios (HR) associated with increasing values of size and number were 1.34 (1.25-1.44) and 1.51 (1.21-1.88), respectively. The effect was linear for size, whereas for number of tumours, the effect tended to plateau above three tumours. The effect of tumour size and number on survival was mediated by recurrence (b=0.08, SE=0.12, p=0.476). The presence of microvascular invasion doubled HRs in all scenarios. The 283 patients without microvascular invasion, but who fell within the Up-to-seven criteria (hepatocellular carcinomas with seven as the sum of the size of the largest tumour [in cm] and the number of tumours) achieved a 5-year overall survival of 71.2% (64.3-77.0).

INTERPRETATION

More patients with hepatocellular carcinoma could be candidates for transplantation if the current dual (yes/no) approach to candidacy, based on the strict Milan criteria, were replaced with a more precise estimation of survival contouring individual tumour characteristics and use of the up-to-seven criteria.

Liver transplantation for hepatocellular carcinoma under calcineurin inhibitors: reassessment of risk factors for tumor recurrence

OBJECTIVE

We assessed the effect of tacrolimus on recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) and compared it with that of the other calcineurin inhibitor, cyclosporine.

INTRODUCTION

HCC recurrence after LT can be favored by overexposure to cyclosporine. Tacrolimus is now the most widely used main immunosuppressant after LT; its possible effect on HCC recurrence has never been investigated.

MATERIALS AND METHODS

One hundred and thirty nine HCC patients who had LT were reviewed; 60 of them were administered tacrolimus, and 79, cyclosporine. The exposure to the drugs was calculated with the trapezoidal rule in each patient, using blood levels measured after transplantation and compared with HCC recurrence together with several clinical and pathologic risk factors.

RESULTS

HCC recurred in 12 of the 60 (20%) patients under tacrolimus in comparison with that in 9 of the 79 (11.4%) patients under cyclosporine; however, the proportion of poorly differentiated and more advanced tumors was significantly higher in the tacrolimus group than in the cyclosporine group. Exposure to tacrolimus was 11.6 +/- 1.5 ng/mL in patients with recurrence and 8.6 +/- 1.7 ng/mL in those without recurrence (P < 0.001). The optimal cut-off values of exposure identified with receiver operating characteristics analysis to categorize the risk of recurrence were 10 ng/mL for tacrolimus (area under the curve (AUC) = 0.913) and 220 ng/mL for cyclosporine (AUC = 0.752). In the tacrolimus group, high drug exposure independently predicted recurrence (P = 0.005). Multivariate analysis, including all patients (tacrolimus + cyclosporine) characterized higher exposure to immunosuppression (P = 0.01), alpha-fetoprotein levels (P = 0.001), tumor grading (P = 0.009), and microvascular invasion (P = 0.04) as independent predictors of HCC recurrence.

CONCLUSIONS

Just as it is with cyclosporine, overexposure to tacrolimus increases the risk of HCC recurrence after LT. Careful management of calcineurin inhibitors is recommended in HCC patients.

Incidence and risk factors for hepatocellular carcinoma after solid organ transplantation

BACKGROUND

Solid organ transplant recipients commonly are infected with hepatitis viruses, are immunosuppressed, and have other potential hepatocellular carcinoma (HCC) risk factors.

METHODS

We studied de novo HCC incidence arising after transplant using U.S. registry data (223,660 recipients, 1987-2005). We used proportional hazards regression to identify HCC risk factors and calculated standardized incidence ratios (SIRs) to compare HCC risk with that in the general population.

RESULTS

Based on 74 cases reported by transplant centers to the registry, HCC incidence was 6.5 per 100,000 person-years among kidney, heart, and lung (non-liver) recipients and 25 per 100,000 person-years among liver recipients. Hepatocellular carcinoma incidence among non-liver recipients was independently associated with hepatitis B surface antigenemia (hazard ratio [HR] 9.7, 95% confidence interval [CI] 2.8-33), hepatitis C virus (HCV) infection (HR 6.9, 95% CI 2.5-19), and diabetes mellitus (HR 2.8, 95% CI 1.2-6.6). Among liver recipients, HCC incidence was associated with advancing age (P<0.001), male sex (HR 4.6, 95% CI 1.4-16), HCV infection (HR 3.1, 95% CI 1.3-7.2), and diabetes mellitus (HR 2.7, 95% CI 1.2-6.2). Among non-liver recipients, overall HCC incidence was similar to the general population (SIR 0.8) but elevated among those with HCV (3.4) or hepatitis B surface antigenemia (6.5). Hepatocellular carcinoma incidence among liver transplant recipients was elevated overall (SIR 3.4) and especially among those with HCV (5.0) or diabetes mellitus (6.2).

CONCLUSIONS

Hepatocellular carcinoma incidence is elevated among liver transplant recipients and subsets of non-liver recipients. These risk factors indicate the need for improved control of viral hepatitis after solid organ transplantation.

Tumour size and differentiation in predicting recurrence of hepatocellular carcinoma after liver transplantation: external validation of a new prognostic score

BACKGROUND

A new prognostic score including tumour differentiation--establishing two groups of patients: group A with >3 points and group B with >4 points--improved the accuracy of the Milan criteria in predicting recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) in a large multicentre study (Decaens 2007).

AIM

The aim of this study was to validate the new score in our HCC cohort.

METHODS

The study involved 100 consecutive patients with mean age 55 years (range 31-68 years) (M/F: 88/22) transplanted for known HCC: 60 unifocal and 40 multifocal (2-3 nodules in 32 and >or=4 nodules in 8) at pre-LT imaging. Survival differences were analysed by log-rank test. Patient/tumour variables before LT and tumour differentiation at explant were assessed by univariate/multivariate analysis.

RESULTS

Median follow-up was 29 months (range 1-145 months). HCC recurrence was recorded in 18 patients. Five-year recurrence-free survival rate was 67 +/- 7%. Patient survival at 3 months was 84 +/- 4% and at 5 years was 45 +/- 6%. Both recurrence-free survival and patient survival were not significantly different between groups A and B. Diameter of largest nodule was the sole pre-LT variable independently associated with recurrence [odd ratio (OR) 1.07; 95% confidence interval (CI) 1.01-1.12; P = 0.012]. Recurrence-free survival was significantly better in patients with diameter <30 mm compared with those with larger nodules (P = 0.0229). Number of nodules and tumour differentiation did not influence recurrence. There were three HCC recurrences with largest nodule size <30 mm, seven recurrences between 30-40 mm, and eight recurrences >40 mm.

CONCLUSION

Tumour differentiation did not add significantly to prediction of HCC recurrence in our cohort. Conversely, diameter of the largest nodule remained a significant risk for recurrence.