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Suddle A, Reeves H, Hubner R, Marshall A, Rowe I, Tiniakos D, Hubscher S, Callaway M, Sharma D, See TC, Hawkins M, Ford-Dunn S, Selemani S, Meyer T. British Society of Gastroenterology guidelines for the management of hepatocellular carcinoma in adults. Gut 2024; 73:1235-1268. [PMID: 38627031 PMCID: PMC11287576 DOI: 10.1136/gutjnl-2023-331695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/19/2024] [Indexed: 05/01/2024]
Abstract
Deaths from the majority of cancers are falling globally, but the incidence and mortality from hepatocellular carcinoma (HCC) is increasing in the United Kingdom and in other Western countries. HCC is a highly fatal cancer, often diagnosed late, with an incidence to mortality ratio that approaches 1. Despite there being a number of treatment options, including those associated with good medium to long-term survival, 5-year survival from HCC in the UK remains below 20%. Sex, ethnicity and deprivation are important demographics for the incidence of, and/or survival from, HCC. These clinical practice guidelines will provide evidence-based advice for the assessment and management of patients with HCC. The clinical and scientific data underpinning the recommendations we make are summarised in detail. Much of the content will have broad relevance, but the treatment algorithms are based on therapies that are available in the UK and have regulatory approval for use in the National Health Service.
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Affiliation(s)
- Abid Suddle
- King's College Hospital NHS Foundation Trust, London, UK
| | - Helen Reeves
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Richard Hubner
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | | | - Ian Rowe
- University of Leeds, Leeds, UK
- St James's University Hospital, Leeds, UK
| | - Dina Tiniakos
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Stefan Hubscher
- Department of Pathology, University of Birmingham, Birmingham, UK
| | - Mark Callaway
- Division of Diagnostics and Therapies, University Hospitals Bristol NHS Trust, Bristol, UK
| | | | - Teik Choon See
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maria Hawkins
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | | | - Sarah Selemani
- King's College Hospital NHS Foundation Trust, London, UK
| | - Tim Meyer
- Department of Oncology, University College, London, UK
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2
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Kakish H, Suraju MO, Seth A, DiGioia ON, Pawar O, Kwon YK, Hemming AW, Aziz H. Liver transplant versus liver resection in patients with multifocal hepatocellular carcinoma. J Gastrointest Surg 2024; 28:1062-1066. [PMID: 38653337 DOI: 10.1016/j.gassur.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/13/2024] [Accepted: 04/19/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND The optimal surgical option in patients with multifocal hepatocellular carcinoma (MHCC) is an area of active research. The preference varies based on geographic variations and institutional policies. We sought to determine long-term outcomes in patients with MHCC based on surgical treatment-liver transplant (LT) vs resection (LR). METHODS We performed a retrospective analysis of the National Cancer Database (2004-2015) and identified patients with MHCC within Milan criteria. Patients with α-fetoprotein ≥ 1000 ng/mL and those who underwent ablation were excluded. The primary outcome measure was long-term survival in patients undergoing LT vs LR. The secondary aim of our study was to determine clinicodemographic factors associated with the receipt of LT and LR. RESULTS A total of 1546 patients were included, of whom 1211 received LT and 335 underwent LR. Patients who were non-Hispanic White (70.8% vs 54.9%; P < .01), privately insured (53.7% vs 36.7%; P < .01), and treated at academic centers (85.4% vs 71.6%; P < .01) were more likely to receive an LT. Multivariable Cox analysis revealed LT was associated with improved survival compared with LR (hazard ratio, 0.34; 95% CI, 0.28-0.42). CONCLUSION We described clinical and sociodemographic differences in LT and LR patients and found LT to be associated with a decreased mortality risk compared with LR. The study's findings should be interpreted in the context of several limitations, including the selection of MHCC criteria within Milan criteria.
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Affiliation(s)
- Hanna Kakish
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Mohammed O Suraju
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Abhinav Seth
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Olivia N DiGioia
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Omkar Pawar
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Yong K Kwon
- Department of Surgery, University of Washington, Seattle, Washington, United States
| | - Alan W Hemming
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Hassan Aziz
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States.
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Martinino A, Bucaro A, Cardella F, Wazir I, Frongillo F, Ardito F, Giovinazzo F. Liver transplantation vs liver resection in HCC: promoting extensive collaborative research through a survival meta-analysis of meta-analyses. Front Oncol 2024; 14:1366607. [PMID: 38567152 PMCID: PMC10986178 DOI: 10.3389/fonc.2024.1366607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
Background HCC is a major global health concern, necessitating effective treatment strategies. This study conducts a meta-analysis of meta-analyses comparing liver resection (LR) and liver transplantation (LT) for HCC. Methods The systematic review included meta-analyses comparing liver resection vs. liver transplantation in HCC, following PRISMA guidelines. Primary outcomes included 5-year overall survival (OS) and disease-free survival (DFS). AMSTAR-2 assessed study quality. Citation matrix and hierarchical clustering validated the consistency of the included studies. Results A search identified 10 meta-analyses for inclusion. The median Pearson correlation coefficient for citations was 0.59 (IQR 0.41-0.65). LT showed better 5-year survival and disease-free survival in all HCC (OR): 0.79; 95% CI: 0.67-0.93, I^2:57% and OR: 0.44; 95% CI: 0.25-0.75, I^2:96%). Five-year survival in early HCC and ITT was 0.63 (95% CI: 0.50-0.78, I^2:0%) and 0.60 (95% CI: 0.39-0.92, I^2:0%). Salvage LT vs. Primary LT did not differ between 5-year survival and disease-free survival (OR: 0.62; 95% CI: 0.33-1.15, I^2:0% and 0.93; 95% CI: 0.82-1.04, I^2:0%). Conclusion Overall, the study underscores the superior survival outcomes associated with LT over LR in HCC treatment, supported by comprehensive meta-analysis and clustering analysis. There was no difference in survival or recurrence rate between salvage LT and primary LT. Therefore, considering the organ shortage, HCC can be resected and transplanted in case of recurrence.
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Affiliation(s)
| | - Angela Bucaro
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesca Cardella
- Surgical Oncology of Gastrointestinal Tract Unit, Vanvitelli University, Naples, Italy
| | - Ishaan Wazir
- Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Francesco Frongillo
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Ardito
- Hepatobilairy and General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Giovinazzo
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Drefs M, Schoenberg MB, Börner N, Koliogiannis D, Koch DT, Schirren MJ, Andrassy J, Bazhin AV, Werner J, Guba MO. Changes of long-term survival of resection and liver transplantation in hepatocellular carcinoma throughout the years: A meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107952. [PMID: 38237275 DOI: 10.1016/j.ejso.2024.107952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/21/2023] [Accepted: 01/03/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Hepatocellular Carcinoma (HCC) still is one of the most detrimental malignant diseases in the world. As two curative surgical therapies exist, the discussion whether to opt for liver resection (LR) or transplantation (LT) is ongoing, especially as novel techniques to improve outcome have emerged for both. The aim of the study was to investigate how the utilization and outcome of the respective modalities changed through time. METHODS We searched Medline and PubMed for relevant publications comparing LT and LR in HCC patients during the time period from 1990 to 2022, prior to March 31, 2023. A total of 63 studies involving 19,804 patients - of whom 8178 patients received a liver graft and 11,626 underwent partial hepatectomy - were included in this meta-analysis. RESULTS LT is associated with significantly better 5-year overall survival (OS) (64.83%) and recurrence-free survival (RFS) (70.20%) than LR (OS: 50.83%, OR: 1.79, p < 0.001; RFS: 34.46%, OR: 5.32, p < 0.001). However, these differences are not as evident in short-term intervals. Older cohorts showed comparable disparities between the outcome of the respective modalities, as did newer cohorts after 2005. This might be due to the similar improvement in survival rates that were observed for both, LT (15-23%) and LR (12-20%) during the last 30 years. CONCLUSION LT still outperforms LR in the therapy of HCC in terms of long-term survival rates. Yet, LR outcome has remarkably improved which is of major importance in reference to the well-known limitations that occur in LT.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany.
| | - Markus B Schoenberg
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Faculty of Medicine, LMU Munich, Germany; Medical Centers Gollierplatz and Nymphenburg, Munich, Germany
| | - Nikolaus Börner
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Dionysios Koliogiannis
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Dominik T Koch
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Malte J Schirren
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Faculty of Medicine, LMU Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Markus O Guba
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Transplantation Center Munich, LMU University Hospital, LMU Munich, Germany
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Eguia E, Baker T, Baker M. Hepatocellular Carcinoma: Surgical Management and Evolving Therapies. Cancer Treat Res 2024; 192:185-206. [PMID: 39212922 DOI: 10.1007/978-3-031-61238-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer in men and the eighth most common cancer in women worldwide. It is also the second leading cause of cancer death worldwide, with 780,000 deaths in 2018. Seventy-two percent of HCC cases occur in Asia, 10% in Europe, 8% in Africa, 5% in North America, and 5% in Latin America (Singal et al. in J Hepatol 72(2):250-261, 2020 [1]).
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Affiliation(s)
- Emanuel Eguia
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Talia Baker
- Huntsman Cancer Center, University of Utah Eccles School of Medicine, Salt Lake City, UT, USA
| | - Marshall Baker
- Huntsman Cancer Center, University of Utah Eccles School of Medicine, Salt Lake City, UT, USA.
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Gu J, Liang BY, Zhang EL, Zhang ZY, Chen XP, Huang ZY. Scientific Hepatectomy for Hepatocellular Carcinoma. Curr Med Sci 2023; 43:897-907. [PMID: 37347369 DOI: 10.1007/s11596-023-2761-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/31/2023] [Indexed: 06/23/2023]
Abstract
With advances in imaging technology and surgical instruments, hepatectomy can be perfectly performed with technical precision for hepatocellular carcinoma (HCC). However, the 5-year tumor recurrence rates remain greater than 70%. Thus, the strategy for hepatectomy needs to be reappraised based on insights of scientific advances. Scientific evidence has suggested that the main causes of recurrence after hepatectomy for HCC are mainly related to underlying cirrhosis and the vascular spread of tumor cells that basically cannot be eradicated by hepatectomy. Liver transplantation and systemic therapy could be the solution to prevent postoperative recurrence in this regard. Therefore, determining the severity of liver cirrhosis for choosing the appropriate surgical modality, such as liver transplantation or hepatectomy, for HCC and integrating newly emerging immune-related adjuvant and/or neoadjuvant therapy into the strategy of hepatectomy for HCC have become new aspects of exploration to optimize the strategy of hepatectomy. In this new area, hepatectomy for HCC has evolved from a pure technical concept emphasizing anatomic resection into a scientific concept embracing technical considerations and scientific advances in underlying liver cirrhosis, vascular invasion, and systemic therapy. By introducing the concept of scientific hepatectomy, the indications, timing, and surgical techniques of hepatectomy will be further scientifically optimized for individual patients, and recurrence rates will be decreased and long-term survival will be further prolonged.
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Affiliation(s)
- Jin Gu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Bin-Yong Liang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Er-Lei Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zun-Yi Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhi-Yong Huang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Yang P, Teng F, Bai S, Xia Y, Xie Z, Cheng Z, Li J, Lei Z, Wang K, Zhang B, Yang T, Wan X, Yin H, Shen H, Pawlik TM, Lau WY, Fu Z, Shen F. Liver resection versus liver transplantation for hepatocellular carcinoma within the Milan criteria based on estimated microvascular invasion risks. Gastroenterol Rep (Oxf) 2023; 11:goad035. [PMID: 37384119 PMCID: PMC10293589 DOI: 10.1093/gastro/goad035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 05/03/2023] [Accepted: 05/25/2023] [Indexed: 06/30/2023] Open
Abstract
Background Preoperative prediction of microvascular invasion (MVI) in hepatocellular carcinoma (HCC) may optimize individualized treatment decision-making. This study aimed to investigate the prognostic differences between HCC patients undergoing liver resection (LR) and liver transplantation (LT) based on predicted MVI risks. Methods We analysed 905 patients who underwent LR, including 524 who underwent anatomical resection (AR) and 117 who underwent LT for HCC within the Milan criteria using propensity score matching. A nomogram model was used to predict preoperative MVI risk. Results The concordance indices of the nomogram for predicting MVI were 0.809 and 0.838 in patients undergoing LR and LT, respectively. Based on an optimal cut-off value of 200 points, the nomogram defined patients as high- or low-risk MVI groups. LT resulted in a lower 5-year recurrence rate and higher 5-year overall survival (OS) rate than LR among the high-risk patients (23.6% vs 73.2%, P < 0.001; 87.8% vs 48.1%, P < 0.001) and low-risk patients (19.0% vs 45.7%, P < 0.001; 86.5% vs 70.0%, P = 0.002). The hazard ratios (HRs) of LT vs LR for recurrence and OS were 0.18 (95% confidence interval [CI], 0.09-0.37) and 0.12 (95% CI, 0.04-0.37) among the high-risk patients and 0.37 (95% CI, 0.21-0.66) and 0.36 (95% CI, 0.17-0.78) among the low-risk patients. LT also provided a lower 5-year recurrence rate and higher 5-year OS rate than AR among the high-risk patients (24.8% vs 63.5%, P = 0.001; 86.7% vs 65.7%, P = 0.004), with HRs of LT vs AR for recurrence and OS being 0.24 (95% CI, 0.11-0.53) and 0.17 (95% CI, 0.06-0.52), respectively. The 5-year recurrence and OS rates between patients undergoing LT and AR were not significantly different in the low-risk patients (19.4% vs 28.3%, P = 0.129; 85.7% vs 77.8%, P = 0.161). Conclusions LT was superior to LR for patients with HCC within the Milan criteria with a predicted high or low risk of MVI. No significant differences in prognosis were found between LT and AR in patients with a low risk of MVI.
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Affiliation(s)
| | | | | | - Yong Xia
- Department of Hepatic Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
| | - Zhihao Xie
- Department of Hepatic Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
| | - Zhangjun Cheng
- Department of Hepatic Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
- Department of General Surgery, The Affiliated Zhongda Hospital, Southeast University, Nanjing, Jiangsu, P. R. China
| | - Jun Li
- Department of Hepatic Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
| | - Zhengqing Lei
- Department of Hepatic Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
- Department of General Surgery, The Affiliated Zhongda Hospital, Southeast University, Nanjing, Jiangsu, P. R. China
| | - Kui Wang
- Department of Hepatic Surgery II and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
| | - Baohua Zhang
- Department of Biliary Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
| | - Tian Yang
- Department of Hepatic Surgery II and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
| | - Xuying Wan
- Department of Chinese Traditional Medicine, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
| | - Hao Yin
- Department of Liver Surgery and Organ Transplantation, The Changzheng Hospital, Naval Medical University, Shanghai, P. R. China
| | - Hao Shen
- Department of Hepatic Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
| | - Timothy M Pawlik
- Department of Surgery, The Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Wan Yee Lau
- Department of Hepatic Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
- Faculty of Medicine, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China
| | - Zhiren Fu
- Corresponding authors. Feng Shen, Department of Hepatic Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, 225 Changhai Road, Shanghai, 200433, China. Tel: +86-21-81875005; Fax: +86-21-65562400; ; Zhiren Fu, Department of Liver Surgery and Organ Transplantation, The Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Shanghai, 200003, China. Tel: +86-21-81885741; Fax: +86-21-63276788;
| | - Feng Shen
- Corresponding authors. Feng Shen, Department of Hepatic Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, 225 Changhai Road, Shanghai, 200433, China. Tel: +86-21-81875005; Fax: +86-21-65562400; ; Zhiren Fu, Department of Liver Surgery and Organ Transplantation, The Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Shanghai, 200003, China. Tel: +86-21-81885741; Fax: +86-21-63276788;
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8
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Lima HA, Moazzam Z, Endo Y, Alaimo L, Shaikh C, Munir MM, Resende V, Guglielmi A, Marques HP, Cauchy F, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Hugh T, Endo I, Kitago M, Shen F, Pawlik TM. TBS-Based Preoperative Score to Predict Non-transplantable Recurrence and Identify Candidates for Upfront Resection Versus Transplantation for Hepatocellular Carcinoma. Ann Surg Oncol 2023; 30:3363-3373. [PMID: 36820934 DOI: 10.1245/s10434-023-13273-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 02/06/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Recurrence following liver resection (LR) for hepatocellular carcinoma (HCC) can be as high as 50-70%. While salvage liver transplantation may be feasible, patients may develop a non-transplantable recurrence (NTR) (recurrence beyond Milan criteria). We sought to identify preoperative risk factors to predict NTR after resection. PATIENTS AND METHODS Patients who underwent curative-intent LR for HCC were identified from a multi-institutional database. Preoperative factors associated with NTR were identified and a risk score model (NTR score) was developed and validated. RESULTS Among 1620 patients, 842 (52.0%) developed recurrence; among patients with recurrence, NTR occurred in 341 (40.5%) with a median recurrence-free survival (RFS) of 30 months (24.7-35.3 months). On multivariable analysis, factors associated with NTR included alpha fetoprotein (AFP) > 400 ng/mL [hazard ratio (HR) 1.71, 95% confidence interval (CI) 1.33-2.19], albumin-bilirubin grade (ALBI) (referent low, medium ALBI: HR 1.41, 95% CI 1.10-1.81, high ALBI: HR 2.47, 95% CI 0.91-6.68), and tumor burden score (TBS) (referent low, high TBS: HR 2.55, 95% CI, 1.99-3.28). A simplified TBS-based NTR score was developed using the β-coefficients of each factor (C-index 0.68, 95% CI 0.65-0.71). Higher NTR score was associated with incrementally worse 5-year RFS (low 44.8%, medium 37.5%, high 24.5%) [area under the curve (AUC) 0.59] and increased incidence of NTR (low 13.7%, medium 25.4%, high 38.2%) (AUC 0.65) (both p < 0.001). Moreover, higher NTR score was associated with higher risk of extrahepatic recurrence (low 11.3%, medium 28.8%, high 37.5%) (p < 0.001). CONCLUSION NTR following curative-intent resection of HCC occurred in one in five patients. A simple TBS-based NTR score accurately predicted the risk of NTR and may help identify candidates for upfront resection versus transplantation.
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Affiliation(s)
- Henrique A Lima
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.,Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Zorays Moazzam
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Chanza Shaikh
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Vivian Resende
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - François Cauchy
- Department of Hepatibiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Tom Hugh
- Department of Surgery, School of Medicine, The University of Sydney, Sydney, NSW, Australia
| | - Itaru Endo
- Yokohama City University School of Medicine, Yokohama, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University, Tokyo, Japan
| | - Feng Shen
- Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
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9
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Salehi O, Vega EA, Kutlu OC, Lunsford K, Freeman R, Ladin K, Alarcon SV, Kazakova V, Conrad C. Poorly differentiated hepatocellular carcinoma: resection is equivalent to transplantation in patients with low liver fibrosis. HPB (Oxford) 2022; 24:1100-1109. [PMID: 34969618 DOI: 10.1016/j.hpb.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/28/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Organ allocation criteria for liver transplantation focus on tumor size and multifocality while tumor differentiation and existing liver damage are omitted. This study analyzes the impact of hepatocellular carcinoma (HCC) grade and liver fibrosis comparing resection (SX) to transplantation (LT). METHODS The National Cancer Database was queried between 2004 and 2016 for solitary HCC meeting Milan criteria undergoing SX vs LT. Two groups were created: low fibrosis (LF) vs high fibrosis (HF) and stratified by grade. Cox multivariable regression models, Kaplan-Meier survival analyses and log-rank tests were performed. RESULTS 1515 patients were identified; 780 had LT and 735 had SX. Median overall survival (mOS) was 39.7 months; LT mOS was 47.9 months vs SX mOS of 34.9 months (P < .001). Multivariate analysis revealed SX, no chemotherapy, longer hospital stays, and age to be associated with worse survival. However, while transplantation conferred survival benefit for well-moderately differentiated tumors, SX vs LT did not impact survival for poorly differentiated HCC in LF patients, independent of tumor size. DISCUSSION HCC differentiation and liver fibrosis, but not size, synergistically determine efficacy of SX vs LT. Therefore, current HCC transplantation criteria should incorporate tumor grade or liver fibrosis for optimal organ allocation.
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Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | - Keri Lunsford
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Keren Ladin
- Department of Occupational Therapy and Community Health, Tufts University, Boston, MA, USA
| | - Sylvia V Alarcon
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, MA, USA
| | - Vera Kazakova
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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10
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Koh JH, Tan DJH, Ong Y, Lim WH, Ng CH, Tay PWL, Yong JN, Muthiah MD, Tan EX, Pang NQ, Kim BK, Syn N, Kow A, Goh BKP, Huang DQ. Liver resection versus liver transplantation for hepatocellular carcinoma within Milan criteria: a meta-analysis of 18,421 patients. Hepatobiliary Surg Nutr 2022; 11:78-93. [PMID: 35284509 DOI: 10.21037/hbsn-21-350] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/09/2021] [Indexed: 12/24/2022]
Abstract
Background Outcomes after liver resection (LR) and liver transplantation (LT) for hepatocellular carcinoma (HCC) are heterogenous and may vary by region, over time periods and disease burden. We aimed to compare overall survival (OS) and disease-free survival (DFS) between LT versus LR for HCC within the Milan criteria. Methods Two authors independently searched Medline and Embase databases for studies comparing survival after LT and LR for patients with HCC meeting the Milan criteria. Meta-analyses and metaregression were conducted using random-effects models. Results We screened 2,278 studies and included 35 studies with 18,421 patients. LR was associated with poorer OS [hazard ratio (HR) =1.44; 95% confidence interval (CI): 1.14-1.81; P<0.01] and DFS (HR =2.71; 95% CI: 2.23-3.28; P<0.01) compared to LT, with similar findings among intention-to-treat (ITT) studies. In uninodular disease, OS in LR was comparable to LT (P=0.13) but DFS remained poorer (HR =2.95; 95% CI: 2.30-3.79; P<0.01). By region, LR had poorer OS versus LT in North America and Europe (P≤0.01), but not Asia (P=0.25). LR had inferior survival versus LT in studies completed before 2010 (P=0.01), but not after 2010 (P=0.12). Cohorts that underwent enhanced surveillance had comparable OS after LT and LR (P=0.33), but cohorts undergoing usual surveillance had worse OS after LR (HR =1.95; 95% CI: 1.24-3.07; P<0.01). Conclusions Mortality after LR for HCC is nearly 50% higher compared to LT. Survival between LR and LT were similar in uninodular disease. The risk of recurrence after LR is threefold that of LT.
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Affiliation(s)
- Jin Hean Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yuki Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Phoebe Wen Lin Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Eunice X Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Ning Qi Pang
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Yonsei Liver Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Alfred Kow
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
| | - Brian K P Goh
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Division of Surgery, Singapore General Hospital, Singapore, Singapore.,Liver Transplant Service, SingHealth Duke-NUS Transplant Centre, Singapore, Singapore
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
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11
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Lozanovski VJ, Ramouz A, Aminizadeh E, Al-Saegh SAH, Khajeh E, Probst H, Picardi S, Rupp C, Chang DH, Probst P, Mehrabi A. Prognostic role of selection criteria for liver transplantation in patients with hepatocellular carcinoma: a network meta-analysis. BJS Open 2022; 6:6536147. [PMID: 35211739 PMCID: PMC8874238 DOI: 10.1093/bjsopen/zrab130] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/27/2021] [Accepted: 11/07/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with hepatocellular carcinoma (HCC) are selected for transplantation if they have a low tumour burden and low risk of recurrence. The morphometric Milan criteria have been the cornerstone for patient selection, but dynamic morphological and biological tumour characteristics surfaced as an encouraging tool to refine the selection of patients with HCC and to support the expansion of the Milan criteria. The outcomes of the most prevalent models that select patients with HCC for liver transplantation were analysed in this study, which aimed to identify the selection model that offered the best recurrence-free and overall survival after transplantation. METHODS Studies that compared Milan, University of California San Francisco (UCSF), up-to-seven (UPTS), alpha-fetoprotein (AFP), and MetroTicket 2.0 (MT2) models were included. One-year, 3-year, and 5-year recurrence-free and overall survival rates of patients selected for transplantation using different models were analysed. RESULTS A total of 60 850 adult patients with HCC selected for liver transplantation using Milan, UCSF, UPTS, AFP, or MT2 criteria were included. Patients selected for transplantation using the MT2 model had the highest 1-, 3-, and 5-year recurrence-free survival. In addition, patients selected for transplantation using MT2 criteria had the best 1- and 3-year overall survival, whereas patients selected for transplantation using the Milan criteria had the best 5-year overall survival rates. CONCLUSION The MT2 model offered the best post-transplant outcomes in patients with HCC, highlighting the importance of considering tumour morphology and biology when selecting patients with HCC for liver transplantation.
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Affiliation(s)
- Vladimir J Lozanovski
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,Liver Cancer Center Heidelberg (LCCH), University Hospital Heidelberg, Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ehsan Aminizadeh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Sadeq Ali-Hasan Al-Saegh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Heike Probst
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Susanne Picardi
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Rupp
- Liver Cancer Center Heidelberg (LCCH), University Hospital Heidelberg, Heidelberg, Germany.,Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - De-Hua Chang
- Liver Cancer Center Heidelberg (LCCH), University Hospital Heidelberg, Heidelberg, Germany.,Department of Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,The Study Center of the German Surgical Society (SDGC), University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,Liver Cancer Center Heidelberg (LCCH), University Hospital Heidelberg, Heidelberg, Germany
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12
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Gholami S, Perry LM, Denbo JW, Chavin K, Newell P, Ly Q, St Hill C, Morris-Stiff G, Kessler J, Frankel TL, Parikh ND, Philips P, Salti G, Augustin T, Aucejo F, Debroy M, Coburn N, Warner SG. Management of early hepatocellular carcinoma: results of the Delphi consensus process of the Americas Hepato-Pancreato-Biliary Association. HPB (Oxford) 2021; 23:753-761. [PMID: 33008733 DOI: 10.1016/j.hpb.2020.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are many potential treatment options for patients with early stage hepatocellular carcinoma (HCC) and practice patterns vary widely. This project aimed to use a Delphi conference to generate consensus regarding the management of small resectable HCC. METHODS A base case was established with review by members of AHPBA Research Committee. The Delphi panel of experts reviewed the literature and scored clinical case statements to identify areas of agreement and disagreement. Following initial scoring, discussion was undertaken, questions were amended, and scoring was repeated. This cycle was repeated until no further likelihood of reaching consensus existed. RESULTS The panel achieved agreement or disagreement consensus regarding 27 statements. The overarching themes included that resection, ablation, transplantation, or any locoregional therapy as a bridge to transplant were all appropriate modalities for early or recurrent HCC. For larger lesions, consensus was reached that radiofrequency ablation and microwave ablation were not appropriate treatments. CONCLUSION Using a validated system for identifying consensus, an expert panel agreed that multiple treatment modalities are appropriate for early stage HCC. These consensus guidelines are intended to help guide physicians through treatment modalities for early HCC; however, clinical decisions should continue to be made on a patient-specific basis.
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Affiliation(s)
- Sepideh Gholami
- Department of Surgery, University of California, Davis, CA, USA
| | - Lauren M Perry
- Department of Surgery, University of California, Davis, CA, USA
| | - Jason W Denbo
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Kenneth Chavin
- Department of Surgery, University Hospitals, Cleveland, OH, USA
| | - Philippa Newell
- Department of Surgery, Providence Portland Medical Center, Portland, OR, USA
| | - Quan Ly
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Charles St Hill
- Department of Surgery, University of Nevada Las Vegas, NV, USA
| | | | | | | | - Neehar D Parikh
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Prejesh Philips
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - George Salti
- Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Toms Augustin
- Department of Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Federico Aucejo
- Department of Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Meelie Debroy
- Department of Surgery, University Hospitals, Cleveland, OH, USA
| | - Natalie Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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13
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Ahmed O, Vachharajani N, Chang SH, Park Y, Khan AS, Chapman WC, Doyle MB. Access to Liver Transplantation for Hepatocellular Carcinoma: Does Candidate Age Matter? J Am Coll Surg 2021; 233:140-151. [PMID: 33652155 DOI: 10.1016/j.jamcollsurg.2021.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/04/2021] [Accepted: 01/27/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Liver transplantation (LT) offers an effective alternative treatment for unresectable hepatocellular carcinoma (HCC). Despite its growing acceptance and longer life expectancy rates, survival data in older patients are conflicting and consensus guidelines are lacking in terms of a cut-off age range for operations. STUDY DESIGN We explored our prospectively maintained institutional database to identify patients diagnosed with HCC between January 1, 2002 and December 31, 2019. Long-term oncologic outcomes were analyzed in patients undergoing LT or hepatic resection, with patient age considered as the primary variable. RESULTS In total, 1,629 patients with HCC were identified, of whom 700 were considered for curative operations (LT, n = 538; resection, n = 162). Patients older than 65 years were less likely to be considered for LT (p < 0.01), although there were no age-related differences in the de-listing rate among age groups (p = 0.90). Older patients had overall survival (OS) outcomes comparable with younger patients after LT (3-year OS: 85.5% vs 84%; 5-year OS: 73.9% vs 77%; p = 0.26). Long-term survival was lower in the group who underwent resection, however, older patients still demonstrated equivalent OS outcomes (3-year OS: 59% vs 64.8%; 5-year OS: 44.8% vs 49%; p = 0.13). There were no differences in the development of local or distant metastatic disease between groups. CONCLUSIONS Although older candidates were less likely to be considered for LT in the management of HCC, judicious matching can lead to OS data comparable with their younger counterparts. Previous age misconceptions need to be challenged without the concern of worse long-term oncologic outcomes after surgery.
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Affiliation(s)
- Ola Ahmed
- Department of Abdominal Organ Transplantation Surgery, Washington University School of Medicine, St Louis, MO
| | - Neeta Vachharajani
- Department of Abdominal Organ Transplantation Surgery, Washington University School of Medicine, St Louis, MO
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Yikyung Park
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Adeel S Khan
- Department of Abdominal Organ Transplantation Surgery, Washington University School of Medicine, St Louis, MO
| | - William C Chapman
- Department of Abdominal Organ Transplantation Surgery, Washington University School of Medicine, St Louis, MO
| | - Majella B Doyle
- Department of Abdominal Organ Transplantation Surgery, Washington University School of Medicine, St Louis, MO.
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14
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Gelli M, Sebagh M, Porcher R, Romanelli E, Vibert E, Sa Cunha A, Castaing D, Rosmorduc O, Samuel D, Adam R, Cherqui D. Liver Resection for Early Hepatocellular Carcinoma: Preoperative Predictors of Non Transplantable Recurrence and Implications for Treatment Allocation. Ann Surg 2020; 272:820-826. [PMID: 32833755 DOI: 10.1097/sla.0000000000004259] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS LR and LT are the standard curative options for early HCC. LT provides best long-term survival but is limited by organ shortage. LR, readily available, is hampered by high recurrence rates. Salvage liver transplantation is an efficient treatment of recurrences within criteria. The aim of the study was to identify preoperative predictors of non transplantable recurrence (NTR) to improve patient selection for upfront LR or LT at initial diagnosis. STUDY DESIGN Consecutive LR for transplantable HCC between 2000 and 2015 were studied. A prediction model for NTR based on preoperative variables was developed using sub-distribution hazard ratio after multiple imputation and internal validation by bootstrapping. Model performance was evaluated by the concordance index after correction for optimism. RESULTS A total of 148 patients were included. Five-year overall survival and recurrence free survival were 73.6% and 29.3%, respectively (median follow-up 45.8 months). Recurrence rate was 54.8%. NTR rate was 38.2%. Preoperative model for NTR identified >1 nodule [sub-distribution hazard ratio 2.35 95% confidence interval (CI) 1.35-4.09], AFP >100 ng/mL (2.14 95% CI 1.17-3.93), and F4 fibrosis (1.93 95% CI 1.03-3.62). The apparent concordance index of the model was 0.664 after correction for optimism. In the presence of 0, 1, and ≥2 factors, NTR rates were 2.6%, 22.7%, and 40.9%, respectively. The number of prognostic factors was significantly associated with the pattern of recurrence (P = 0.001) and 5-year recurrence free survival (P < 0.001). CONCLUSIONS Cirrhosis, >1 nodule, and AFP >100 ng/mL were identified as preoperative predictors of NTR. In the presence of 2 factors or more upfront transplantation should be probably preferred to resection in regard of organ availability. Other patients are good candidates for LR and salvage liver transplantation should be encouraged in eligible patients with recurrence.
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Affiliation(s)
- Maximiliano Gelli
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Mylène Sebagh
- Department of Pathology, APHP - Université Paris Saclay, Hôpital Paul Brousse, Villejuif, France
| | - Raphaël Porcher
- Centre de Recherche Épidémiologie et Statistique (CRESS-UMR1153) Université Paris Descartes-Hôpital Hôtel-Dieu, Paris, France
| | - Elena Romanelli
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Eric Vibert
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Antonio Sa Cunha
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Denis Castaing
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Olivier Rosmorduc
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Didier Samuel
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - René Adam
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Daniel Cherqui
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
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15
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Safety and feasibility of laparoscopic liver resection for hepatocellular carcinoma with clinically significant portal hypertension: a propensity score-matched study. Surg Endosc 2020; 35:3267-3278. [DOI: 10.1007/s00464-020-07763-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/25/2020] [Indexed: 02/08/2023]
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16
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Hao D, Deng F, Shi H, Wang H, Xiao F, Sun C, Xu Y, Li P. In vivo inhibitory effect of suberoylanilide hydroxamic acid combined with sorafenib on human hepatocellular carcinoma cells. BRAZ J PHARM SCI 2020. [DOI: 10.1590/s2175-97902019000318254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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17
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Lee TC, Morris MC, Patel SH, Shah SA. Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors. Surg Oncol Clin N Am 2019; 28:763-782. [PMID: 31472918 DOI: 10.1016/j.soc.2019.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.
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Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Sameer H Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA.
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18
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Liver Transplantation and Hepatic Resection can Achieve Cure for Hepatocellular Carcinoma. Ann Surg 2019; 268:868-875. [PMID: 30080736 DOI: 10.1097/sla.0000000000002889] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The aim of this study was to estimate probabilities of achieving the statistical cure from hepatocellular carcinoma (HCC) with hepatic resection (HR) and liver transplantation (LT). BACKGROUND Statistical cure occurs when the mortality of a specific population returns to values of that of general population. Resection and transplantation are considered potentially curative therapies for HCC, but their effect on the residual entire life-expectancy has never been investigated. METHODS Data from 3286 HCC patients treated with LT (n = 1218) or HR (n = 2068) were used to estimate statistical cure. Disease-free survival (DFS) was the primary survival measure to estimate cure fractions through a nonmixture model. Overall survival (OS) was a secondary measure. In both, patients were matched with general population by age, sex, year, and race/ethnicity. Cure variations after LT were also adjusted for different waiting-list drop-outs. RESULTS Considering DFS, the cure fraction after LT was 74.1% and after HR was 24.1% (effect size >0.8). LT outperformed HR within all transplant criteria considered (effect size >0.8), especially for multiple tumors (>0.9) and even in presence of a drop-out up to 20% (>0.5). Considering OS, the cure fraction after LT marginally increased to 75.8%, and after that HR increased to 40.5%. The effect size of LT over HR in terms of cure decreased for oligonodular tumors (<0.5), became small for drop-out up to ∼20% (<0.2), and negligible for single tumors <5 cm (∼0.1). CONCLUSION As other malignancies, statistical cure can occur for HCC, primarily with LT and secondarily with HR, depending on waiting-list capabilities and efficacy of tumor recurrence therapies after resection.
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19
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Takemura N, Aoki T, Hasegawa K, Kaneko J, Arita J, Akamatsu N, Makuuchi M, Kokudo N. Hepatectomy for hepatocellular carcinoma after perioperative management of portal hypertension. Br J Surg 2019; 106:1066-1074. [DOI: 10.1002/bjs.11153] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/24/2019] [Accepted: 02/06/2019] [Indexed: 01/27/2023]
Abstract
Abstract
Background
Indications for hepatectomy in patients with hepatocellular carcinoma (HCC) who have portal hypertension (PH) have been controversial. Some studies have concluded that PH is a contraindication to hepatectomy, whereas others have suggested that perioperative prophylactic management (PPM) can help overcome complications after hepatectomy associated with PH. The objective of this retrospective study was to assess the short- and long-term outcomes after hepatectomy for HCC in patients with PH, with or without PPM.
Methods
Records were reviewed of consecutive patients who underwent hepatectomy for HCC, with or without PPM of PH, in a single institution from 1994 to 2015. Patients were divided into three groups: those who received PPM for PH (PPM group), patients who had PH but did not receive PPM (no-PPM group) and those without PH (no-PH group).
Results
A total of 1259 patients were enrolled, including 123 in the PPM group, 181 in the no-PPM group and 955 in the no-PH group. Three- and 5-year overall survival rates were 74·3 and 53·1 per cent respectively in the PPM group, 69·2 and 54·9 per cent in the no-PPM group, and 78·1 and 64·2 per cent in the no-PH group (P = 0·520 for PPM versus no PPM, P = 0·027 for PPM versus no PH, and P < 0·001 for no PPM versus no PH). Postoperative morbidity and mortality rates were 26·0 and 0·8 per cent respectively in the PPM group, 29·8 and 1·1 per cent in the no-PPM group, and 20·3 and 0 per cent in the no-PH group.
Conclusion
The present study has demonstrated acceptable outcomes among patients with HCC who received appropriate management for PH in an Asian population. Enhancement of the safety of hepatic resection through use of PPM may provide a rationale for expansion of indications for hepatectomy in patients with PH.
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Affiliation(s)
- N Takemura
- Department of Surgery, Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- National Centre for Global Health and Medicine, Tokyo, Japan
| | - T Aoki
- Department of Surgery, Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - K Hasegawa
- Department of Surgery, Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - J Kaneko
- Department of Surgery, Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - J Arita
- Department of Surgery, Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - N Akamatsu
- Department of Surgery, Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | | | - N Kokudo
- National Centre for Global Health and Medicine, Tokyo, Japan
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Survival outcomes of liver transplantation versus liver resection among patients with hepatocellular carcinoma: A SEER-based longitudinal study. J Formos Med Assoc 2019; 118:790-796. [DOI: 10.1016/j.jfma.2018.09.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 07/02/2018] [Accepted: 09/19/2018] [Indexed: 01/14/2023] Open
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Chopinet S, Grégoire E, Bollon E, Hak JF, Palen A, Vidal V, Hardwigsen J, Le Treut YP. Short-term outcomes after major hepatic resection in patients with cirrhosis: a 75-case unicentric western experience. HPB (Oxford) 2019; 21:352-360. [PMID: 30120001 DOI: 10.1016/j.hpb.2018.07.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/20/2018] [Accepted: 07/21/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The benefit of performing major hepatic resection (MHR) for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial because of its high risk of posthepatectomy liver failure (PHLF). This study was conducted to assess the risk of MHR for HCC in patients with cirrhosis. METHODS Patients with Child-Pugh A or B cirrhosis and HCC who underwent MHR from January 2000 to June 2014 were retrospectively identified. Risk factors for postoperative morbidity and mortality using univariate and multivariate analyses were evaluated. RESULTS Seventy patients with Child-Pugh A (93%) and 5 (7%) with Child-Pugh B cirrhosis underwent MHR for HCC. Thirteen (17%) had Barcelona Clinic Liver Cancer (BCLC) stage A, 39 (50%) had BCLC B, and 23 (32%) had BCLC C disease. A perioperative blood transfusion was performed in 18 patients (24%). Ninety-day postoperative mortality was 9% (n=7). Major complications occurred in 16 patients (21%), including PHLF in 9 patients (12%). A multivariate analysis showed that perioperative blood transfusion was the main independent factor associated with mortality (OR= 6.5) and major morbidity (OR=10). CONCLUSION In selected patients with HCC and cirrhosis, MHR is feasible and has acceptable mortality, but careful perioperative management and limiting blood loss are required.
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Affiliation(s)
- Sophie Chopinet
- Department of Digestive Surgery, Hôpital de la Timone, Marseille, France; European Center for Medical Imaging Research CERIMED/LIIE, Université Aix-Marseille, France.
| | - Emilie Grégoire
- Department of Digestive Surgery, Hôpital de la Timone, Marseille, France; European Center for Medical Imaging Research CERIMED/LIIE, Université Aix-Marseille, France
| | - Emilie Bollon
- Department of Digestive Surgery, Hôpital de la Timone, Marseille, France
| | - Jean-François Hak
- Department of radiology, Hôpital de la Timone, Marseille, France; European Center for Medical Imaging Research CERIMED/LIIE, Université Aix-Marseille, France
| | - Anaïs Palen
- Department of Digestive Surgery, Hôpital de la Timone, Marseille, France
| | - Vincent Vidal
- Department of radiology, Hôpital de la Timone, Marseille, France; European Center for Medical Imaging Research CERIMED/LIIE, Université Aix-Marseille, France
| | - Jean Hardwigsen
- Department of Digestive Surgery, Hôpital de la Timone, Marseille, France; Université Aix-Marseille, 27 Boulevard Jean Moulin, 13385, Marseille, France
| | - Yves-Patrice Le Treut
- Department of Digestive Surgery, Hôpital de la Timone, Marseille, France; Université Aix-Marseille, 27 Boulevard Jean Moulin, 13385, Marseille, France
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Siy AB, Rendell VR, Winslow ER. Analysis of National Presentations of Surgical Case Series Discussions: What Matters to Surgeons? J Surg Res 2019; 238:240-247. [PMID: 30776743 DOI: 10.1016/j.jss.2019.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/05/2018] [Accepted: 01/11/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although the surgical case series is a useful study design for surgical disciplines, elements of its presentation have not been standardized with a widely accepted reporting guideline. Hence, case series may not include all components necessary for surgeons to best interpret their results. We aimed to determine core elements of case series through qualitative analysis of discussions after presentations at national meetings. METHODS Case series with accompanying discussions in three high-impact journals from 2010 to 2015 were analyzed with conventional content analysis. All interrogative sentences were selected for analysis and were classified by a redundant iterative process into descriptive categories and subcategories. RESULTS Two hundred twenty-one case series were identified, 56 of which included discussion transcripts. Four hundred seventy six unique interrogatives were classified into 4 categories and 13 subcategories. The main categories identified were "Application of Results to Patient Care," "Clarification of Study Methodology," "Facilitation of Author Insight," and "Request for Additional Study-Specific Data." The most frequent subcategories of inquiry pertained to the changes to current standard of care, clarification of study variables, and subgroup data and outcomes. CONCLUSIONS We determined major themes of inquiry that reflected core elements surgeons use to evaluate case series for relevance and applicability to their own practice. Discussants frequently questioned how the study's results changed the author's standard of care. Specifically encouraging surgical case series authors to comment on changes they made to their practice as a result of their findings would allow the surgical audience to quickly assess potential clinical applicability.
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Affiliation(s)
- Alexander B Siy
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Victoria R Rendell
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Emily R Winslow
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Colombo M, Lleo A. Refining surgical therapy of liver cancer in cirrhosis: etiology makes the difference. Transl Gastroenterol Hepatol 2019; 3:104. [PMID: 30701211 DOI: 10.21037/tgh.2018.12.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Ana Lleo
- Humanitas Clinical and Research Center, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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Maegawa FB, Shehorn L, Aziz H, Kettelle J, Jie T, Riall TS. Association Between Noninvasive Fibrosis Markers and Postoperative Mortality After Hepatectomy for Hepatocellular Carcinoma. JAMA Netw Open 2019; 2:e187142. [PMID: 30657533 PMCID: PMC6484540 DOI: 10.1001/jamanetworkopen.2018.7142] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE The selection criteria for hepatectomy for hepatocellular carcinoma (HCC) is not well established. The role of noninvasive fibrosis markers in this setting is unknown in the US population. OBJECTIVE To evaluate whether aspartate aminotransferase-platelet ratio index (APRI) and fibrosis 4 (Fib4) values are associated with perioperative mortality and overall survival after hepatectomy for HCC. DESIGN, SETTING, AND PARTICIPANTS In a multicenter cohort study, Veterans Administration Corporate Data Warehouse was used to evaluate a retrospective cohort of 475 veterans who underwent hepatectomy for HCC between January 1, 2000, and December 31, 2012, in Veterans Administration hospitals. Data analysis occurred between September 30, 2016, and December 30, 2017. Logistic regression, survival analysis, and change in concordance index analysis were performed to evaluate the association between APRI and Fib4 values and mortality. EXPOSURES The cohort was stratified based on preoperative APRI and Fib4 values. Analysis was performed accounting for the validated and established predictors of outcome. MAIN OUTCOMES AND MEASURES Thirty-day mortality, 90-day mortality, and overall survival were the primary outcomes. An APRI value greater than 1.5 was considered high risk (cirrhosis), and an Fib4 value greater than 4.0 was considered high risk (advanced fibrosis). Portal hypertension (diagnosis of ascites or encephalopathy indicates presence of portal hypertension) and Child-Turcotte-Pugh (CTP) class (A indicates preserved liver function; B, mild to moderate liver dysfunction) served as 2 other measures of liver function. RESULTS A total of 475 patients with HCC underwent hepatectomy. The mean (SD) age was 65.6 (9.4) years; Model for End-Stage Liver Disease score, 8.9 (3.1); and body mass index, 28.1 (4.9) (calculated as weight in kilograms divided by height in meters squared). A total of 361 patients (76.0%) were men, 294 (61.9%) were white; 308 (64.8%) were hepatitis C positive, and 346 (72.8%) were categorized as CTP class A. The most common surgical procedure was partial lobectomy, with 321 (67.6%) procedures. The APRI value greater than 1.5 vs 1.5 or lower was associated with increased 30-day mortality (odds ratio [OR], 6.45; 95% CI, 2.80-14.80) and 90-day mortality (OR, 2.65; 95% CI, 1.35-5.22), as was Fib4 greater than 4.0 vs Fib4 4.0 or lower for 30-day mortality (OR, 5.41; 95% CI, 2.35-12.50) and 90-day mortality (OR, 2.74; 95% CI, 1.41-5.35). Survival analysis showed that overall survival was significantly different for APRI greater than 1.5 vs 1.5 or lower (mean survival time, 3.6 vs 5.4 years; log-rank P < .001) and Fib4 greater than 4.0 vs 4.0 or lower (mean survival time, 4.1 vs 5.3 years; log rank P = .01). Adjusted Cox proportional hazards regression analysis revealed that elevated APRI was significantly associated with worse survival (hazard ratio [HR], 1.13; 95% CI, 1.03-1.23) but Fib4 values were not (HR, 1.04; 95% CI, 0.99-1.09). Change in concordance index showed that APRI and Fib4 improved the ability of CTP class and portal hypertension to predict postoperative mortality. CONCLUSIONS AND RELEVANCE Elevated APRI and Fib4 values, which are noninvasive markers of fibrosis, were associated with higher perioperative mortality. The APRI was also associated with worse overall survival. Use of APRI and Fib4 measures improved the ability of established markers to predict postoperative mortality. These findings suggest incorporating APRI and Fib4 to the selection process for hepatectomy for HCC as predictors associated with mortality may be warranted.
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Affiliation(s)
- Felipe B. Maegawa
- Surgical Care Line, Southern Arizona Veterans Affairs Health Care System, Tucson
- Department of Surgery, University of Arizona, Tucson
| | - Lauren Shehorn
- Quality Management, Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky
| | - Hassan Aziz
- Department of Surgery, University of Southern California, Los Angeles
| | - John Kettelle
- Surgical Care Line, Southern Arizona Veterans Affairs Health Care System, Tucson
- Department of Surgery, University of Arizona, Tucson
| | - Tun Jie
- Department of Surgery, University of Arizona, Tucson
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Jin X, Zimmers TA, Zhang Z, Koniaris LG. Resveratrol Improves Recovery and Survival of Diet-Induced Obese Mice Undergoing Extended Major (80%) Hepatectomy. Dig Dis Sci 2019; 64:93-101. [PMID: 30284135 DOI: 10.1007/s10620-018-5312-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/28/2018] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Loss of hepatic epidermal growth factor receptor (EGFR) expression is a cause for the increased perioperative risk for complications and death in patients with obesity and fatty liver undergoing liver resection. Herein, we set out to identify agents that might increase EGFR expression and improve recovery for patients with fatty liver undergoing resection. Using the diet-induced obese (DIO) mouse model of fatty liver, we examined resveratrol as a therapy to induce EGFR expression and improve outcomes following 80% partial hepatectomy (PH) in a murine model. METHODS DIO mice were fed resveratrol or carrier control by gavage. EGFR expression and the response to major (80%) PH were examined. RESULTS Based on an Illumina analysis, resveratrol was identified as increasing EGFR gene expression in A549 cells. Resveratrol was observed to also increase EGFR protein expression in A549 cells. DIO mice fed resveratrol by gavage (75 mg/kg) demonstrated an increased EGFR expression without the identified hepatic toxicity. Resveratrol and control mice subjected to 80% PH, a model of high mortality hepatectomy in DIO mice, demonstrated macroscopically decreased fatty liver and fewer liver hemorrhagic petechiae. Resveratrol pretreatment ameliorated liver injury and accelerated regeneration of the hepatic remnant after 80% PH including decreasing serum ALT and bilirubin, while increasing hepatic PCNA expression. Resveratrol increased induction of p-STAT3 and p-AKT after 80% hepatectomy. Resveratrol pretreatment significantly improved survival rates in DIO mice undergoing extended 80% PH. CONCLUSIONS Oral resveratrol restores EGFR expression in fatty liver. Resveratrol may be a promising protective agent in instances where extensive hepatic resection of fatty liver is required.
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Affiliation(s)
- Xiaoling Jin
- Department of Surgery, Thomas Jefferson University School of Medicine, Philadelphia, PA, USA
| | - Teresa A Zimmers
- Department of Surgery, Indiana University School of Medicine, EH 511 SGEN, Indianapolis, IN, 46202, USA
| | - Zongxiu Zhang
- Department of Surgery, Thomas Jefferson University School of Medicine, Philadelphia, PA, USA
| | - Leonidas G Koniaris
- Department of Surgery, Indiana University School of Medicine, EH 511 SGEN, Indianapolis, IN, 46202, USA.
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Schoenberg MB, Bucher JN, Vater A, Bazhin AV, Hao J, Guba MO, Angele MK, Werner J, Rentsch M. Resection or Transplant in Early Hepatocellular Carcinoma. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:519-526. [PMID: 28835324 DOI: 10.3238/arztebl.2017.0519] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 12/07/2016] [Accepted: 05/22/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) has an incidence of 5-10 per 100 000 persons per year in the Western world. In 20% of cases, surgical liver resection (LR) or liver transplantation (LT) can be performed. LT results in longer survival, as it involves resection not only of the tumor, but of pre - cancerous tissue as well. The optimal allocation of donor organs depends on the identification of patients for whom LR is adequate treatment. In this meta-analysis, we compare LT and LR for patients with early HCC and wellcompensated cirrhosis. METHODS A systematic review of the pertinent literature was followed by a subgroup analysis of the studies in which patients with early HCC and wellcompensated cirrhosis were followed up after either LR or LT. Overall survival at 1, 3, and 5 years, as well as morbidity and mortality, were compared in a random effects meta-analysis. RESULTS 54 studies with a total of 13 794 patients were included. Among patients with early HCC, the overall survival after LT became higher than the overall survival after LR 5 years after surgery (66.67% versus 60.35%, odds ratio 0.60 [0.45; 0.78], p <0.001); there was no significant difference 1 year or 3 years after surgery. Nor was there any significant difference in morbidity or mortality between the two types of treatment in this subgroup. These findings contrast with the results obtained in all of the studies, which documented significantly better survival 3 years after LT. CONCLUSION Three years after surgery, the survival rates and complication rates of patients with early HCC treated with either LR or LT are comparable. Resection should therefore be the preferred form of treatment if the prerequisites for it are met. In case of recurrent tumor, these patients can still be evaluated for liver transplantation. This strategy could improve the allocation of donor organs.
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Affiliation(s)
- Markus B Schoenberg
- Markus B. Schoenberg and Julian N. Bucher shared first authorship; Department of General, Visceral and Transplantation Surgery, University Hospital of Munich, Campus Großhadern; Munich Transplant Center, University Hospital of Munich, Campus Großhadern; Liver Center Munich, University Hospital of Munich, Campus Großhadern
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Wu L, Swan P, McCall J, Gane E, Holden A, Merrilees S, Munn S, Johnston P, Bartlett A. Intention-to-treat analysis of liver transplantation, resection and thermal ablation for hepatocellular carcinoma in a single centre. HPB (Oxford) 2018; 20:966-976. [PMID: 29843986 DOI: 10.1016/j.hpb.2018.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/26/2018] [Accepted: 04/03/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND potentially curative treatment options for hepatocellular carcinoma (HCC) include liver transplantation (LT), liver resection (LR) and thermal ablation (TA). Long term intent-to-treat (ITT) analysis from a single-centre using all three modalities contemporaneously has not been published. METHODS An ITT analysis was undertaken of all patients with HCC listed for LT, or have undergone LR or TA. RESULTS 444 patients were identified; 145 were listed for LT (121 underwent LT), 190 underwent LR and 109 underwent TA. One and 3-year overall survival (OS) was similar among LT, LR and TA (88/77%, 88/64% and 95/72%) whereas 5-year OS was higher following LT than LR or TA (73% vs. 54% vs. 49%). Disease-free survival at 1- and 5-years was higher for LT (97% and 84%) than LR (66% and 35%) or TA (73%, and 19%). CONCLUSION LT offered the lowest rate of cancer recurrence and highest chance of long-term survival. Differences in outcome likely reflect a combination of cancer-related factors (AFP, micro- and macrovascular invasion), patient-related factors (performance status, co-morbidities and psychosocial issues) and treatment type. Two thirds of patients treated by LR and three quarters treated by TA had HCC recurrence by 5 years, reinforcing the need for close long-term surveillance.
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Affiliation(s)
- Lily Wu
- New Zealand Liver Transplant Unit, Level 15, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand; Hepatopancreaticobiliary Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Peter Swan
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - John McCall
- New Zealand Liver Transplant Unit, Level 15, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand; Hepatopancreaticobiliary Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand; Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Edward Gane
- New Zealand Liver Transplant Unit, Level 15, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
| | - Andrew Holden
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Stephen Merrilees
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Stephen Munn
- New Zealand Liver Transplant Unit, Level 15, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
| | - Peter Johnston
- New Zealand Liver Transplant Unit, Level 15, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand; Hepatopancreaticobiliary Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Adam Bartlett
- New Zealand Liver Transplant Unit, Level 15, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand; Hepatopancreaticobiliary Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand; Department of Surgery, University of Auckland, Auckland, New Zealand.
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Li W, Li L, Han J, Wu H. Liver transplantation vs liver resection in patients with HBV-related hepatocellular carcinoma beyond Milan criterion: A meta-analysis. Clin Transplant 2018; 32:e13193. [PMID: 29315813 DOI: 10.1111/ctr.13193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of this study was to conduct a meta-analysis of published reports to compare long-term outcomes after liver transplantation (LT) and liver resection (LR), respectively, in patients with HBV-related hepatocellular carcinoma (HCC) beyond the Milan criterion. METHODS A systematic search of the Embase, Medline, PubMed databases, and the Cochrane Library was performed using both medical subject headings (MeSH) and truncated word searches to identify all comparative studies published on this topic. The primary outcomes were postoperative overall survival (OS) and disease-free survival (DFS). We calculated the pooled hazard ratios (HR) with 95% confidence intervals (95% CI) of OS and DFS. RESULTS Pooled analysis of six studies, with a total of 1697 patients with HCC beyond Milan criteria, did not reveal a statistically significant improvement in OS in patients undergoing LT vs LR (LT vs LR, HR: 0.83, 95% CI: 0.68-1.01, P = .06), without significant heterogeneity (χ2 = 8.38, I2 = 40.3%, P = .137). Five studies with a total of 1511 patients were included in pooled analysis of DFS between LT and LR group. In the fixed-effects model, patients in the LT group gained significantly better DFS (LT vs LR, HR: 0.45, 95% CI: 0.37-0.56, P < .001) than patients in the LR group, with no significant heterogeneity (χ2 = 6.80, I2 = 41.6%, P = .144). Four studies provided the data of adjusted HRs (LT vs LR). In the fixed-effects model, patients in the LT group had significantly better OS (HR: 0.58, 95% CI: 0.44-0.77, P < .001, I2 = 0%) and DFS (HR: 0.14, 95% CI: 0.08-0.23, P < .001, I2 = 0%) than those of patients in the LR group. The sensitivity analyses revealed that the results were robust. CONCLUSION Our meta-analysis demonstrated that HBV-related patients with HCC beyond Milan criterion who underwent LT gained better OS and DFS compared with patients who underwent LR after adjusting confounding factors.
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Affiliation(s)
- Wei Li
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Long Li
- Department of General Surgery, Dingxi People's Hospital, Lanzhou University Second Hospital Dingxi Hospital, Dingxi, China
| | - Jun Han
- Department of Critical Care Medicine, Sichuan Provincial Hospital for Women and Children, Chengdu, China
| | - Hong Wu
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
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Orcutt ST, Anaya DA. Liver Resection and Surgical Strategies for Management of Primary Liver Cancer. Cancer Control 2018; 25:1073274817744621. [PMID: 29327594 PMCID: PMC5933574 DOI: 10.1177/1073274817744621] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 08/30/2017] [Indexed: 02/06/2023] Open
Abstract
Primary liver cancer-including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC)-incidence is increasing and is an important source of cancer-related mortality worldwide. Management of these cancers, even when localized, is challenging due to the association with underlying liver disease and the complex anatomy of the liver. Although for ICC, surgical resection provides the only potential cure, for HCC, the risks and benefits of the multiple curative intent options must be considered to individualize treatment based upon tumor factors, baseline liver function, and the functional status of the patient. The principles of surgical resection for both HCC and ICC include margin-negative resections with preservation of adequate function of the residual liver. As the safety of surgical resection has improved in recent years, the role of liver resection for HCC has expanded to include selected patients with preserved liver function and small tumors (ablation as an alternative), tumors within Milan criteria (transplant as an alternative), and patients with large (>5 cm) and giant (>10 cm) HCC or with poor prognostic features (for whom surgery is infrequently offered) due to a survival benefit with resection for selected patients. An important surgical consideration specifically for ICC includes the high risk of nodal metastasis, for which portal lymphadenectomy is recommended at the time of hepatectomy for staging. For both diseases, onco-surgical strategies including portal vein embolization and parenchymal-sparing resections have increased the number of patients eligible for curative liver resection by improving patient outcomes. Multidisciplinary evaluation is critical in the management of patients with primary liver cancer to provide and coordinate the best treatments possible for these patients.
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Affiliation(s)
- Sonia T. Orcutt
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Daniel A. Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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Guo Z, Zhong Y, Hu B, Jiang JH, Li LQ, Xiang BD. Hepatic resection or transarterial chemoembolization for hepatocellular carcinoma within Milan criteria: A propensity score matching analysis. Medicine (Baltimore) 2017; 96:e8933. [PMID: 29390426 PMCID: PMC5758128 DOI: 10.1097/md.0000000000008933] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
This study aimed to compare the long-term survival of patients with hepatocellular carcinoma (HCC) within the Milan criteria who underwent hepatic resection (HR) or transarterial chemoembolization (TACE).Medical records were retrospectively analyzed for HCC patients within the Milan criteria treated at Affiliated Tumor Hospital of Guangxi Medical University between March 2003 and March 2008, 159 of whom underwent HR and 42 of whom underwent TACE. Long-term overall survival (OS) was evaluated using the Kaplan-Meier method before and after propensity score matching. Cox proportional hazard modeling was used to identify possible predictors of OS.Propensity score matching was used to generate 32 pairs of patients, for which OS was significantly higher after HR than TACE at 1 year, 96.6% versus 84.4%; 3 years, 75.4% versus 53.1%; 5 years, 48.8% versus 29.7%, respectively (P = .038). Among all patients with multinodular HCC (2-3 tumors ≤3 cm), HR was also associated with significantly higher OS than TACE at 1 year, 95.2% versus 72.7%; 3 years, 71.4% versus 9.1%; 5 years, 35.1% versus 0%, respectively (P < .001). By contrast, among all patients with a single HCC tumor ≤5 cm, HR and TACE were associated with similar OS at 1 year, 85.9% versus 90.3%; 3 years, 62.0% versus 61.3%; 5 years, 42.1% versus 33.2%, respectively (P = .332).HR provides survival benefit over TACE in HCC patients within the Milan criteria, especially patients with multinodular HCC involving 2 to 3 tumors ≤3 cm. However, HR and TACE appear to be similarly effective for patients with single-tumor HCC ≤5 cm.
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Affiliation(s)
- Zhe Guo
- Department of Hepatobiliary Surgery, Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region
- Department of Thyroid and Breast Surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Yuan Zhong
- Department of Thyroid and Breast Surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Bo Hu
- Department of Thyroid and Breast Surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Jing-Hang Jiang
- Department of General Surgery, The Second People's Hospital of Jing Men, Jingmen, Hubei Province, China
| | - Le-Qun Li
- Department of Hepatobiliary Surgery, Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region
| | - Bang-De Xiang
- Department of Hepatobiliary Surgery, Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region
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Liu JB, Baker TB, Suss NR, Talamonti MS, Roggin KK, Winchester DJ, Baker MS. Orthotopic liver transplantation provides a survival advantage compared with resection in patients with hepatocellular carcinoma and preserved liver function. Surgery 2017; 162:1032-1039. [DOI: 10.1016/j.surg.2017.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/07/2017] [Accepted: 07/14/2017] [Indexed: 01/27/2023]
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Yang A, Ju W, Yuan X, Han M, Wang X, Guo Z, Wei X, Wang D, Zhu X, Wu L, He X. Comparison between liver resection and liver transplantation on outcomes in patients with solitary hepatocellular carcinoma meeting UNOS criteria: a population-based study of the SEER database. Oncotarget 2017; 8:97428-97438. [PMID: 29228622 PMCID: PMC5722574 DOI: 10.18632/oncotarget.22134] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 08/27/2017] [Indexed: 02/06/2023] Open
Abstract
Liver resection (LR) and liver transplantation (LT) are potential curative treatment methods for early hepatocellular carcinoma (HCC). However, it is controversial which treatment is more beneficial to patients with solitary HCC meeting the United Network for Organ Sharing (UNOS) criteria (single lesion, diameter≤50mm, no vascular invasion, no extrahepatic metastasis). We retrieved patients with solitary HCC meeting UNOS criteria diagnosed between 2004-2013 from the Surveillance Epidemiology and End Results (SEER) database. Multivariate Cox proportional hazards regression models were used to evaluate the impact of surgery type (LR/LT) on overall survival (OS) and disease-specific survival (DSS) in both the whole study group and subgroups. Our analyses show that LT Patients had significantly superior OS (Adjusted HR (95% CI): 0.39 [0.26-0.59]) and DSS (Adjusted HR (95% CI): 0.19 [0.10-0.35]) than those receiving LR, although compared with the 288 patients receiving LR, the 258 patients receiving LT had younger age, smaller tumor size, and higher fibrosis score (P<0.001). Subgroup analyses identified significant interactions between surgery type (LR/LT) and gender (Male/Female) in both OS (P=0.02) and DSS (P=0.02). Male patients benefit more from LT compared with LR in both OS (Adjusted HR (95% CI): 0.29 [0.18-0.47]) and DSS (Adjusted HR (95% CI): 0.10 [0.05-0.21]), but there is no difference between patients receiving LT and LR in female patients. In conclusion, LT is associated with superior survival than LR in patients with solitary HCC meeting UNOS criteria. Moreover, male patients benefits more from LT than LR, while female patients do not show different outcomes between the two procedures.
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Affiliation(s)
- Anli Yang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Weiqiang Ju
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaopeng Yuan
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Ming Han
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaoping Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaoli Wei
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Dongping Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaofeng Zhu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Linwei Wu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
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Zimmers TA, Jin X, Zhang Z, Jiang Y, Koniaris LG. Epidermal growth factor receptor restoration rescues the fatty liver regeneration in mice. Am J Physiol Endocrinol Metab 2017; 313:E440-E449. [PMID: 28655714 PMCID: PMC5668597 DOI: 10.1152/ajpendo.00032.2017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/01/2017] [Accepted: 06/19/2017] [Indexed: 02/06/2023]
Abstract
Hepatic steatosis is a common histological finding in obese patients. Even mild steatosis is associated with delayed hepatic regeneration and poor outcomes following liver resection or transplantation. We sought to identify and target molecular pathways that mediate this dysfunction. Lean mice and mice made obese through feeding of a high-fat, hypercaloric diet underwent 70 or 80% hepatectomy. After 70% resection, obese mice demonstrated 100% survival but experienced increased liver injury, reduced energy stores, reduced mitoses, increased necroapoptosis, and delayed recovery of liver mass. Increasing liver resection to 80% was associated with mortality of 40% in lean and 80% in obese mice (P < 0.05). Gene expression profiling showed decreased epidermal growth factor receptor (EGFR) in fatty liver. Meta-analysis of expression studies in mice, rats, and patients also demonstrated reduction of EGFR in fatty liver. In mice, both EGFR and phosphorylated EGFR decreased with increasing percent body fat. Hydrodynamic transfection of EGFR plasmids in mice corrected fatty liver regeneration, reducing liver injury, increasing proliferation, and improving survival after 80% resection. Loss of EGFR expression is rate limiting for liver regeneration in obesity. Therapies directed at increasing EGFR in steatosis might promote liver regeneration and survival following hepatic resection or transplantation.
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Affiliation(s)
- Teresa A Zimmers
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Xiaoling Jin
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
- Department of Cancer Biology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Zongxiu Zhang
- Department of Cancer Biology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yanlin Jiang
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Leonidas G Koniaris
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana;
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana
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Locoregional Therapy With Curative Intent Versus Primary Liver Transplant for Hepatocellular Carcinoma. Transplantation 2017; 101:e249-e257. [DOI: 10.1097/tp.0000000000001730] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kays JK, Milgrom DP, Koniaris LG. Resection or transplantation for hepatocellular carcinoma: is the decision clear for patients beyond Milan criteria? Hepatobiliary Surg Nutr 2017; 6:284-286. [PMID: 28848756 DOI: 10.21037/hbsn.2017.04.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Joshua K Kays
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel P Milgrom
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Leonidas G Koniaris
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
Hepatocellular carcinoma (HCC) is a major cause of cancer death and is increasing in incidence. This review focuses on HCC surveillance and treatment of early-stage disease, which are essential to improving outcomes. Multiple societies have published HCC surveillance guidelines, but screening efforts have been limited by noncompliance and overall lack of testing for patients with undiagnosed chronic liver disease. Treatment of early-stage HCC has become increasingly complex due to expanding therapeutic options and better outcomes with established treatments. Surgical indications for HCC have broadened with improved preoperative liver testing, neoadjuvant therapy, portal vein embolization, and perioperative care. Advances in post-procedural monitoring have improved efficacies of transarterial chemoembolization and radiofrequency ablation, and novel therapies involving delivery of radiochemicals are being studied in small trials. Finally, advances in liver transplantation have allowed for expanded indications beyond Milan criteria with non-inferior outcomes. More clinical trials evaluating new therapies and multimodal regimens are necessary to help clinicians design better treatment algorithms and improve outcomes.
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Affiliation(s)
| | - Kenneth K Tanabe
- Harvard Medical School.,Division of Surgical Oncology.,Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Boston, MA, USA
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Kobayashi T, Aikata H, Kobayashi T, Ohdan H, Arihiro K, Chayama K. Patients with early recurrence of hepatocellular carcinoma have poor prognosis. Hepatobiliary Pancreat Dis Int 2017; 16:279-288. [PMID: 28603096 DOI: 10.1016/s1499-3872(16)60181-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Early recurrence (ER) after hepatic resection (HR) is a poor prognostic factor for patients with hepatocellular carcinoma (HCC). This study aimed to identify the clinicopathological features, outcomes, and risk factors for ER after HR for small HCC in order to clarify the reasons why ER is a worse recurrence pattern. METHODS We retrospectively examined 130 patients who underwent HR for small HCC (≤30 mm). Recurrence was classified into ER (<2 years) and late recurrence (LR) (≥2 years). The clinicopathological features, outcomes, and risk factors for ER were analyzed by multivariate analysis. RESULTS ER was observed in 39 patients (30.0%). The survival rate of the ER group was significantly lower than that of the LR group (P<0.005), and ER was an independent prognostic factor for poor survival (P=0.0001). The ER group had a significantly higher frequency (P=0.0039) and shorter interval (P=0.027) of development to carcinoma beyond the Milan criteria (DBMC) compared with the LR group, and ER was an independent risk factor for DBMC (P<0.0001). Multi-nodularity, non-simple nodular type, and microvascular invasion were independent predictors for ER (P=0.012, 0.010, and 0.019, respectively). CONCLUSIONS ER was a highly malignant recurrence pattern associated with DBMC and subsequent poor survival after HR for small HCC. Multi-nodularity, non-simple nodular type, and microvascular invasion predict ER, and taking these factors into consideration may be useful for the decision of the treatment strategy for small HCC after HR.
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Affiliation(s)
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan.
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Menahem B, Lubrano J, Duvoux C, Mulliri A, Alves A, Costentin C, Mallat A, Launoy G, Laurent A. Liver transplantation versus liver resection for hepatocellular carcinoma in intention to treat: An attempt to perform an ideal meta-analysis. Liver Transpl 2017; 23:836-844. [PMID: 28295992 DOI: 10.1002/lt.24758] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/17/2017] [Indexed: 12/14/2022]
Abstract
This meta-analysis compared the effects of liver transplantation (LT) and liver resection (LR) on overall survival (OS) and disease-free survival (DFS) in patients with hepatocellular carcinoma (HCC) small transplantable HCC or within Milan criteria. Articles comparing LR with LT for HCC, based on Milan criteria or small size, published up to June 2015 were selected, and a meta-analysis was performed. No randomized controlled trial has been published to date comparing survival outcomes in patients with HCC who underwent LR and LT. Nine studies were identified, including 570 patients who underwent LR and 861 who underwent LT. For HCC within the Milan criteria, the 1-year OS rates following LR and LT were 84.5% (473/560) and 84.4% (710/841), respectively (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.71-1.33; P = 0.8), and the 5-year OS rates were 47.9% (273/570) and 59.3% (509/858), respectively (OR, 0.60; 95% CI, 0.35-1.02; P = 0.06). One-year DFS rates were similar (OR, 1.00; 95% CI, 0.39-2.61; P = 1.00), whereas the 3-year DFS rate was significantly lower in the LR group (54.4%, 210/386) than in the LT group (74.2%, 317/427; OR, 0.24; 95% CI, 0.07-0.80; P = 0.02), and the 5-year DFS rate was significantly lower for LR than LT (OR, 0.18; 95% CI, 0.06-0.53; P < 0.01). For small HCCs, the 5-year OS rate was significantly lower for patients who underwent LR than LT (OR, 0.30; 95% CI, 0.19-0.48; P < 0.001). In conclusion, relative to LR, LT in patients with HCC meeting the Milan criteria had no benefits before 10 years for OS. For DFS, the benefit is obtained after 3 years. Liver Transplantation 23 836-844 2017 AASLD.
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Affiliation(s)
- Benjamin Menahem
- Department of Digestive Surgery, University Hospital of Caen, Caen, France.,Normandie Université, UNICAEN, CEA, Centre National de la Recherche Scientifique, Centre Hospitalier Universitaire Caen, INSERM Unités Mixtes de Recherche 1086, Centre François Baclesse, Caen, France
| | - Jean Lubrano
- Department of Digestive Surgery, University Hospital of Caen, Caen, France.,Normandie Université, UNICAEN, CEA, Centre National de la Recherche Scientifique, Centre Hospitalier Universitaire Caen, INSERM Unités Mixtes de Recherche 1086, Centre François Baclesse, Caen, France
| | - Christophe Duvoux
- Department of Hepatology, University Hospital of Henri Mondor, Créteil, France
| | - Andrea Mulliri
- Department of Digestive Surgery, University Hospital of Caen, Caen, France
| | - Arnaud Alves
- Department of Digestive Surgery, University Hospital of Caen, Caen, France
| | - Charlotte Costentin
- Department of Hepatology, University Hospital of Henri Mondor, Créteil, France
| | - Ariane Mallat
- Department of Hepatology, University Hospital of Henri Mondor, Créteil, France
| | - Guy Launoy
- Normandie Université, UNICAEN, CEA, Centre National de la Recherche Scientifique, Centre Hospitalier Universitaire Caen, INSERM Unités Mixtes de Recherche 1086, Centre François Baclesse, Caen, France
| | - Alexis Laurent
- Department of Hepatobiliary Surgery and Liver Transplantation, University Hospital of Henri Mondor, Créteil, France.,Unité INSERM U 1855, University Hospital of Henri Mondor, Créteil, France
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Liver Resection and Transplantation for Patients With Hepatocellular Carcinoma Beyond Milan Criteria. Ann Surg 2017; 264:650-8. [PMID: 27433910 DOI: 10.1097/sla.0000000000001866] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To assess survival after liver resection and transplantation in patients with hepatocellular carcinoma (HCC) beyond Milan criteria. BACKGROUND The role of liver resection and transplantation remains controversial for patients with HCC beyond Milan criteria. Resection of advanced tumors and transplantation using extended-criteria are pursued at select high-volume center. METHODS Patients from 5 liver cancer centers in the United States who had liver resection or transplantation for HCC beyond Milan criteria between 1990 and 2011 were included in the study. Multivariable and propensity-matching analyses estimated the effects of clinical factors and operative selection on survival. RESULTS Of 608 patients beyond Milan without vascular invasion, 480 (79%) patients underwent resection and 128 (21%) underwent transplantation. Clinicopathologic profiles between resection and transplant patients differed significantly. Hepatitis C and cirrhosis were more prevalent in transplantation group (P < 0.001). Resection patients had larger tumors [median 9 cm, interquartile range (IQR): 6.5-12.9 cm vs. median 4.1, IQR: 3.4-5.3 cm, P < 0.001]; transplant patients were more likely to have multiple tumors (78% vs 28%, P < 0.001).Overall (OS) and disease-free survival (DFS) were both greater after tumor downstaging and transplantation than resection (all P < 0.001). OS did not differ between liver transplant recipients who were not pretreated or pretreated and failed to downstage compared with propensity-matched liver resection patients (P ≥ 0.176); DFS in this propensity matched cohort was greater after liver transplantation (P ≤ 0.017). CONCLUSIONS Liver resection and transplantation provide curative options for patients with HCC beyond Milan criteria. Further treatment strategies aimed at the efficiency and durability of tumor downstaging and expansion of the role of transplantation among suitable candidates could improve outcomes in patients with large or multifocal HCC.
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Lopes FDLM, Coelho FF, Kruger JAP, Fonseca GM, Araujo RLCD, Jeismann VB, Herman P. INFLUENCE OF HEPATOCELLULAR CARCINOMA ETIOLOGY IN THE SURVIVAL AFTER RESECTION. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:105-8. [PMID: 27438037 PMCID: PMC4944746 DOI: 10.1590/0102-6720201600020010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/22/2016] [Indexed: 12/31/2022]
Abstract
Background: Hepatocellular carcinoma (HCC) is the most frequent type of primary liver cancer
and its incidence is increasing around the world in the last decades, making it
the third cause of death by cancer in the world. Hepatic resection is one of the
most effective treatments for HCC with five-year survival rates from 50-70%,
especially for patients with a single nodule and preserved liver function. Some
studies have shown a worse prognosis for HCC patients whose etiology is viral.
That brings us to the question about the existence of a difference between the
various causes of HCC and its prognosis. Aim: To compare the prognosis (overall and disease-free survival at five years) of
patients undergoing hepatectomy for the treatment of HCC with respect to various
causes of liver disease. Method: Was performed a review of medical records of patients undergoing hepatectomy
between 2000 and 2014 for the treatment of HCC. They were divided into groups
according to the cause of liver disease, followed by overall and disease-free
survival analysis for comparison. Results: There was no statistically significant difference in the outcomes of the groups of
patients divided according to the etiology of HCC. Overall and disease-free
survival at five years of the patients in this sample were 49.9% and 40.7%,
respectively. Conclusion: From the data of this sample, was verified that there was no prognostic
differences among the groups of HCC patients of the various etiologies.
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Affiliation(s)
| | - Fabricio Ferreira Coelho
- Liver Unit, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | | | - Gilton Marques Fonseca
- Liver Unit, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | | | - Vagner Birk Jeismann
- Liver Unit, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Paulo Herman
- Liver Unit, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, SP, Brazil
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Shen JY, Li C, Wen TF, Yan LN, Li B, Wang WT, Yang JY, Xu MQ, Nazar Highness T. Liver transplantation versus surgical resection for HCC meeting the Milan criteria: A propensity score analysis. Medicine (Baltimore) 2016; 95:e5756. [PMID: 28033289 PMCID: PMC5207585 DOI: 10.1097/md.0000000000005756] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The optimal treatment (liver transplantation [LT] vs surgical resection [SR]) for early-stage hepatocellular carcinoma (HCC) remains controversial.A total of 209 SR patients and 129 LT patients were identified at our institution. After eliminating 27 patients with Child-Pugh C, the data from 209 SR patients and 102 LT patients were analyzed using a propensity score matching (PSM) model. Forty-six pairs were generated. A subgroup analysis was conducted based on the alpha-fetoprotein (AFP) level or platelet count (PLT). A survival analysis was performed using the Kaplan-Meier method.Gender, satellite lesions, and the treatment method were predictors of HCC recurrence. The Ishak score and treatment methods were associated with long-term survival after surgery. Before PSM, LT patients had a better prognosis than those treated by SR. Among HCC patients with childhood A/B cirrhosis, after PSM, SR achieved similar overall survival outcomes compared with LT. LT and SR resulted in comparable long-term survival for patients with or without thrombocytopenia. Patients with an AFP ≥ 400 ng/mL might achieve more survival benefits from LT.Our propensity score model provided evidence that, compared with transplantation, surgical resection could result in comparable long-term survival for resectable early-stage HCC patients, except for the AFP ≥ 400 ng/mL HCC subgroup. Surgical resection might not be a contraindication for early-stage HCC patients with thrombocytopenia due to their similar prognosis after transplantation.
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Wong LL, Hernandez BY, Shvetsov YB, Kawano Y, Tang ZY, Ji JF. Liver resection for early hepatocellular cancer: Comparison of centers in 3 different countries. World J Hepatol 2016; 8:1327-1335. [PMID: 27872684 PMCID: PMC5099585 DOI: 10.4254/wjh.v8.i31.1327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/28/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To compare patients who underwent resection of early stage hepatocellular cancer (HCC) in three different countries.
METHODS This retrospective study characterizes 573 stage I/II HCC patients treated with liver resection in 3 tertiary-referral centers: Tokyo (n = 250), Honolulu (n = 146) and Shanghai (n = 177).
RESULTS Shanghai patients were younger, predominantly male, hepatitis-B seropositive (94%) and cirrhotic (93%). Tokyo patients were older and more likely to have hepatitis-C (67%), smaller tumors, low albumin, and normal alpha-fetoprotein. The Honolulu cohort had the largest tumors and 30% had no viral hepatitis. Age-adjusted mortality at 1 and 5-years were lower in the Tokyo cohort compared to Honolulu and there was no difference in mortality between Shanghai and Honolulu cohorts. Elevated alpha-fetoprotein, low albumin and tumor > 5 cm were associated with increased 1-year mortality. These factors and cirrhosis were independently associated with increased 5-year mortality. Independent risk factors of survival varied when examined separately by center.
CONCLUSION The profile of early-stage HCC patients is strikingly different across countries and likely contributes to survival differences. Underlying differences in patient populations including risk factors/comorbidities influencing disease progression may also account for variation in outcomes.
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Lei JY, Yan LN, Wang WT, Zhu JQ, Li DJ. Health-Related Quality of Life and Psychological Distress in Patients With Early-Stage Hepatocellular Carcinoma After Hepatic Resection or Transplantation. Transplant Proc 2016; 48:2107-11. [PMID: 27569954 DOI: 10.1016/j.transproceed.2016.04.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/25/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of our study was to compare the post-operative health-related quality of life in patients with small hepatocellular carcinoma (HCC; within the Milan criteria) after liver resection or liver transplantation. METHODS From August 2000 to December 2010, 207 patients were diagnosed with early HCC within the Milan criteria. We divided these patients into 2 groups according to their curative schedule: the liver transplantation group (n = 95) and the liver resection group (n = 110). We compared the baseline characteristics of these 2 groups of patients, after which we focused on comparing the post-operative health-related quality of life (HRQOL) and psychological outcome in these 2 groups. RESULTS The demographics of the patients in the 2 groups were similar, and there were no significant differences except for higher family income in the transplantation group (P = .002).With long-term follow-up, there were no significant differences in the 8 domains of the HRQOL and the 9 domains of the psychological outcome measure between the 2 groups. Both the transplantation and resection groups exhibited good outcomes in both HRQOL and psychological outcome measures. CONCLUSIONS Several years after operation, early-stage HCC patients who underwent liver transplantation or resection had similar long-term HRQOL and psychological outcomes.
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Affiliation(s)
- J Y Lei
- Thyroid and Parathyroid Surgery Center, West China Hospital of Sichuan University, Chengdu, China; Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - L N Yan
- Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - W T Wang
- Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - J Q Zhu
- Thyroid and Parathyroid Surgery Center, West China Hospital of Sichuan University, Chengdu, China
| | - D J Li
- The Medical Department, West China Hospital of Sichuan University, Chengdu, China.
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Mohkam K, Golse N, Bonal M, Ledochowski S, Rode A, Selmaji IE, Merle P, Ducerf C, Mornex F, Mabrut JY. Conformal radiotherapy as a bridge to liver transplantation for hepatocellular carcinoma: is it safe? Future Oncol 2016; 12:1577-86. [DOI: 10.2217/fon-2016-0083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aim: To report a preliminary experience of conformal radiotherapy (CRT) as bridge to orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC). Methods: Data of 12 patients undergoing CRT for HCC followed by OLT between 2012 and 2014 were reviewed. Results: CRT was used in a neoadjuvant or downstaging setting in nine and three patients, respectively. No radiation-related systemic toxicity was observed. Median blood loss and operating time were 1450 ml (600–4000) and 420 min (240–510), respectively. Four patients had diaphragmatic injury. Complete histological response was observed in six patients, and partial response in five. Seven patients developed severe postoperative morbidity including five anastomosis-related complications and one death. Conclusion: CRT for HCC provides satisfactory histological response but may compromise OLT safety.
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Affiliation(s)
- Kayvan Mohkam
- Department of General Surgery & Liver Transplant, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
- Equipe Mixte de Recherche 3738, Ecole Doctorale EDISS 205, Université Claude Bernard Lyon 1, Lyon, France
| | - Nicolas Golse
- Department of General Surgery & Liver Transplant, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Mathieu Bonal
- Department of General Surgery & Liver Transplant, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Stanislas Ledochowski
- Intensive Care Unit, Hospices Civils de Lyon, Lyon-Sud University Hospital, Pierre-Bénite, France
| | - Agnès Rode
- Department of Radiology, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Imad E Selmaji
- Department of Radiation Oncology, Hospices Civils de Lyon, Lyon-Sud University Hospital, Pierre-Bénite, France
| | - Philippe Merle
- Department of Hepatology, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Christian Ducerf
- Department of General Surgery & Liver Transplant, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Françoise Mornex
- Equipe Mixte de Recherche 3738, Ecole Doctorale EDISS 205, Université Claude Bernard Lyon 1, Lyon, France
- Department of Radiation Oncology, Hospices Civils de Lyon, Lyon-Sud University Hospital, Pierre-Bénite, France
| | - Jean-Yves Mabrut
- Department of General Surgery & Liver Transplant, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
- Equipe Mixte de Recherche 3738, Ecole Doctorale EDISS 205, Université Claude Bernard Lyon 1, Lyon, France
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46
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Liver transplantation for hepatobiliary malignancies: a new era of "Transplant Oncology" has begun. Surg Today 2016; 47:403-415. [PMID: 27130463 DOI: 10.1007/s00595-016-1337-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/06/2016] [Indexed: 01/10/2023]
Abstract
The indications of liver transplantation for hepatobiliary malignancies have been carefully expanded in a stepwise fashion, despite the fundamental limitations in oncological, immunological, and technical aspects. A new era of "Transplant Oncology," the fusion of transplant surgery and surgical oncology, has begun, and we stand at the dawn of a paradigm shift in multidisciplinary cancer treatment. For hepatocellular carcinoma, new strategies have been undertaken to select recipients based on biological and dynamic markers instead of conventional morphological and static parameters, opening the doors for a more deliberate expansion of the Milan criteria and locoregional therapies before liver transplantation. Neoadjuvant chemoradiation therapy followed by liver transplantation for unresectable perihilar cholangiocarcinoma developed by the Mayo Clinic provided excellent outcomes in a US multicenter study; however, the surgical indications are not necessarily universal and await international validation. Similarly, an aggressive multidisciplinary approach has been applied for other tumors, including intrahepatic cholangiocarcinoma, hepatoblastoma, liver metastases from colorectal and neuroendocrine primary and gastrointestinal stromal tumors as well as rare tumors, such as hepatic undifferentiated embryonal sarcoma and infantile choriocarcinoma. In conclusion, liver transplantation is an important option for hepatobiliary malignancies; however, prospective studies are urgently needed to ensure the appropriate patient selection, organ allocation and living donation policies, and administration of antineoplastic immunosuppression.
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The role of liver transplantation or resection for patients with early hepatocellular carcinoma. Tumour Biol 2015; 37:4193-201. [PMID: 26490991 DOI: 10.1007/s13277-015-4243-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 10/12/2015] [Indexed: 12/14/2022] Open
Abstract
Liver resection (LR) and liver transplantation (LT) are curative treatments for early hepatocellular carcinoma (HCC), although their performance remains debated. We compared the survival of patients with HCC conforming to the Milan criteria (MC) after LT and LR and analyzed factors affecting clinical outcomes. Between January 2006 and January 2013, 65 and 184 patients received LT and LR for HCCs fulfilling the MC, respectively. Overall survival (OS) and disease-free survival (DFS) rates were compared between the two groups. To investigate effects of liver function and living donor liver transplantation (LDLT) on survival, two subgroup analyses were performed and associations with OS and DFS were examined. We found that OS rates were higher after LT than after LR since 3 years postoperatively. DFS rates were significantly better after LT than after LR. Performance of LR, vascular invasion, and tumor multiplicity were associated with poor DFS, and factors affecting OS included the presence of vascular invasions, liver cirrhosis, and tumor multiplicity. In conclusion, despite of the effects of tumor characteristics on clinical outcomes, LT, including LDLT, should be considered the treatment of choice for patients with HCCs who met the MC. The role of LR is to identify poor prognostic factors through pathological examination.
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Zhang HM, Jiang WT, Pan C, Deng YL, Zheng H, Shen ZY. Milan criteria, University of California, San Francisco, criteria, and model for end-stage liver disease score as predictors of salvage liver transplantation. Transplant Proc 2015; 47:438-44. [PMID: 25769587 DOI: 10.1016/j.transproceed.2014.10.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/12/2014] [Accepted: 10/28/2014] [Indexed: 02/07/2023]
Abstract
The selection criteria for salvage liver transplantation (SLT) candidates have not been previously established. A global analysis for the association between the criteria and prognosis is required. All of the adult patients who underwent liver transplantation with a diagnosis of hepatocellular carcinoma (HCC) from January 1, 2000, to December 31, 2011, were retrospectively analyzed. A total of 1,554 cases were involved, including 1,392 primary liver transplantation (PLT) and 162 SLT cases. All the cases were classified into 3 groups according to the Milan criteria combined with the University of California, San Francisco (UCSF), criteria, and significant differences were found between the 2 groups. The overall graft survival rate was lower in all cases of SLT than in PLT (P = .030). Within the Milan criteria, no significant difference in the graft survival rate was found between PLT and SLT. In a Cox regression analysis, the Model for End-Stage Liver Disease (MELD) score and tumor levels graded according to the Milan/UCSF criteria were found to be independent risk factors for the graft survival rate. Receiver operating characteristic (ROC) curves were generated by the fatality risk values calculated by means of the Cox model and the 1-year graft survival rates of all the patients and of the SLT patients. The areas under the ROC curves were 0.922 and 0.935, respectively. Compared with PLT, the global graft survival rate of SLT was compromised. The MELD score and Milan/UCSF criteria were effective in predicting the prognosis of PLT and SLT. Therefore, when the recurrent lesions of HCC are within the Milan criteria, SLT can be performed with a good prognosis.
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Affiliation(s)
- H-M Zhang
- Transplantation Department, First Central Clinical College of Tianjin Medical University, Tianjin First Central Hospital, Tianjin Key Laboratory of Organ Transplantation, Tianjin, People's Republic of China.
| | - W-T Jiang
- Transplantation Department, First Central Clinical College of Tianjin Medical University, Tianjin First Central Hospital, Tianjin Key Laboratory of Organ Transplantation, Tianjin, People's Republic of China
| | - C Pan
- Transplantation Department, First Central Clinical College of Tianjin Medical University, Tianjin First Central Hospital, Tianjin Key Laboratory of Organ Transplantation, Tianjin, People's Republic of China
| | - Y-L Deng
- Transplantation Department, First Central Clinical College of Tianjin Medical University, Tianjin First Central Hospital, Tianjin Key Laboratory of Organ Transplantation, Tianjin, People's Republic of China
| | - H Zheng
- Transplantation Department, First Central Clinical College of Tianjin Medical University, Tianjin First Central Hospital, Tianjin Key Laboratory of Organ Transplantation, Tianjin, People's Republic of China
| | - Z-Y Shen
- Transplantation Department, First Central Clinical College of Tianjin Medical University, Tianjin First Central Hospital, Tianjin Key Laboratory of Organ Transplantation, Tianjin, People's Republic of China
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Microvascular infiltration has limited clinical value for treatment and prognosis in hepatocellular carcinoma. World J Surg 2015; 38:1769-76. [PMID: 24378549 DOI: 10.1007/s00268-013-2426-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Microvascular infiltration (MVI) is considered a necessary step in the metastatic evolution of hepatocellular carcinoma (HCC), but its prognostic value after liver resection (LR) is uncertain. We studied the clinical value of MVI compared to the Milan criteria in a consecutive series of patients submitted to radical LR. METHODS A total of 441 patients were retrospectively evaluated. MVI and the Milan criteria were analyzed and compared as prognostic factors for overall and disease-free survival (DFS). RESULTS MVI was present in 189 patients (42.8 %). Grading, satellitosis, size of cancer, and alfa fetoprotein value were significantly related to MVI, which was present in 34.3 and 53.2 % of Milan+ and Milan- patients, respectively (p = 0.00001). Both MVI and the Milan criteria were associated with a lower overall and DFS, but only the Milan criteria were associated with the rate of early recurrence and the feasibility of a curative treatment of the recurrence. The application of MVI parameters to patients classified by the Milan criteria further selects the outcome in Milan+ patients (5-year survival rate of 54.1 and 67.9 %, respectively, in the presence or absence of MVI) but not in Milan- patients. CONCLUSIONS MVI is related to survival after LR for HCC, but the clinical value of this information is limited. In Milan+ patients, the absence of MVI selects the cases with better prognosis. In the presence of a liver recurrence, the Milan criteria related to the primary HCC show a better prognostic accuracy and have clinical relevance in the decision-making process.
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Scatton O, Goumard C, Cauchy F, Fartoux L, Perdigao F, Conti F, Calmus Y, Boelle PY, Belghiti J, Rosmorduc O, Soubrane O. Early and resectable HCC: Definition and validation of a subgroup of patients who could avoid liver transplantation. J Surg Oncol 2015; 111:1007-15. [PMID: 25918872 DOI: 10.1002/jso.23916] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 03/16/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Liver transplantation (LT) remains the best curative option for early hepatocellular carcinoma (HCC) but is limited by the ongoing graft shortage. The present study aimed at defining the population in which primary liver resection (LR) could represent the best alternative to LT. METHODS An exploration set of 357 HCC patients (LR n = 221 and LT n = 136) operated between 2000-2012 was used in order to identify factors associated with survival following LR and define a good prognosis (GP) group for which LR may challenge the results of upfront LT. These factors were validated in an external validation set of 565 HCC patients operated at another center (LR n = 287 LR and LT n = 278). RESULTS In the exploration set, factors associated with survival on multivariate analysis were a solitary lesion, a diameter <50 mm, a well-moderately differentiated lesion, the absence of microvascular invasion, and preoperative AST level <2N. Thirty-nine patients (18%) displayed all these criteria and constituted the GP patients. Overall survivals at 1, 3, and 5 years did not significantly differ between GP resected patients, and the in Milan transplanted patients (93, 80.4, and 80.4% vs. 86.9, 82, and 78.8%, P = 0.79). In the validation cohort, patients with GP factors of survival still displayed better overall survivals than those without (P = 0.036) but also displayed better survivals than in Milan HCC transplanted patients (P = 0.005). CONCLUSION In a group of early HCC patients gathering all factors of GP, primary LR achieves at least similar survival as upfront LT and should be the approach of choice.
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Affiliation(s)
- Olivier Scatton
- Departments of Hepatobiliary Surgery and Liver Transplantation, Hôpital Pitié Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France. .,Université Pierre et Marie Curie, Paris 6.
| | - Claire Goumard
- Departments of Hepatobiliary Surgery and Liver Transplantation, Hôpital Pitié Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Francois Cauchy
- Department of Hepatobiliary surgery and Liver Transplantation, Hopital Beaujon, Assistance Publique Hopitaux de Paris, Paris, France
| | - Laetitia Fartoux
- Université Pierre et Marie Curie, Paris 6.,Department of Hepatology, Hopital Pitié Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Fabiano Perdigao
- Departments of Hepatobiliary Surgery and Liver Transplantation, Hôpital Pitié Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Filomena Conti
- Université Pierre et Marie Curie, Paris 6.,Department of Pathology, Hopital Pitié Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Yvon Calmus
- Université Pierre et Marie Curie, Paris 6.,Department of Pathology, Hopital Pitié Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Pierre Yves Boelle
- Department of Biostatistics, Hopital Saint Antoine, Assistance Publique Hopitaux de Paris, Paris, France
| | - Jacques Belghiti
- Department of Hepatobiliary surgery and Liver Transplantation, Hopital Beaujon, Assistance Publique Hopitaux de Paris, Paris, France
| | - Olivier Rosmorduc
- Université Pierre et Marie Curie, Paris 6.,Department of Hepatology, Hopital Pitié Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France
| | - Olivier Soubrane
- Departments of Hepatobiliary Surgery and Liver Transplantation, Hôpital Pitié Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France.,Université Pierre et Marie Curie, Paris 6
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