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Tabrizian P, Holzner M, Ajmera V, Kim AK, Zhou K, Schnickel GT, Torosian K, Hoteit M, Marino R, Li M, Yao F, Florman SS, Schwartz ME, Mehta N. Intention-to-treat outcomes of patients with hepatocellular carcinoma receiving immunotherapy before liver transplant: the multicenter VITALITY study. J Hepatol 2024:S0168-8278(24)02541-8. [PMID: 39255928 DOI: 10.1016/j.jhep.2024.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 08/23/2024] [Accepted: 09/03/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND AND AIMS The use of immune checkpoint inhibitors (ICI) in patients with advanced hepatocellular carcinoma (HCC) has become widespread with encouraging outcomes in the neoadjuvant setting. Safety and intention to treat (ITT) outcomes in the peri transplant setting are currently based on small and heterogenous single center reports. METHODS This first multiregional US study (2016-2023) included 117 consecutive HCC patients assessed for LT and treated preoperatively with ICIs. Intention to treat ITT and survival analyses were conducted with evaluation of post LT rejection rates. RESULTS In total, 86 (73.5%) patients exceeded MC and 65 (75.6%) were successfully downstaged (DS) within a median of 5.6 months. 43 (36.7%) underwent transplantation, including 18 (15.4%) within MC and 23 (19.7%) initially beyond and DS. Overall, 94% of the cohort received concurrent ICIs and locoregional therapies. No grade 4-5 adverse events occurred on the waiting list. The 3-year cumulative probability of dropout was 28% for those within MC and 48% for those beyond. Independent predictors of dropout included: being beyond MC (p<0.001), AFP doubling from baseline (p=0.014) and radiographic responses (p<0.001). The 3-year ITT survival was 71.1% (73.5% within MC vs 69.7% beyond MC, p=0.329), with 3-year post LT survival rate of 85%. Post-LT rejection occurred in 7 patients, six received their last dose of ICI less than 3 months prior to LT, resulting in one graft loss. CONCLUSIONS The first multicenter evaluation of HCC patients receiving ICI pre-LT demonstrates favorable survival and safety outcomes, justifying continued utilization and further evaluation of this strategy in clinical practice. High tumor burden, doubling of AFP levels, and radiographic response were identified as predictors of unfavorable oncologic outcomes. IMPACT AND IMPLICATIONS The first multicenter evaluation of pre-transplant immune-checkpoint-inhibitors in hepatocellular carcinoma to show promising intention-to-treat survival, safety and rejection rates. Immune-checkpoint-inhibitors, either alone or combined with LRT, demonstrate reliable efficacy. This preoperative strategy could be particularly beneficial for high-risk patients, including those requiring downstaging or with elevated AFP levels despite locoregional treatment. These findings fill current knowledge gaps and offer reassuring evidence for the feasibility of pre-transplant use of immune-checkpoint-inhibitors, pending results from ongoing trials.
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Affiliation(s)
- Parissa Tabrizian
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Matthew Holzner
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Veeral Ajmera
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, San Diego, California
| | - Amy K Kim
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kali Zhou
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Gabriel T Schnickel
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Kelly Torosian
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, San Diego, California
| | - Maarouf Hoteit
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca Marino
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael Li
- Division of Gastroenterology/Hepatology, University of California San Francisco, San Francisco, California
| | - Francis Yao
- Division of Gastroenterology/Hepatology, University of California San Francisco, San Francisco, California; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Sander S Florman
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Myron E Schwartz
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neil Mehta
- Division of Gastroenterology/Hepatology, University of California San Francisco, San Francisco, California
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Pahari H, Peer JA, Tripathi S, Singhvi SK, Dhir U. Downstaging of advanced hepatocellular carcinoma followed by liver transplantation using immune checkpoint inhibitors: Where do we stand? World J Gastrointest Pharmacol Ther 2024; 15:97570. [DOI: 10.4292/wjgpt.v15.i5.97570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 08/22/2024] [Accepted: 08/28/2024] [Indexed: 09/03/2024] Open
Abstract
Liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) and chronic liver disease (CLD) is limited by factors such as tumor size, number, portal venous or hepatic venous invasion and extrahepatic disease. Although previously established criteria, such as Milan or UCSF, have been relaxed globally to accommodate more potential recipients with comparable 5-year outcomes, there is still a subset of the population that has advanced HCC with or without portal vein tumor thrombosis without detectable extrahepatic spread who do not qualify or are unable to be downstaged by conventional methods and do not qualify for liver transplantation. Immune checkpoint inhibitors (ICI) such as atezolizumab, pembrolizumab, or nivolumab have given hope to this group of patients. We completed a comprehensive literature review using PubMed, Google Scholar, reference citation analysis, and CrossRef. The search utilized keywords such as 'liver transplant', 'HCC', 'hepatocellular carcinoma', 'immune checkpoint inhibitors', 'ICI', 'atezolizumab', and 'nivolumab'. Several case reports have documented successful downstaging of HCC using the atezolizumab/bevacizumab combination prior to LT, with acceptable early outcomes comparable to other criteria. Adverse effects of ICI have also been reported during the perioperative period. In such cases, a 1.5-month interval between ICI therapy and LT has been suggested. Overall, the results of downstaging using combination immunotherapy were encouraging and promising. Early reports suggested a potential ray of hope for patients with CLD and advanced HCC, especially those with multifocal HCC or branch portal venous tumor thrombosis. However, prospective studies and further experience will reveal the optimal dosage, duration, and timing prior to LT and evaluate both short- and long-term outcomes in terms of rejection, infection, recurrence rates, and survival.
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Affiliation(s)
- Hirak Pahari
- Department of Liver Transplant and Hepatobiliary Surgery, Sir Ganga Ram Hospital, New Delhi 110060, Delhi, India
| | - Javid A Peer
- Department of Surgical Gastroenterology and Liver Transplant, Sir Ganga Ram Hospital, New Delhi 110060, Delhi, India
| | - Shikhar Tripathi
- Department of Surgical Gastroenterology and Liver Transplant, Sir Ganga Ram Hospital, New Delhi 110060, Delhi, India
| | - Suresh K Singhvi
- Department of Liver Transplant and Hepatobiliary Surgery, Sir Ganga Ram Hospital, New Delhi 110060, Delhi, India
| | - Ushast Dhir
- Department of Liver Transplant and Hepatobiliary Surgery, Sir Ganga Ram Hospital, New Delhi 110060, Delhi, India
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3
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Mauro E, Sanduzzi-Zamparelli M, Jutras G, Garcia R, Soler Perromat A, Llarch N, Holguin Arce V, Ruiz P, Rimola J, Lopez E, Ferrer-Fàbrega J, García-Criado Á, Colmenero J, Lai JC, Forner A. Challenges in Liver Transplantation for Hepatocellular Carcinoma: A Review of Current Controversies. Cancers (Basel) 2024; 16:3059. [PMID: 39272917 DOI: 10.3390/cancers16173059] [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: 07/24/2024] [Revised: 08/29/2024] [Accepted: 08/30/2024] [Indexed: 09/15/2024] Open
Abstract
Liver transplantation (LT) remains one of the most effective treatments for hepatocellular carcinoma (HCC) and significantly enhances patient survival. However, the application of LT for HCC faces challenges owing to advancements in cancer-specific treatment modalities and the increased burden of patients' comorbidities. This narrative review explores current controversies and advancements in LT for HCC. Key areas of focus include the management of comorbidities and patient education by advanced practice nurses, impacts of frailty on waitlists and post-LT outcomes, selection criteria for LT in the era of new downstaging tools, role of radiology in patient selection, and implications of potential immunotherapy use both before and after LT. Additionally, the importance of immunosuppression management with strategies aimed at minimizing rejection while considering the risk of HCC recurrence and the role of surveillance for HCC recurrence is highlighted. This review also underscores the importance of a multidisciplinary approach for optimizing outcomes in patients with HCC undergoing LT.
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Affiliation(s)
- Ezequiel Mauro
- Liver Oncology Unit, Liver Unit, ICMDM, Hospital Clinic Barcelona, 08036 Barcelona, Spain
- Barcelona Clinic Liver Cancer (BCLC) Group, IDIBAPS, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Marco Sanduzzi-Zamparelli
- Liver Oncology Unit, Liver Unit, ICMDM, Hospital Clinic Barcelona, 08036 Barcelona, Spain
- Barcelona Clinic Liver Cancer (BCLC) Group, IDIBAPS, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Gabrielle Jutras
- Department of Medicine, Division of Hepatology, Centre Hospitalier de l'Université de Montréal, Montreal, QC H2X 3E4, Canada
| | - Raquel Garcia
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Liver Transplant Unit, Liver Unit, ICMDM, Hospital Clinic Barcelona, IDIBAPS, University of Barcelona, 08007 Barcelona, Spain
| | - Alexandre Soler Perromat
- Barcelona Clinic Liver Cancer (BCLC) Group, IDIBAPS, 08036 Barcelona, Spain
- Radiology Department, CDI, Hospital Clinic Barcelona, IDIBAPS, 08036 Barcelona, Spain
| | - Neus Llarch
- Liver Oncology Unit, Liver Unit, ICMDM, Hospital Clinic Barcelona, 08036 Barcelona, Spain
- Barcelona Clinic Liver Cancer (BCLC) Group, IDIBAPS, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Victor Holguin Arce
- Barcelona Clinic Liver Cancer (BCLC) Group, IDIBAPS, 08036 Barcelona, Spain
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Hospital Clinic Barcelona, 08036 Barcelona, Spain
| | - Pablo Ruiz
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Liver Transplant Unit, Liver Unit, ICMDM, Hospital Clinic Barcelona, IDIBAPS, University of Barcelona, 08007 Barcelona, Spain
| | - Jordi Rimola
- Barcelona Clinic Liver Cancer (BCLC) Group, IDIBAPS, 08036 Barcelona, Spain
- Radiology Department, CDI, Hospital Clinic Barcelona, IDIBAPS, 08036 Barcelona, Spain
| | - Eva Lopez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Liver Transplant Unit, Liver Unit, ICMDM, Hospital Clinic Barcelona, IDIBAPS, University of Barcelona, 08007 Barcelona, Spain
- Universidad Jaume I, 12006 Castellón de la Plana, Spain
| | - Joana Ferrer-Fàbrega
- Barcelona Clinic Liver Cancer (BCLC) Group, IDIBAPS, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Hospital Clinic Barcelona, 08036 Barcelona, Spain
- University of Barcelona, 08007 Barcelona, Spain
| | - Ángeles García-Criado
- Barcelona Clinic Liver Cancer (BCLC) Group, IDIBAPS, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Radiology Department, CDI, Hospital Clinic Barcelona, IDIBAPS, 08036 Barcelona, Spain
- University of Barcelona, 08007 Barcelona, Spain
| | - Jordi Colmenero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Liver Transplant Unit, Liver Unit, ICMDM, Hospital Clinic Barcelona, IDIBAPS, University of Barcelona, 08007 Barcelona, Spain
- University of Barcelona, 08007 Barcelona, Spain
| | - Jennifer C Lai
- Departament of Medicine, Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, CA 94115, USA
| | - Alejandro Forner
- Liver Oncology Unit, Liver Unit, ICMDM, Hospital Clinic Barcelona, 08036 Barcelona, Spain
- Barcelona Clinic Liver Cancer (BCLC) Group, IDIBAPS, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- University of Barcelona, 08007 Barcelona, Spain
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Bambha K, Biggins SW, Hughes C, Humar A, Ganesh S, Sturdevant M. Future of U.S. living donor liver transplant: Donor and recipient criteria, transplant indications, transplant oncology, liver paired exchange, and non-directed donor graft allocation. Liver Transpl 2024:01445473-990000000-00437. [PMID: 39172018 DOI: 10.1097/lvt.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 07/24/2024] [Indexed: 08/23/2024]
Abstract
In the United States, living donor liver transplant (LDLT), from both directed and nondirected living donors, has expanded over the past several years. LDLT is viewed as an important opportunity to expand the overall donor pool for liver transplantation (LT), shorten waiting times for a life-prolonging LT surgery, and reduce LT waitlist mortality. The LT community's focus on LDLT expansion in the United States is fostering discussions around future opportunities, which include the safe expansion of donor and recipient candidate eligibility criteria, broadening indications for LDLT including applications in transplant oncology, developing national initiatives around liver paired exchange, and maintaining vigilance to living donor and recipient candidate risk/benefit equipoise. Potential opportunities for expanding living liver donor and recipient candidate criteria include using donors with more than minimal hepatic steatosis, evaluating older donors, performing LDLT in older recipients to facilitate timely transplantation, and providing candidates who would benefit from an LT, but may otherwise have limited access (ie, lower MELD scores), an avenue to receive a life-prolonging organ. Expansion opportunities for LDLT are particularly robust in the transplant oncology realm, including leveraging LDLT for patients with advanced HCC beyond Milan, intrahepatic cholangiocarcinoma, and nonresectable colorectal cancer liver metastases. With ongoing investment in the deliberate growth of LDLT surgical expertise, experience, and technical advances in the United States, the LT community's future vision to increase transplant access to more patients with end-stage liver disease and selected oncology patients may be successfully realized.
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Affiliation(s)
- Kiran Bambha
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott W Biggins
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christopher Hughes
- Division of Transplantation, Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abhi Humar
- Division of Transplantation, Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Swaytha Ganesh
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mark Sturdevant
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
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5
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Hogen R, Barry T, Subramanian V. Expanding Indications for Liver Transplantation in the Treatment of Hepatocellular Carcinoma. Curr Oncol 2024; 31:4753-4761. [PMID: 39195338 DOI: 10.3390/curroncol31080355] [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: 07/18/2024] [Revised: 08/12/2024] [Accepted: 08/18/2024] [Indexed: 08/29/2024] Open
Abstract
Improvements in downstaging therapies have expanded the indications for liver transplantation (LT) for hepatocellular carcinoma (HCC). Patients with more advanced disease are now considered candidates due to advancements in radiation therapy, combination therapies, and immunotherapy. Combination stereotactic body radiation therapy (SBRT) and trans-arterial chemoembolization (TACE) has been shown to be superior to the historic treatment, sorafenib, in patients with macrovascular invasion. These patients are now candidates for LT with stable disease after LRT. Patients with ruptured HCC and prolonged stability have also been shown to have acceptable outcomes. The role of neoadjuvant immunotherapy needs to be further defined and has the potential to further improve tumor control prior to transplant.
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Affiliation(s)
- Rachel Hogen
- Transplant Institute, Tampa General Hospital, Tampa, FL 33606, USA
| | - Tara Barry
- Transplant Institute, Tampa General Hospital, Tampa, FL 33606, USA
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6
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Pan Y, Hu J, Li T, Zhang S, Zhou W, Sun J, Wang J, Li W, Xu J. Prior to ABOi liver transplant with PD-1 inhibitor in patients with hepatocellular carcinoma: A case report. Transpl Immunol 2024; 85:102079. [PMID: 38964516 DOI: 10.1016/j.trim.2024.102079] [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: 02/13/2024] [Revised: 04/12/2024] [Accepted: 06/30/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Liver transplantation (LT) is a unique and effective method for treating end-stage liver diseases and acute liver failure, bringing hope to many patients with liver cancer. LT is currently widely used in the treatment of liver diseases. However, there have been no patients with liver cancer who have undergone ABO-incompatible (ABOi) LT after treatment with the programmed cell death protein 1 (PD-1) inhibitor reported in the literature. CASE PRESENTATION A patient with liver cancer who received sintilimab injection, an anti-PD1 therapy, before LT was admitted in the transplantation centre. This patient underwent ABOi LT. The perioperative treatment strategy of this patient was reported. A desensitisation protocol was conducted urgently for the patient before operation, and the immunosuppression programme of LT was adjusted. After operation, isoagglutinin titer and liver function indicators were strictly monitored. The patient recovered well after operation, and no sign of rejection reaction was observed. CONCLUSION We reported a patient with hepatocellular carcinoma (HCC) who received PD-1 inhibitor treatment before operation and successfully underwent ABOi LT. The present case report provides novel insights into the perioperative management of utilizing PD-1 inhibitors prior to ABOi LT in patients diagnosed with hepatocellular carcinoma (HCC).
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Affiliation(s)
- Yipeng Pan
- Department of Transplantation, the Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570311, PR China
| | - Jicheng Hu
- Department of Transplantation, the Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570311, PR China
| | - Tao Li
- Department of Transplantation, the Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570311, PR China
| | - Shanbin Zhang
- Department of Transplantation, the Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570311, PR China
| | - Wanbang Zhou
- Department of Transplantation, the Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570311, PR China
| | - Jiangbo Sun
- Department of Transplantation, the Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570311, PR China
| | - Jianli Wang
- Department of Transplantation, the Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570311, PR China; Organ Transplant Center, Tianjin First Central Hospital, Tianjin 300190, PR China.
| | - Wei Li
- Department of Transplantation, the Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570311, PR China.
| | - Jian Xu
- Department of Transplantation, the Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570311, PR China.
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7
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Rose MG, Kennedy EB, Abou-Alfa GK, Finn RS, Gade T, Kelley RK, Taddei T, Gordan JD. Systemic Therapy for Advanced Hepatocellular Carcinoma: ASCO Guideline Update Clinical Insights. JCO Oncol Pract 2024; 20:1035-1039. [PMID: 38662970 DOI: 10.1200/op.24.00189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/12/2024] [Accepted: 03/22/2024] [Indexed: 08/15/2024] Open
Affiliation(s)
- Michal G Rose
- Yale University School of Medicine and VA Connecticut Healthcare System, West Haven, CT
| | | | - Ghassan K Abou-Alfa
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
- Trinity College Dublin Medical School, Dublin, Ireland
| | | | | | - R Kate Kelley
- University of California, San Francisco, San Francisco, CA
| | - Tamar Taddei
- Yale University School of Medicine and VA Connecticut Healthcare System, West Haven, CT
| | - John D Gordan
- University of California, San Francisco, San Francisco, CA
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8
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Salerno DM, Shertel T, Brown RS. Pre-Transplant Immune Checkpoint Inhibitor Use: the Intersection Between Medicine, Surgery and Pharmacy. J Hepatol 2024:S0168-8278(24)02429-2. [PMID: 39074560 DOI: 10.1016/j.jhep.2024.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/31/2024]
Affiliation(s)
- David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY.
| | - Tara Shertel
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY
| | - Robert S Brown
- Division of Gastroenterology, Department of Medicine, Weill Cornell Medicine, New York, NY
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9
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Rezaee-Zavareh MS, Yeo YH, Wang T, Guo Z, Tabrizian P, Ward SC, Barakat F, Hassanein TI, Shravan D, Veeral A, Bhoori S, Mazzaferro V, Chascsa DMH, Liu MC, Aby ES, Lake JR, Sogbe M, Sangro B, Abdelrahim M, Esmail A, Schmiderer A, Chouik Y, Rudolph M, Sohal D, Giudicelli H, Allaire M, Akce M, Guadagno J, Tow CY, Massoumi H, De Simone P, Kang E, Gartrell RD, Martinez M, Paz-Fumagalli R, Toskich BB, Tran NH, Solino GA, Poltronieri Pacheco DM, Kalman RS, Agopian VG, Mehta N, Parikh ND, Singal AG, Yang JD. Impact of pre-transplant immune checkpoint inhibitor use on post-transplant outcomes in HCC: A systematic review and individual patient data meta-analysis. J Hepatol 2024:S0168-8278(24)02354-7. [PMID: 38996924 DOI: 10.1016/j.jhep.2024.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/05/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND AND AIM Treatment with immune checkpoint inhibitors (ICIs) for hepatocellular carcinoma (HCC) prior to liver transplantation (LT) has been reported; however, ICIs may elevate the risk of allograft rejection and impact other clinical outcomes. This study aims to summarize the impact of ICI use on post-LT outcomes. MATERIALS AND METHODS In this individual patient data meta-analysis, we searched databases to identify HCC cases treated with ICIs before LT, detailing allograft rejection, HCC recurrence, and overall survival. We performed Cox regression analysis to identify risk factors for allograft rejection. RESULTS Among 91 eligible patients, with a median (interquartile range [IQR]) follow-up of 690.0 (654.5) days, there were 24 (26.4%) allograft rejections, 9 (9.9%) HCC recurrences, and 9 (9.9%) deaths. Age (adjusted hazard ratio [aHR] per 10 years=0.72, 95% confidence interval [CI]=0.53, 0.99, P=0.044) and ICI washout time (aHR per 1 week=0.92, 95% CI=0.86, 0.99, P=0.022) were associated with allograft rejection. The median (IQR) washout period for patients with ≤20% probability of allograft rejection was 94 (196) days. Overall survival did not differ between cases with and without allograft rejection (log-rank test, p=0.2). Individuals with HCC recurrence had fewer median (IQR) ICI cycles than those without recurrence (4.0 [1.8]) vs. 8.0 [9.0]); p=0.025). The proportion of patients within Milan post-ICI was lower for those with recurrence vs. without (16.7% vs. 65.3%, p=0.032) CONCLUSION: Patients have acceptable post-LT outcomes after ICI therapy. Age and ICI washout length relate to the allograft rejection risk, and a 3-month washout may reduce it to that of patients without ICI exposure. Number of ICI cycles and tumor burden may affect recurrence risk. Large prospective studies are necessary to confirm these associations. IMPACT AND IMPLICATIONS This systematic review and individual patient data meta-analysis of 91 patients with hepatocellular carcinoma and immune checkpoint inhibitors use prior to liver transplantation suggests acceptable overall post-transplant outcomes. Older age and longer immune checkpoint inhibitor washout period have a significant inverse association with the risk of allograft rejection. A 3-month washout may reduce it to that of patients without ICI exposure. Additionally, a higher number of immune checkpoint inhibitor cycles and tumor burden within Milan criteria at the completion of immunotherapy may predict a decreased risk of hepatocellular carcinoma recurrence, but this observation requires further validation in larger prospective studies. CODE FOR INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS (PROSPERO): CRD42023494951.
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Affiliation(s)
| | - Yee Hui Yeo
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles 90048, CA, USA
| | - Tielong Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Parissa Tabrizian
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York
| | - Stephen C Ward
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Fatma Barakat
- Southern California Liver Centers, 131 Orange Avenue, Suite 101, Coronado, CA, 92118, USA
| | - Tarek I Hassanein
- Southern California Liver Centers, 131 Orange Avenue, Suite 101, Coronado, CA, 92118, USA
| | - Dave Shravan
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California, San Diego, La Jolla CA
| | - Ajmera Veeral
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California, San Diego, La Jolla CA
| | - Sherrie Bhoori
- HPB Surgery, Hepatology and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Vincenzo Mazzaferro
- HPB Surgery, Hepatology and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy; Department of Oncology, and Hemato-Oncology University of Milan, Milan, Italy
| | - David M H Chascsa
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA; Transplant Center, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Margaret C Liu
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Elizabeth S Aby
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN
| | - John R Lake
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN
| | - Miguel Sogbe
- Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra and CIBEREHD, Pamplona, Spain
| | - Bruno Sangro
- Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra and CIBEREHD, Pamplona, Spain
| | - Maen Abdelrahim
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Neal Cancer Center, Houston, TX 77030, USA; Cockrell Center of Advanced Therapeutics Phase I Program, Houston Methodist Research Institute, Houston, TX 77030, USA; Department of Internal Medicine, Weill Cornell Medical College, New York, NY 10021, USA
| | - Abdullah Esmail
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Neal Cancer Center, Houston, TX 77030, USA; Cancer Clinical Trials, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Andreas Schmiderer
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology and Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - Yasmina Chouik
- Cancer Research Center of Lyon (CRCL), INSERM U1052, Centre National de la Recherche Scientifique UMR5286, Lyon, France; Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Mark Rudolph
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Davendra Sohal
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Heloise Giudicelli
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Manon Allaire
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France; INSERM UMR 1138, Centre de recherche des Cordeliers, 75006 Paris, France
| | - Mehmet Akce
- Division of Hematology and Oncology, Department of Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Jessica Guadagno
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Clara Y Tow
- Division of Hepatology, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | - Hatef Massoumi
- Division of Hepatology, Northwell 261 East 78th Street, Floor 4, New York, NY 10075
| | - Paolo De Simone
- Hepatobiliary surgery and liver transplantation, University of Pisa Medical School Hospital, Via Paradisa 2, Pisa, 56124, Italy
| | - Elise Kang
- Department of Pediatrics, Division of Pediatric Hematology/Oncology/SCT, Columbia University Irving Medical Center, New York, New York, USA
| | - Robyn D Gartrell
- Department of Pediatrics, Division of Pediatric Hematology/Oncology/SCT, Columbia University Irving Medical Center, New York, New York, USA; Department of Oncology, Division of Pediatric Oncology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Mercedes Martinez
- Department of Pediatrics. Vagelos College of Physician and Surgeons. Columbia University, USA
| | | | - Beau B Toskich
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Nguyen H Tran
- Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Gabriela Azevedo Solino
- Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória - Department of Internal Medicine - Vitória/ES - Brazil
| | - Dra Mariana Poltronieri Pacheco
- Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória - Department of Gastroenterology and Hepatology - Vitória/ES - Brazil
| | - Richard S Kalman
- Division of Hepatology, Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Vatche G Agopian
- The Dumont-University of California, Los Angeles; Transplant Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Neil Mehta
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles 90048, CA, USA; Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles 90048, CA, USA; Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles 90048, CA, USA.
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10
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Martin SP, Mehta N, Emamaullee J. Immune checkpoint inhibitors in liver transplantation: Current practice, challenges, and opportunities. Liver Transpl 2024; 30:742-752. [PMID: 38345379 DOI: 10.1097/lvt.0000000000000350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/08/2024] [Indexed: 06/15/2024]
Abstract
Immune checkpoint inhibitors are becoming a mainstay of cancer treatment. While first studied and approved for patients with unresectable disease, due to their efficacy, they are becoming increasingly used in the perioperative period across many cancer types. In patients with HCC, immune checkpoint inhibitors have now become the standard of care in the advanced setting and have shown promising results in the adjuvant setting after liver resection. While these drugs continue to show promise, their role in the peritransplant setting still remains a question. In this review, we explore the current use of this class of medications in patients with HCC, as well as the immunologic role of the pathways that they inhibit. We also identify potential for future research opportunities to better understand the role of these medications.
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Affiliation(s)
- Sean P Martin
- Department of Surgery, Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Surgery, Division of Transplantation, Penn State Health Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Neil Mehta
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, UCSF, San Francisco, California, USA
| | - Juliet Emamaullee
- Department of Surgery, Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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11
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Mehta N, Kelley RK, Yao FY. Refining the approach to down-staging of HCC prior to liver transplantation: Patient selection, loco-regional treatments, and systemic therapies. Hepatology 2024; 80:238-253. [PMID: 37183865 DOI: 10.1097/hep.0000000000000452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - R Katie Kelley
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California, USA
| | - Francis Y Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, California, USA
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12
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De Stefano N, Patrono D, Colli F, Rizza G, Paraluppi G, Romagnoli R. Liver Transplantation for Hepatocellular Carcinoma in the Era of Immune Checkpoint Inhibitors. Cancers (Basel) 2024; 16:2374. [PMID: 39001436 PMCID: PMC11240403 DOI: 10.3390/cancers16132374] [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: 05/26/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/16/2024] Open
Abstract
Hepatocellular carcinoma (HCC) remains the leading oncological indication for liver transplantation (LT), with evolving and broadened inclusion criteria. Immune checkpoint inhibitors (ICIs) gained a central role in systemic HCC treatment and showed potential in the peri-transplant setting as downstaging/bridging therapy before LT or as a treatment for HCC recurrence following LT. However, the antagonistic mechanisms of action between ICIs and immunosuppressive drugs pose significant challenges, particularly regarding the risk of acute rejection (AR). This review analyzes the main signaling pathways targeted by ICI therapies and summarizes current studies on ICI therapy before and after LT. The literature on this topic is limited and highly heterogeneous, precluding definitive evidence-based conclusions. The use of ICIs before LT appears promising, provided that a sufficient wash-out period is implemented. In contrast, the results of post-LT ICI therapy do not support its wide clinical application due to high AR rates and overall poor response to treatment. In the future, modern graft preservation techniques might support the selection of good ICI responders, but data from high-level studies are urgently needed.
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Affiliation(s)
| | | | | | | | | | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Corso Bramante 88-90, 10126 Torino, Italy; (N.D.S.); (D.P.); (F.C.); (G.R.); (G.P.)
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13
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Li M, Bhoori S, Mehta N, Mazzaferro V. Immunotherapy for hepatocellular carcinoma: The next evolution in expanding access to liver transplantation. J Hepatol 2024:S0168-8278(24)00423-9. [PMID: 38848767 DOI: 10.1016/j.jhep.2024.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/22/2024] [Accepted: 05/25/2024] [Indexed: 06/09/2024]
Abstract
Immunotherapy has revolutionised the treatment of advanced hepatocellular carcinoma (HCC). In addition, several phase III trials of immunotherapy in combination with surgical or locoregional therapies for early-to intermediate-stage HCC have recently reported positive results, and other phase III trials in the same patient population are currently in progress. As the application of immunotherapy is shifting to include patients with earlier stages of HCC, one looming question now emerges: What is the role of immunotherapy in the pre-liver transplant population? Liver transplantation is a potentially curative therapy for HCC and confers the additional advantage of restoring a normal, healthy liver. In pre-transplant patients, immunotherapy may improve downstaging success and tumour control at the cost of some immunologic risks. These include immune-related toxicities, which are particularly relevant in a uniquely vulnerable population with chronic liver disease, and the possibility of acute rejection after transplantation. Ultimately, the goal of immunotherapy in this population will be to effectively expand access to liver transplantation while preserving pre- and post-transplant outcomes. In this review, we discuss the mechanisms supporting combination immunotherapy, summarise key recent clinical data from major immunotherapy trials, and explore how immunotherapy can be applied in the neoadjuvant setting prior to liver transplantation in selected high-risk patients.
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Affiliation(s)
- Michael Li
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco CA, USA
| | - Sherrie Bhoori
- Division of HPB Surgery, Hepatology and Liver Transplantation, University of Milan, and Fondazione IRCCS Istituto Nazionale Tumori, Milan Italy
| | - Neil Mehta
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco CA, USA.
| | - Vincenzo Mazzaferro
- Division of HPB Surgery, Hepatology and Liver Transplantation, University of Milan, and Fondazione IRCCS Istituto Nazionale Tumori, Milan Italy.
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14
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Kumar P, Krishna P, Nidoni R, Adarsh CK, Arun MG, Shetty A, Mathangi J, Sandhya, Gopasetty M, Venugopal B. Atezolizumab plus bevacizumab as a downstaging therapy for liver transplantation in hepatocellular carcinoma with portal vein thrombosis: The first report. Am J Transplant 2024; 24:1087-1090. [PMID: 38219868 DOI: 10.1016/j.ajt.2024.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 01/16/2024]
Abstract
Atezolizumab plus bevacizumab is the preferred first-line treatment regimen for patients with advanced hepatocellular carcinoma. Limited data have shown promising results with the use of immune checkpoint inhibitors like nivolumab to downstage these patients for liver transplantation (LT). Here, we describe the first case of successful downstaging with atezolizumab plus bevacizumab in a patient with multifocal hepatocellular carcinoma and main portal vein tumoral thrombosis, followed by ABO-incompatible live donor LT. This illustrated case highlights that atezolizumab plus bevacizumab therapy may be a potential bridging tool for curative LT.
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Affiliation(s)
- Pramod Kumar
- Department of Hepatology, BGS Gleneagles Global Hospital, Bengaluru, Karnataka, India.
| | - Pradeep Krishna
- Department of HPB and Liver Transplantation Surgery, BGS Gleneagles Global Hospital, Bengaluru, Karnataka, India
| | - Ravindra Nidoni
- Department of HPB and Liver Transplantation Surgery, BGS Gleneagles Global Hospital, Bengaluru, Karnataka, India
| | - C K Adarsh
- Department of Gastroenterology, BGS Gleneagles Global Hospital, Bengaluru, Karnataka, India
| | - M G Arun
- Department of Liver transplantation anesthesia, BGS Gleneagles Global Hospital, Bengaluru, Karnataka, India
| | - Aashish Shetty
- Department of Liver transplantation anesthesia, BGS Gleneagles Global Hospital, Bengaluru, Karnataka, India
| | - J Mathangi
- Department of Radiation Oncology, BGS Gleneagles Global Hospital, Bengaluru, Karnataka, India
| | - Sandhya
- Department of Pathology, BGS Gleneagles Global Hospital, Bengaluru, Karnataka, India
| | - Mahesh Gopasetty
- Department of HPB and Liver Transplantation Surgery, BGS Gleneagles Global Hospital, Bengaluru, Karnataka, India
| | - B Venugopal
- Department of HPB and Liver Transplantation Surgery, BGS Gleneagles Global Hospital, Bengaluru, Karnataka, India
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15
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Saleh Y, Abu Hejleh T, Abdelrahim M, Shamseddine A, Chehade L, Alawabdeh T, Mohamad I, Sammour M, Turfa R. Hepatocellular Carcinoma: The Evolving Role of Systemic Therapies as a Bridging Treatment to Liver Transplantation. Cancers (Basel) 2024; 16:2081. [PMID: 38893200 PMCID: PMC11171314 DOI: 10.3390/cancers16112081] [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: 05/02/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related deaths. Classically, liver transplantation (LT) can be curative for HCC tumors within the Milan criteria. Bridging strategies to reduce the dropouts from LT waiting lists and/or to downstage patients who are beyond the Milan criteria are widely utilized. We conducted a literature-based review to evaluate the role of systemic therapies as a bridging treatment to liver transplantation (LT) in HCC patients. Tyrosine kinase inhibitors (TKIs) can be used as a systemic bridging therapy to LT in patients with contraindications for locoregional liver-directed therapies. Immune checkpoint inhibitor (ICI) treatment can be utilized either as a monotherapy or as a combination therapy with bevacizumab or TKIs prior to LT. Acute rejection after liver transplantation is a concern in the context of ICI treatment. Thus, a safe ICI washout period before LT and cautious post-LT immunosuppression strategies are required to reduce post-LT rejections and to optimize clinical outcomes. Nevertheless, prospective clinical trials are needed to establish definitive conclusions about the utility of systemic therapy as a bridging modality prior to LT in HCC patients.
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Affiliation(s)
- Yacob Saleh
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (T.A.H.); (T.A.); (M.S.)
| | - Taher Abu Hejleh
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (T.A.H.); (T.A.); (M.S.)
| | - Maen Abdelrahim
- Section of GI Oncology, Houston Methodist Neal Cancer Center, Houston, TX 77030, USA;
| | - Ali Shamseddine
- Division of Hematology and Oncology, Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Beirut P.O. Box 11-0236, Lebanon; (A.S.); (L.C.)
| | - Laudy Chehade
- Division of Hematology and Oncology, Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Beirut P.O. Box 11-0236, Lebanon; (A.S.); (L.C.)
| | - Tala Alawabdeh
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (T.A.H.); (T.A.); (M.S.)
| | - Issa Mohamad
- Department of Radiation Oncology, King Hussein Cancer Center, Amman 11941, Jordan;
| | - Mohammad Sammour
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (T.A.H.); (T.A.); (M.S.)
| | - Rim Turfa
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (T.A.H.); (T.A.); (M.S.)
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16
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Abdelrahim M, Esmail A, Divatia MK, Xu J, Kodali S, Victor DW, Brombosz E, Connor AA, Saharia A, Elaileh A, Kaseb AO, Ghobrial RM. Utilization of Immunotherapy as a Neoadjuvant Therapy for Liver Transplant Recipients with Hepatocellular Carcinoma. J Clin Med 2024; 13:3068. [PMID: 38892779 PMCID: PMC11172993 DOI: 10.3390/jcm13113068] [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: 04/03/2024] [Revised: 05/09/2024] [Accepted: 05/14/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Hepatocellular carcinoma (HCC) is widely recognized as the predominant type of primary liver malignancy. Orthotopic liver transplantation (OLT) has emerged as a highly effective treatment option for unresectable HCC. Immunotherapies as neoadjuvant options are now being actively investigated in the transplant oncology era to enhance outcomes in patients with HCC. Here, we report our experience with patients with HCC who had received Immune Checkpoint Inhibitors (ICPI) prior to curative OLT. Methods: This was a retrospective cohort that included patients with HCC who received ICPI prior to OLT at a single institution from January 2019 to August 2023. Graft rejection was assessed and reported along with the type of ICPI, malignancy treated, and the timing of ICPI in association with OLT. Results: During this cohort period, six patients with HCC underwent OLT after neoadjuvant ICPI. All patients were male with a median age of 61 (interquartile range: 59-64) years at OLT. Etiology associated with HCC was viral (N = 4) or Non-alcoholic steatohepatitis, NASH (N = 2). Tumor focality was multifocal (N = 4) and unifocal (N = 2). Lymphovascular invasion was identified in four patients. No perineural invasion was identified in any of the patients. All patients received ICPI including atezolizumab/bevacizumab (N = 4), nivolumab/ipilimumab (N = 1), and nivolumab as monotherapy (N = 1). All patients received either single or combined liver-directed/locoregional therapy, including transarterial chemoembolization (TACE), Yttrium-90 (Y90), stereotactic body radiotherapy (SBRT), and radiofrequency ablation (RFA). The median washout period was 5 months. All patients responded to ICPI and achieved a safe and successful OLT. All patients received tacrolimus plus mycophenolate as immunosuppressant (IS) therapy post-OLT and one patient received prednisone as additional IS. No patient had clinical evidence of rejection. Conclusions: This cohort emphasizes the success of tumor downstaging by ICPI for OLT when employed as the neoadjuvant therapy strategy. In addition, this study illustrated the importance of timing for the administration of ICPI before OLT. Given the lack of conclusive evidence in this therapeutic area, we believe that our study lays the groundwork for prospective trials to further examine the impact of ICPI prior to OLT.
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Affiliation(s)
- Maen Abdelrahim
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Neal Cancer Center, Houston Meth-Odist Hospital, Houston, TX 77030, USA; (A.E.)
- Cockrell Center of Advanced Therapeutics Phase I Program, Houston Methodist Research Institute, Houston, TX 77030, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Abdullah Esmail
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Neal Cancer Center, Houston Meth-Odist Hospital, Houston, TX 77030, USA; (A.E.)
| | - Mukul K. Divatia
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Jiaqiong Xu
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Neal Cancer Center, Houston Meth-Odist Hospital, Houston, TX 77030, USA; (A.E.)
| | - Sudha Kodali
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Lynda K. and David M. Underwood Center for Digestive Disorders, Department of Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - David W. Victor
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Lynda K. and David M. Underwood Center for Digestive Disorders, Department of Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Elizabeth Brombosz
- Department of Surgery, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Ashton A. Connor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX 77030, USA
- Department of Surgery, Weill Cornell Medical College, New York, NY 10065, USA
| | - Ashish Saharia
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX 77030, USA
- Department of Surgery, Weill Cornell Medical College, New York, NY 10065, USA
| | - Ahmed Elaileh
- Department of Surgery, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Ahmed O. Kaseb
- Department of Gastrointestinal (GI) Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Rafik Mark Ghobrial
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX 77030, USA
- Department of Surgery, Weill Cornell Medical College, New York, NY 10065, USA
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17
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Gordan JD, Kennedy EB, Abou-Alfa GK, Beal E, Finn RS, Gade TP, Goff L, Gupta S, Guy J, Hoang HT, Iyer R, Jaiyesimi I, Jhawer M, Karippot A, Kaseb AO, Kelley RK, Kortmansky J, Leaf A, Remak WM, Sohal DPS, Taddei TH, Wilson Woods A, Yarchoan M, Rose MG. Systemic Therapy for Advanced Hepatocellular Carcinoma: ASCO Guideline Update. J Clin Oncol 2024; 42:1830-1850. [PMID: 38502889 DOI: 10.1200/jco.23.02745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 12/28/2023] [Indexed: 03/21/2024] Open
Abstract
PURPOSE To update an evidence-based guideline to assist in clinical decision-making for patients with advanced hepatocellular carcinoma (HCC). METHODS ASCO convened an Expert Panel to update the 2020 guideline on systemic therapy for HCC. The panel updated the systematic review to include randomized controlled trials (RCTs) published through October 2023 and updated recommendations. RESULTS Ten new RCTs met the inclusion criteria and were added to the evidence base. RECOMMENDATIONS Atezolizumab + bevacizumab (atezo + bev) or durvalumab + tremelimumab (durva + treme) may be offered first-line for patients with advanced HCC, Child-Pugh class A liver disease, and Eastern Cooperative Oncology Group performance status 0-1. Where there are contraindications to these therapies, sorafenib, lenvatinib, or durvalumab may be offered first-line. Following first-line treatment with atezo + bev, second-line therapy with a tyrosine kinase inhibitor (TKI), ramucirumab (for patients with alpha-fetoprotein [AFP] ≥400 ng/mL), durva + treme, or nivolumab + ipilimumab (nivo + ipi) may be recommended for appropriate candidates. Following first-line therapy with durva + treme, second-line therapy with a TKI is recommended. Following first-line treatment with sorafenib or lenvatinib, second-line therapy options include cabozantinib, regorafenib for patients who previously tolerated sorafenib, ramucirumab (AFP ≥400 ng/mL), nivo + ipi, or durvalumab; atezo + bev or durva + treme may be considered for patients who did not have access to these therapies in the first-line setting, and do not have contraindications. Pembrolizumab or nivolumab are also options for appropriate patients following sorafenib or lenvatinib. Third-line therapy may be considered in Child-Pugh class A patients with good PS, using one of the agents listed previously that has a nonidentical mechanism of action with previously received therapy. A cautious approach to systemic therapy is recommended for patients with Child-Pugh class B advanced HCC. Further guidance on choosing between options is included within the guideline.Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines.
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Affiliation(s)
- John D Gordan
- University of California, San Francisco, San Francisco, CA
| | | | - Ghassan K Abou-Alfa
- Memorial Sloan Kettering Cancer Center and Weill Medical College at Cornell University, New York, NY
- Trinity College Dublin Medical School, Dublin, Ireland
| | | | | | | | - Laura Goff
- Vanderbilt Ingram Cancer Center, Nashville, TN
| | | | | | | | - Renuka Iyer
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | | | | | | | - R Kate Kelley
- University of California, San Francisco, San Francisco, CA
| | | | - Andrea Leaf
- VA New York Harbor Healthcare System, Brooklyn, NY
| | - William M Remak
- California Hepatitis C Task Force, California Chronic Care Coalition, FAIR Foundation, San Francisco, CA
| | | | - Tamar H Taddei
- Yale University School of Medicine and VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Michal G Rose
- Yale Cancer Center and VA Connecticut Healthcare System, West Haven, CT
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18
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Kim SJ, Cummins KC, Tsung A. Immunotherapy as a Complement to Surgical Management of Hepatocellular Carcinoma. Cancers (Basel) 2024; 16:1852. [PMID: 38791931 PMCID: PMC11120323 DOI: 10.3390/cancers16101852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/29/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver tumor in adults, and the fourth leading cause of cancer-related deaths worldwide. While surgical and ablative therapies remain the standard of care in early localized disease, late presentation with advanced stages of disease, impaired hepatic function, or local recurrence following surgical resection preclude operative management as the sole treatment modality in a subgroup of patients. As such, systemic therapies, namely immunotherapy, have become an integral part of the HCC treatment algorithm over the past decade. While agents, such as atezolizumab/bevacizumab, have well-established roles as first-line systemic therapy in intermediate- and advanced-stage HCC, the role of immunotherapy in disease amenable to surgical management continues to evolve. In this review, we will discuss the current evidence and aggregate impact of immunotherapy in the context of HCC amenable to surgical management, including its application in the neoadjuvant and adjuvant settings.
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Affiliation(s)
| | | | - Allan Tsung
- Department of Surgery, University of Virginia, Charlottesville, VA 22908, USA
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19
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Tabrizian P, Abdelrahim M, Schwartz M. Immunotherapy and transplantation for hepatocellular carcinoma. J Hepatol 2024; 80:822-825. [PMID: 38253289 DOI: 10.1016/j.jhep.2024.01.011] [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: 08/14/2023] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as the primary treatment for advanced hepatocellular carcinoma (HCC) and have shown promise in the neoadjuvant setting prior to resection. Liver transplantation (LT) is the preferred treatment for unresectable early HCC or locally advanced disease post locoregional therapy, but the need for immunosuppression after LT conflicts with ICIs' immune augmenting effects. Neoadjuvant ICI may benefit select LT candidates, but challenges arise in understanding response indicators and managing post-LT risks. Reports of severe rejection after LT have raised concerns, though liver-specific factors may mitigate rejection risks, prompting exploration of pre-LT ICI usage. While focus has been on PD-1/PD-L1 inhibitors, the optimal pre-LT ICI regimen remains uncertain, and trials must emphasize careful patient selection and management. Living donor LT is advantageous because ICIs can be withheld for a predefined washout period. In the post-LT setting, use of ICIs is generally avoided, though a few reports suggest that PD-L1 expression in the transplanted liver may be a safety biomarker and that, despite the risk, ICI therapy may be better than supportive care for patients with otherwise-untreatable HCC recurrence. This expert opinion highlights the complexities in the management of HCC vis-à-vis LT. Prospective studies and biomarkers are needed to define safe and effective pre- and post-LT immunotherapy protocols.
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Affiliation(s)
- Parissa Tabrizian
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Maen Abdelrahim
- Medical Oncology, Houston Methodist Texas Medical Center, Texas, United States
| | - Myron Schwartz
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, United States.
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20
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Guo Z, Liu Y, Ling Q, Xu L, Wang T, Zhu J, Lin Y, Lu X, Qu W, Zhang F, Zhu Z, Zhang J, Jia Z, Zeng P, Wang W, Sun Q, Luo Q, Hu Z, Zheng Z, Jia Y, Li J, Zheng Y, Wang M, Wang S, Han Z, Yu S, Li C, Zhang S, Xiong J, Deng F, Liu Y, Chen H, Wang Y, Li L, Liang W, Schlegel A, Björn N, Liu C, Zheng S, He X. Pre-transplant Use of Immune Checkpoint Inhibitors for Hepatocellular Carcinoma: A Multicenter, Retrospective Cohort Study. Am J Transplant 2024:S1600-6135(24)00278-8. [PMID: 38642712 DOI: 10.1016/j.ajt.2024.04.007] [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: 12/19/2023] [Revised: 03/24/2024] [Accepted: 04/15/2024] [Indexed: 04/22/2024]
Abstract
Immune checkpoint inhibitors (ICIs) as a downstaging or bridging therapy for liver transplantation (LT) in hepatocellular carcinoma (HCC) patients is rapidly increasing. However, the evidence about the feasibility and safety of pre-LT ICIs therapy is limited and controversial. To this end, a multicenter, retrospective cohort study was conducted in 11 Chinese centers. The results showed that 83 recipients received pre-LT ICIs therapy during the study period. The median post-LT follow up was 8.1 (interquartile range [IQR] 3.3-14.6) months. During the short follow-up, 23 (27.7%) recipients developed allograft rejection, and 7 of them (30.4%) was diagnosed by liver biopsy. Multivariate logistics regression analysis showed that time interval between the last administration of ICIs therapy and LT (TLAT) ≥ 30 days was an independent protective factor for allograft rejection (OR = 0.096, 95%CI 0.026-0.357; P < 0.001). Multivariate Cox analysis showed that allograft rejection was an independent risk factor for overall survival (OS) (HR = 9.960, 95%CI 1.006-98.610; P = 0.043). We conclude that patients who receive a pre-LT ICIs therapy with a TLAT shorter than 30 days have a much higher risk of allograft rejection than those with a TLAT longer than 30 days. The presence of rejection episodes might be associated with a higher post-LT mortality.
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Affiliation(s)
- Zhiyong Guo
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China; NHC key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou 510080, China
| | - Yao Liu
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Qi Ling
- Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 311121, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 311121, China
| | - Leibo Xu
- Department of Pancreato-Biliary Surgery and Liver Transplantation Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Tielong Wang
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Jiaxing Zhu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510120, China
| | - Yimou Lin
- Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 311121, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 311121, China
| | - Xinjun Lu
- Department of Pancreato-Biliary Surgery and Liver Transplantation Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Wei Qu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing100000, China; Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing100000, China
| | - Fan Zhang
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing100000, China; Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing100000, China
| | - Zhijun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing100000, China; Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing100000, China
| | - Jian Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou 510080, China
| | - Zehua Jia
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Ping Zeng
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Wenjing Wang
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510120, China
| | - Qiang Sun
- Department of General Surgery, Zhongshan People's Hospital, Zhongshan 528403, China
| | - Qijie Luo
- Department of General Surgery, Zhongshan People's Hospital, Zhongshan 528403, China
| | - Zemin Hu
- Department of General Surgery, Zhongshan People's Hospital, Zhongshan 528403, China
| | - Zhouying Zheng
- Department of Hepatobiliary Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Yingbin Jia
- Department of Urology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Jian Li
- Department of Hepatobiliary Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Yujian Zheng
- Department of Hepatobiliary Surgery & Liver Transplantation Center, General Hospital of Southern Theater Command, Guangzhou 510010, China
| | - Mengchao Wang
- Department of Hepatobiliary Surgery & Liver Transplantation Center, General Hospital of Southern Theater Command, Guangzhou 510010, China
| | - Shaoping Wang
- Department of Hepatobiliary Surgery & Liver Transplantation Center, General Hospital of Southern Theater Command, Guangzhou 510010, China
| | - Zemin Han
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Sheng Yu
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Chuanjiang Li
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Shuhua Zhang
- Department of Hepatobiliary Surgery of General Surgery, Liver transplant center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jun Xiong
- Department of Hepatobiliary Surgery of General Surgery, Liver transplant center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Feiwen Deng
- Liver Surgery Department, The First People's Hospital of Foshan, Foshan 528010, China
| | - Ying Liu
- Liver Surgery Department, The First People's Hospital of Foshan, Foshan 528010, China
| | - Huanwei Chen
- Liver Surgery Department, The First People's Hospital of Foshan, Foshan 528010, China
| | - Yanfeng Wang
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430071, China
| | - Ling Li
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430071, China
| | - Wenjin Liang
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430071, China
| | - Andrea Schlegel
- Transplantation Center, Digestive Disease and Surgery Institute, Department of Immunity and Inflammation, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44106, USA
| | - Nashan Björn
- Organ Transplantation Center, The First Affiliated Hospital of the University of Science and Technology of China, Hefei 230001, China
| | - Chao Liu
- Department of Pancreato-Biliary Surgery and Liver Transplantation Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China.
| | - Shusen Zheng
- Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 311121, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 311121, China.
| | - Xiaoshun He
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China.
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21
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Guba M, Werner J. [Liver transplantation for treatment of nonresectable primary and secondary liver malignancies : Hepatocellular and cholangiocellular carcinomas and colorectal liver metastases]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:268-273. [PMID: 38329517 DOI: 10.1007/s00104-024-02036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND With the increasing efficacy of systemic therapy, liver transplantation plays an important role not only for hepatocellular carcinoma (HCC) but also for nonresectable intrahepatic cholangiocellular carcinoma (iCC), perihilar cholangiocellular carcinoma (phCC) and colorectal liver metastases (CRLM). AIM To review the current state of knowledge regarding the indications, patient selection and expected outcomes of liver transplantation for HCC, iCC, phCC and CRLM. RESULTS When combined with neoadjuvant locoregional therapy (LRT) and/or systemic therapy, patients with nonresectable HCC, iCC, pCC and CRLM confined to the liver can be successfully transplanted with 5‑year survival rates exceeding 65%. The key to success is strict patient selection, which includes oncogenetic (e.g., BRAFV600E mutation status) and clinical criteria indicative of individual tumor biology (tumor markers: alpha-fetoprotein, AFP/carbohydrate antigen 19‑9, CA19-9/carcinoembryonic antigen, CEA, stable response to neoadjuvant therapy) in addition to morphometric criteria. CONCLUSION Liver transplantation offers the possibility of curative treatment even for nonresectable hepatic malignancies. A major limitation of this treatment is the lack of donor organs. Crucial for success is patient selection based on individual tumor biology.
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Affiliation(s)
- Markus Guba
- Klinik für Allgemein‑, Viszeral-, und Transplantationschirurgie, LMU München, Marchioninistraße 15, 81377, München, Deutschland.
| | - Jens Werner
- Klinik für Allgemein‑, Viszeral-, und Transplantationschirurgie, LMU München, Marchioninistraße 15, 81377, München, Deutschland
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22
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Tabrizian P, Zeitlhoefler M, Hassan AT, Marino R. Immunotherapy for transplantation of hepatocellular carcinoma: the next frontier in adjunctive therapy. Curr Opin Organ Transplant 2024; 29:144-154. [PMID: 38164882 DOI: 10.1097/mot.0000000000001133] [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: 01/03/2024]
Abstract
PURPOSE OF REVIEW The increasing success of liver transplantation in hepatocellular carcinoma (HCC) drives an ever-evolving search for innovative strategies to broaden eligible patients' pools. Recent advances in immuno-oncology have turned the spotlight on immune checkpoint inhibitors (ICIs). This review offers an updated overview of ICIs in liver transplantation for HCC, exploring neoadjuvant and adjuvant approaches and addressing unanswered questions on safety, patients' selection, and response predictors. RECENT FINDINGS ICIs have transitioned from being a last-chance therapeutic hope to becoming an integral cornerstone in the treatment of advanced HCC, holding great promise as a compelling option not only to downstage patients for transplantation but also as an alternative strategy in addressing posttransplantation disease recurrence. Despite ongoing refinements in immunotherapeutic agents, the complex molecular pathways involved emphasize the need for a comprehensive approach to integrate immunotherapy in liver transplantation. SUMMARY Initial concerns about graft rejection, with ICIs as a bridging therapy to liver transplantation, were successfully addressed using adequate immunosuppressants strategies and minimized with a sufficient washout period. Post-liver transplantation disease recurrence remains challenging, requiring a balance between effective therapy and preserving graft function. Emphasis should be placed on clinical trials validating the risk-benefit ratio of ICIs for liver transplantation, guiding appropriate patients' selection, and establishing clear management pathways.
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Affiliation(s)
- Parissa Tabrizian
- Liver Transplant and Hepatobiliary Surgery, Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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23
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Lerut J. Liver transplantation and liver resection as alternative treatments for primary hepatobiliary and secondary liver tumors: Competitors or allies? Hepatobiliary Pancreat Dis Int 2024; 23:111-116. [PMID: 38195351 DOI: 10.1016/j.hbpd.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/28/2023] [Indexed: 01/11/2024]
Affiliation(s)
- Jan Lerut
- Institute for Experimental and Clinical Research (IREC), Université catholique Louvain (UCL), Avenue Hippocrate 56, 1200 Woluwe Saint Pierre, Brussels, Belgium.
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24
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Haber PK, Krenzien F, Sarıbeyoğlu K, Pratschke J, Schöning W. Integrating the new systemic treatment landscape and surgical therapy in hepatocellular carcinoma. Turk J Surg 2024; 40:1-10. [PMID: 39036000 PMCID: PMC11257723 DOI: 10.47717/turkjsurg.2024.6375] [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: 03/07/2024] [Accepted: 03/12/2024] [Indexed: 07/23/2024]
Abstract
The treatment landscape of hepatocellular carcinoma has evolved rapidly within the last decade. Minimally-invasive techniques have reached a new level of safety, affording surgeons to pursue more aggressive treatment strategies to ultimately improve oncological outcomes. These procedures have been increasingly applied to treat patients with more progressed tumors and in select case even patients with advanced stage disease confined to the liver. Concomitantly, a dramatic increase in research into immunotherapy has altered the treatment paradigm in advanced disease stages, where the emerging treatment regimens can provide durable responses in a subset of the patient population for whom prognosis is dramatically improved. These treatments are now tested in early-stage disease to address the pressing unmet need of high recurrence rates after resection and in intermediate stage to complement the proven efficacy of intraarterial embolization in delaying progression. This review provides an in-depth discussion of these trends and describes how the treatment landscape has already changed and which impediments remain.
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Affiliation(s)
| | - Felix Krenzien
- Department of Surgery, Charité University, Berlin, Germany
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25
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Lindemann J, Doyle MBM. Expanding the Boundaries for Liver Transplantation for Hepatocellular Carcinoma. Surg Clin North Am 2024; 104:129-143. [PMID: 37953032 DOI: 10.1016/j.suc.2023.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer, which was the third most common cause of cancer death worldwide in 2020. Transplantation remains the preferred treatment for cure in otherwise unresectable HCC. There are several areas of active research that have led to expansion of eligibility criteria for transplantation including local-regional therapy for downstaging patients presenting outside of the Milan criteria and identification of tumor biomarkers aiding in the early diagnosis, determining prognosis and likelihood of recurrence after transplantation for HCC. New neoadjuvant therapies and post-transplant immunosuppression regimens may also result in expansion of transplant eligibility criteria for HCC.
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Affiliation(s)
- Jessica Lindemann
- Department of Surgery, Division of Abdominal Organ Transplantation, Washington University School of Medicine, Saint Louis, MO, USA
| | - Maria Bernadette Majella Doyle
- Section of Abdominal Transplantation, Department of Surgery, Division of Abdominal Organ Transplantation, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8109, Saint Louis, MO 63110, USA.
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26
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Krendl FJ, Bellotti R, Sapisochin G, Schaefer B, Tilg H, Scheidl S, Margreiter C, Schneeberger S, Oberhuber R, Maglione M. Transplant oncology - Current indications and strategies to advance the field. JHEP Rep 2024; 6:100965. [PMID: 38304238 PMCID: PMC10832300 DOI: 10.1016/j.jhepr.2023.100965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/31/2023] [Accepted: 11/04/2023] [Indexed: 02/03/2024] Open
Abstract
Liver transplantation (LT) was originally described by Starzl as a promising strategy to treat primary malignancies of the liver. Confronted with high recurrence rates, indications drifted towards non-oncologic liver diseases with LT finally evolving from a high-risk surgery to an almost routine surgical procedure. Continuously improving outcomes following LT and evolving oncological treatment strategies have driven renewed interest in transplant oncology. This is not only reflected by constant refinements to the criteria for LT in patients with HCC, but especially by efforts to expand indications to other primary and secondary liver malignancies. With new patient-centred oncological treatments on the rise and new technologies to expand the donor pool, the field has the chance to come full circle. In this review, we focus on the concept of transplant oncology, current indications, as well as technical and ethical aspects in the context of donor organs as precious resources.
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Affiliation(s)
- Felix J. Krendl
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Austria
| | - Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Austria
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Benedikt Schaefer
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Austria
| | - Herbert Tilg
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Austria
| | - Stefan Scheidl
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Austria
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Austria
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Austria
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27
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Liu H, Sethi V, Li X, Xiao Y, Humar A. Liver Transplantation for Hepatocellular Carcinoma: A Narrative Review and A Glimpse into The Future. Semin Liver Dis 2024; 44:79-98. [PMID: 38211621 DOI: 10.1055/a-2242-7543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Liver transplantation (LT) is a highly effective treatment for carefully selected patients with hepatocellular carcinoma (HCC). In this review, we explored the development of LT selection criteria and organ allocation policies, comparing original data to underscore their historical progression into the intricate task of quantitatively estimating pre- and post-LT survivals. We emphasized the role of biomarkers such as serum alpha-fetoprotein, Des-gamma-carboxy-prothrombin, circulating tumor cells, and circulating tumor DNA in predicting patient outcomes. Additionally, we examined the transplant-associated survival benefits and the difficulties in accurately calculating these benefits. We also reviewed recent advancements in targeted therapy and checkpoint inhibitors for advanced, inoperable HCC and projected their integration into LT for HCC. We further discussed the growing use of living donor liver transplants in the United States and compared its outcomes with those of deceased donor liver transplants. Furthermore, we examined the progress in machine perfusion techniques, which have shown potential in improving patient outcomes and enlarging the donor pool. These advancements present opportunities to enhance LT patient survivals, refine selection criteria, establish new priority metrics, develop innovative bridging and downstaging strategies, and formulate redesigned LT strategies for HCC treatments.
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Affiliation(s)
- Hao Liu
- Department of Surgery, Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vrishketan Sethi
- Department of Surgery, Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Xingjie Li
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Yao Xiao
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Abhinav Humar
- Department of Surgery, Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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28
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Tabrizian P, Yu A, Debnath N, Myers B, Marron T. Immunotherapy and Liver Transplantation: The Future or the Failure? Surg Clin North Am 2024; 104:163-182. [PMID: 37953034 DOI: 10.1016/j.suc.2023.07.009] [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] [Indexed: 11/14/2023]
Abstract
A quarter century has passed since the milestone study by Mazzaferro and colleagues on liver transplantation (LT) for hepatocellular carcinoma (HCC). The increasing demand for LT for HCC has led to the continued efforts to expand LT indications. Downstaging to within Milan criteria has been incorporated into the organ allocation policy for HCC in the United States in 2017 and provides acceptable long-term survival. The present review focuses on the rationale of neoadjuvant immune checkpoint inhibitor (ICI) in HCC, the experience of ICI in the pre- and posttransplant setting.
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Affiliation(s)
- Parissa Tabrizian
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy, New York, NY 10029, USA.
| | - Allen Yu
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy, New York, NY 10029, USA
| | - Neha Debnath
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy, New York, NY 10029, USA
| | - Bryan Myers
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy, New York, NY 10029, USA
| | - Thomas Marron
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy, New York, NY 10029, USA
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29
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Matevish L, Patel MS, Vagefi PA. Downstaging Techniques for Hepatocellular Carcinoma in Candidates Awaiting Liver Transplantation. Surg Clin North Am 2024; 104:145-162. [PMID: 37953033 DOI: 10.1016/j.suc.2023.07.004] [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] [Indexed: 11/14/2023]
Abstract
During the last decade, downstaging for hepatocellular carcinoma has expanded the pool of patients eligible for liver transplantation. The literature is rife with attempts to elucidate best treatment strategies with novel locoregional and systemic therapies continuing to emerge. Several trials have confirmed the large-scale success of downstaging protocols, with equitable long-term survival and recurrence rates after liver transplant. We review the currently available techniques used for downstaging, including their indications, complications, and efficacies. New frontiers have focused on the potential role of immunotherapy in the neoadjuvant setting, although more research is needed to delineate its role in current treatment paradigms.
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Affiliation(s)
- Lauren Matevish
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Parsia A Vagefi
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Block PD, Strazzabosco M, Jaffe A. Approach to immunotherapy for HCC in the liver transplant population. Clin Liver Dis (Hoboken) 2024; 23:e0158. [PMID: 38707244 PMCID: PMC11068135 DOI: 10.1097/cld.0000000000000158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/14/2024] [Indexed: 05/07/2024] Open
Affiliation(s)
- Peter D. Block
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mario Strazzabosco
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Liver Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Smilow Cancer Hospital and Liver Cancer Program, New Haven, Connecticut, USA
| | - Ariel Jaffe
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Liver Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Smilow Cancer Hospital and Liver Cancer Program, New Haven, Connecticut, USA
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31
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Lindemann J, Yu J, Doyle MBM. Downstaging Hepatocellular Carcinoma before Transplantation: Role of Immunotherapy Versus Locoregional Approaches. Surg Oncol Clin N Am 2024; 33:143-158. [PMID: 37945140 DOI: 10.1016/j.soc.2023.07.001] [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] [Indexed: 11/12/2023]
Abstract
Hepatocellular carcinoma (HCC) continues to be a leading cause of cancer-related death in the United States. With advances in locoregional therapy for unresectable HCC during the last 2 decades and the recent expansion of transplant criteria for HCC, as well as ongoing organ shortages, patients are spending more time on the waitlist, which has resulted in an increased usage of locoregional therapies. The plethora of molecularly targeted therapies and immune checkpoint inhibitors under investigation represent the new horizon of treatment of HCC not only in advanced stages but also potentially at every stage of diagnosis and management.
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Affiliation(s)
- Jessica Lindemann
- Department of Surgery, Division of Abdominal Organ Transplantation, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8109, St Louis, MO 63110, USA
| | - Jennifer Yu
- Department of Surgery, Division of Abdominal Organ Transplantation, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8109, St Louis, MO 63110, USA
| | - Maria Bernadette Majella Doyle
- Department of Surgery, Division of Abdominal Organ Transplantation, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8109, St Louis, MO 63110, USA.
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32
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Singal AG, Llovet JM, Yarchoan M, Mehta N, Heimbach JK, Dawson LA, Jou JH, Kulik LM, Agopian VG, Marrero JA, Mendiratta-Lala M, Brown DB, Rilling WS, Goyal L, Wei AC, Taddei TH. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology 2023; 78:1922-1965. [PMID: 37199193 PMCID: PMC10663390 DOI: 10.1097/hep.0000000000000466] [Citation(s) in RCA: 283] [Impact Index Per Article: 283.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Josep M. Llovet
- Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Mount Sinai School of Medicine, New York, New York, USA
- Translational Research in Hepatic Oncology, Liver Unit, August Pi i Sunyer Biomedical Research Institute, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Catalonia, Spain
| | - Mark Yarchoan
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Neil Mehta
- University of California, San Francisco, San Francisco, California, USA
| | | | - Laura A. Dawson
- Radiation Medicine Program/University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Janice H. Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Laura M. Kulik
- Northwestern Medical Faculty Foundation, Chicago, Illinois, USA
| | - Vatche G. Agopian
- The Dumont–University of California, Los Angeles, Transplant Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Jorge A. Marrero
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mishal Mendiratta-Lala
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Daniel B. Brown
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William S. Rilling
- Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lipika Goyal
- Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA
| | - Alice C. Wei
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Tamar H. Taddei
- Department of Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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Abdelrahim M, Esmail A, Abudayyeh A, Murakami N, Victor D, Kodali S, Cheah YL, Simon CJ, Noureddin M, Connor A, Saharia A, Moore LW, Heyne K, Kaseb AO, Gaber AO, Ghobrial RM. Transplant Oncology: An Emerging Discipline of Cancer Treatment. Cancers (Basel) 2023; 15:5337. [PMID: 38001597 PMCID: PMC10670243 DOI: 10.3390/cancers15225337] [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: 10/20/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
Transplant oncology is an emerging concept of cancer treatment with a promising prospective outcome. The applications of oncology, transplant medicine, and surgery are the core of transplant oncology to improve patients' survival and quality of life. The main concept of transplant oncology is to radically cure cancer by removing the diseased organ and replacing it with a healthy one, aiming to improve the survival outcomes and quality of life of cancer patients. Subsequently, it seeks to expand the treatment options and research for hepatobiliary malignancies, which have seen significantly improved survival outcomes after the implementation of liver transplantation (LT). In the case of colorectal cancer (CRC) in the transplant setting, where the liver is the most common site of metastasis of patients who are considered to have unresectable disease, initial studies have shown improved survival for LT treatment compared to palliative therapy interventions. The indications of LT for hepatobiliary malignancies have been slowly expanded over the years beyond Milan criteria in a stepwise manner. However, the outcome improvements and overall patient survival are limited to the specifics of the setting and systematic intervention options. This review aims to illustrate the representative concepts and history of transplant oncology as an emerging discipline for the management of hepatobiliary malignancies, in addition to other emerging concepts, such as the uses of immunotherapy in a peri-transplant setting as well as the use of circulating tumor DNA (ctDNA) for surveillance post-transplantation.
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Affiliation(s)
- Maen Abdelrahim
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX 77030, USA; (A.E.)
- Cockrell Center of Advanced Therapeutics Phase I Program, Houston Methodist Research Institute, Houston, TX 77030, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Abdullah Esmail
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX 77030, USA; (A.E.)
| | - Ala Abudayyeh
- Section of Nephrology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - David Victor
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Sudha Kodali
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Yee Lee Cheah
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Caroline J. Simon
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Mazen Noureddin
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Ashton Connor
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Ashish Saharia
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Linda W. Moore
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Kirk Heyne
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX 77030, USA; (A.E.)
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Ahmed O. Kaseb
- Department of Gastrointestinal (GI) Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - A. Osama Gaber
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Rafik Mark Ghobrial
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, JC Walter Jr. Center for Transplantation, Houston Methodist Hospital, Houston, TX 77030, USA
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Alghamdi S, Al-Hamoudi W. Hepatocellular Carcinoma: The Role of Immunotherapy and Transplantation in the Era of Transplant Oncology. Cancers (Basel) 2023; 15:5115. [PMID: 37958291 PMCID: PMC10648843 DOI: 10.3390/cancers15215115] [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: 08/31/2023] [Revised: 09/25/2023] [Accepted: 10/05/2023] [Indexed: 11/15/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most common causes of cancer deaths worldwide. As most patients present with advanced disease, curative therapy such as surgical resection and radiofrequency ablation are rarely utilized. With the advent of immunotherapy, historical treatment approaches such as liver transplantation are being challenged. In particular, the use of immune checkpoint inhibitors (ICIs) has emerged as a safe and useful option in the treatment of HCC. However, there is concern over adverse effects, such as graft rejection and graft loss. This updated review discusses the role of immunotherapy in the pre- and post-transplantation setting and provides insights into the potential of immunotherapy as an adjunct to liver transplantation. We deliberate on the use of ICI in the setting of the Milan criteria as well as the University of California San Francisco's expanded criteria for liver transplantation. Current data suggest that ICI has utility, especially in the pretransplantation setting. Nevertheless, larger, purposefully designed clinical trials are needed to clearly identify patients who will benefit most from ICI treatment in the transplant setting and determine parameters that will minimize the risk of graft rejection and maximize the benefits of this adjunct treatment.
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Affiliation(s)
- Saad Alghamdi
- Liver & Small Bowel Health Centre Department, Organ Transplant Center of Excellence, King Faisal Specialist Hospital & Research Center, Riyadh 11211, Saudi Arabia;
| | - Waleed Al-Hamoudi
- Liver & Small Bowel Health Centre Department, Organ Transplant Center of Excellence, King Faisal Specialist Hospital & Research Center, Riyadh 11211, Saudi Arabia;
- Liver Disease Research Center, College of Medicine, King Saud University, Riyadh 11211, Saudi Arabia
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Wassmer CH, El Hajji S, Papazarkadas X, Compagnon P, Tabrizian P, Lacotte S, Toso C. Immunotherapy and Liver Transplantation: A Narrative Review of Basic and Clinical Data. Cancers (Basel) 2023; 15:4574. [PMID: 37760542 PMCID: PMC10526934 DOI: 10.3390/cancers15184574] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have improved the management of patients with intermediate- and advanced-stage HCC, even making some of them potential candidates for liver transplantation. However, acute rejection has been observed after ICI therapy, challenging its safety in transplant settings. We summarize the key basic impact of immune checkpoints on HCC and liver transplantation. We analyze the available case reports and case series on the use of ICI therapy prior to and after liver transplantation. A three-month washout period is desirable between ICI therapy and liver transplantation to reduce the risk of acute rejection. Whenever possible, ICIs should be avoided after liver transplantation, and especially so early after a transplant. Globally, more robust prospective data in the field are required.
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Affiliation(s)
- Charles-Henri Wassmer
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (S.E.H.); (X.P.); (S.L.); (C.T.)
| | - Sofia El Hajji
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (S.E.H.); (X.P.); (S.L.); (C.T.)
| | - Xenofon Papazarkadas
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (S.E.H.); (X.P.); (S.L.); (C.T.)
| | - Philippe Compagnon
- Division of Transplantation, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland;
| | - Parissa Tabrizian
- Mount Sinai Liver Cancer Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10019, USA;
| | - Stéphanie Lacotte
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (S.E.H.); (X.P.); (S.L.); (C.T.)
| | - Christian Toso
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (S.E.H.); (X.P.); (S.L.); (C.T.)
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Claasen MPAW, Sneiders D, Rakké YS, Adam R, Bhoori S, Cillo U, Fondevila C, Reig M, Sapisochin G, Tabrizian P, Toso C. European Society of Organ Transplantation (ESOT) Consensus Report on Downstaging, Bridging and Immunotherapy in Liver Transplantation for Hepatocellular Carcinoma. Transpl Int 2023; 36:11648. [PMID: 37779513 PMCID: PMC10533675 DOI: 10.3389/ti.2023.11648] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023]
Abstract
Liver transplantation offers the best chance of cure for most patients with non-metastatic hepatocellular carcinoma (HCC). Although not all patients with HCC are eligible for liver transplantation at diagnosis, some can be downstaged using locoregional treatments such as ablation and transarterial chemoembolization. These aforementioned treatments are being applied as bridging therapies to keep patients within transplant criteria and to avoid them from dropping out of the waiting list while awaiting a liver transplant. Moreover, immunotherapy might have great potential to support downstaging and bridging therapies. To address the contemporary status of downstaging, bridging, and immunotherapy in liver transplantation for HCC, European Society of Organ Transplantation (ESOT) convened a dedicated working group comprised of experts in the treatment of HCC to review literature and to develop guidelines pertaining to this cause that were subsequently discussed and voted during the Transplant Learning Journey (TLJ) 3.0 Consensus Conference that took place in person in Prague. The findings and recommendations of the working group on Downstaging, Bridging and Immunotherapy in Liver Transplantation for Hepatocellular Carcinoma are presented in this article.
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Affiliation(s)
- Marco Petrus Adrianus Wilhelmus Claasen
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, Netherlands
- Multi-Organ Transplant Program, University Health Network (UHN), Toronto, ON, Canada
| | - Dimitri Sneiders
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Yannick Sebastiaan Rakké
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - René Adam
- Centre Hépato-Biliaire, APHP Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Paris, France
| | - Sherrie Bhoori
- Hepatology, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Umberto Cillo
- Chirurgia Generale 2, Epato-Bilio-Pancreatica e Centro Trapianto di Fegato, Azienda Ospedale Università Padova, Padova, Italy
| | | | - Maria Reig
- BCLC Group, Liver Unit, Digestive Disease Institute, Hospital Clínic, IDIBAPS CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network (UHN), Toronto, ON, Canada
| | - Parissa Tabrizian
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Christian Toso
- Division of Abdominal Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Takamoto T, Maruki Y, Kondo S. Recent updates in the use of pharmacological therapies for downstaging in patients with hepatocellular carcinoma. Expert Opin Pharmacother 2023; 24:1567-1575. [PMID: 37357809 DOI: 10.1080/14656566.2023.2229728] [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: 03/29/2023] [Accepted: 06/22/2023] [Indexed: 06/27/2023]
Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is the most frequent primary liver cancer, but only 20-30% of patients benefit from potentially curative treatments such as liver resection or transplantation. This article reviews conventional treatments and recent progress in pharmacotherapy for advanced HCC, with a focus on downstaging unresectable tumors to resectable status. AREAS COVERED In this article, conventional treatments and recent progress in pharmacotherapy for advanced HCC, aiming at downstaging from unresectable to resectable status, are reviewed. Future prospectives of combination therapies using immune checkpoint inhibitors were also introduced by reviewing recent clinical trials, paying attention to the objective response rate as its potential of downstaging treatments. EXPERT OPINION The newly developed pharmacological therapies showed higher responses. Although various tumor statuses in advanced HCC hamper detailed analysis of successful conversion rate, the novel combined immunotherapies are expected to provide more opportunities for subsequent curative surgery for initially unresectable advanced HCC. The conversion treatment strategies for unresectable HCC should be separately discussed for 'technically resectable but oncologically unfavorable' HCC and metastatic or invasive HCC beyond curative surgical treatments. The optimal downstaging treatment strategy for advanced HCC is awaited. Elucidation of preoperatively available factors that predict successful downstaging will allow the tailoring of promising initial treatments leading to conversion surgery.
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Affiliation(s)
- Takeshi Takamoto
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yuta Maruki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Shunsuke Kondo
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
- Department of Experimental Therapeutics, National Cancer Center Hospital, Tokyo, Japan
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Brown ZJ, Ruff SM, Pawlik TM. The effect of liver disease on hepatic microenvironment and implications for immune therapy. Front Pharmacol 2023; 14:1225821. [PMID: 37608898 PMCID: PMC10441240 DOI: 10.3389/fphar.2023.1225821] [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: 05/19/2023] [Accepted: 07/31/2023] [Indexed: 08/24/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver cancer and the fourth leading cause of cancer-related death worldwide. HCC often occurs in the setting of chronic liver disease or cirrhosis. Recent evidence has highlighted the importance of the immune microenvironment in the development and progression of HCC, as well as its role in the potential response to therapy. Liver disease such as viral hepatitis, alcohol induced liver disease, and non-alcoholic fatty liver disease is a major risk factor for the development of HCC and has been demonstrated to alter the immune microenvironment. Alterations in the immune microenvironment may markedly influence the response to different therapeutic strategies. As such, research has focused on understanding the complex relationship among tumor cells, immune cells, and the surrounding liver parenchyma to treat HCC more effectively. We herein review the immune microenvironment, as well as the relative effect of liver disease on the immune microenvironment. In addition, we review how changes in the immune microenvironment can lead to therapeutic resistance, as well as highlight future strategies aimed at developing the next-generation of therapies for HCC.
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Affiliation(s)
- Zachary J. Brown
- Department of Surgery, New York University Long Island School of Medicine, Mineola, NY, United States
| | - Samantha M. Ruff
- James Comprehensive Cancer Center, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Timothy M. Pawlik
- James Comprehensive Cancer Center, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Cesario S, Genovesi V, Salani F, Vasile E, Fornaro L, Vivaldi C, Masi G. Evolving Landscape in Liver Transplantation for Hepatocellular Carcinoma: From Stage Migration to Immunotherapy Revolution. Life (Basel) 2023; 13:1562. [PMID: 37511937 PMCID: PMC10382048 DOI: 10.3390/life13071562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/30/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
Liver transplantation (LT) represents the primary curative option for HCC. Despite the extension of transplantation criteria and conversion with down-staging loco-regional treatments, transplantation is not always possible. The introduction of new standards of care in advanced HCC including a combination of immune checkpoint inhibitor-based therapies led to an improvement in response rates and could represent a promising strategy for down-staging the tumor burden. In this review, we identify reports and series, comprising a total of 43 patients who received immune checkpoint inhibitors as bridging or down-staging therapies prior to LT. Overall, treated patients registered an objective response rate of 21%, and 14 patients were reduced within the Milan criteria. Graft rejection was reported in seven patients, resulting in the death of four patients; in the remaining cases, LT was performed safely after immunotherapy. Further investigations are required to define the duration of immune checkpoint inhibitors, their minimum washout period and the LT long-term safety of this strategy. Some randomized clinical trials including immunotherapy combinations, loco-regional treatment and/or tyrosine kinase inhibitors are ongoing and will likely determine the appropriateness of immune checkpoint inhibitors' administration before LT.
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Affiliation(s)
- Silvia Cesario
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
| | - Virginia Genovesi
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
| | - Francesca Salani
- Institute of Interdisciplinary Research "Health Science", Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56124 Pisa, Italy
| | - Enrico Vasile
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
| | - Lorenzo Fornaro
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
| | - Caterina Vivaldi
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Gianluca Masi
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
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40
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Singal AG, Kudo M, Bruix J. Breakthroughs in Hepatocellular Carcinoma Therapies. Clin Gastroenterol Hepatol 2023; 21:2135-2149. [PMID: 36813012 PMCID: PMC10293061 DOI: 10.1016/j.cgh.2023.01.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/22/2022] [Accepted: 01/23/2023] [Indexed: 02/24/2023]
Abstract
Several breakthroughs in hepatocellular carcinoma (HCC) therapy across tumor stages provide hope to improve its dismal prognosis. Although surgical and local ablative therapies have few significant changes in technique, an improved understanding of tumor biology has facilitated increase numbers of patients who are now eligible to undergo curative-intent procedures. Most notably, acceptable post-transplant outcomes can be achieved in well selected patients whose tumors are downstaged into Milan Criteria. Adjuvant therapy in patients at high risk of recurrence also significantly improves recurrence-free survival after resection or ablation. For patients with liver-localized disease who are not eligible for curative-intent procedures, transarterial chemoembolization (TACE) was historically the treatment modality of choice, regardless of tumor burden; however, there is now increased recognition of patients who are "TACE unsuitable" and may be better treated with systemic therapy. The greatest evolution in HCC treatment options has occurred with systemic therapy, where several new agents are now available in the first- and second-line setting, including immune checkpoint inhibitor combinations. Objective responses are observed in approximately 30% of patients and median survival is approaching 2 years. The availability of immune checkpoint inhibitors has renewed interest in combination therapies for earlier tumor stages, with several phase III trials ongoing. Considering increasing complexities of HCC care, requiring decisions between therapies delivered by different providers, multidisciplinary care is critical and is associated with improved clinical outcomes. In this review, we detail major breakthroughs in HCC therapy, how these breakthroughs can be applied in clinical practice, and remaining areas in need of further research.
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Affiliation(s)
- Amit G Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka Japan.
| | - Jordi Bruix
- Barcelona Clinic Liver Cancer Group, Liver Unit, August Pi i Sunyer Biomedical Research Institute, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Hospital Clinic, University of Barcelona, Barcelona, Spain.
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Chouik Y, Erard D, Demian H, Schulz T, Mazard T, Hartig-Lavie K, Antonini T, Mabrut JY, Mohkam K, Rode A, Merle P. Case Report: Successful liver transplantation after achieving complete clinical remission of advanced HCC with Atezolizumab plus Bevacizumab combination therapy. Front Immunol 2023; 14:1205997. [PMID: 37377975 PMCID: PMC10291060 DOI: 10.3389/fimmu.2023.1205997] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
Background Atezolizumab plus Bevacizumab combination therapy has recently emerged as the new standard of care for unresectable HCC. Significant tumor burden reduction can be observed under that treatment, raising the question of liver transplantation (LT). The safety of another immune checkpoint inhibitor (ICI), nivolumab, is unclear in the pre-transplant setting. Method We report the case of a 57-y old man, with initial unresectable multinodular HCC contraindicated to LT and locoregional therapies, who achieves complete tumor response after Atezolizumab/Bevacizumab, and subsequently underwent LT for liver failure. Results Explant analysis revealed complete pathological response with no tumor remnant. The patient suffered from several post-operative complications but no HCC recurrence or biopsy-proven acute rejection occurred 10 months after LT. Conclusions Atezolizumab/Bevacizumab therapy may enable complete pathological response of advanced HCC. Safety of prolonged treatment need to be assessed.
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Affiliation(s)
- Yasmina Chouik
- Cancer Research Center of Lyon (CRCL), INSERM U1052, Centre National de la Recherche Scientifique UMR5286, Lyon, France
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Domitille Erard
- Cancer Research Center of Lyon (CRCL), INSERM U1052, Centre National de la Recherche Scientifique UMR5286, Lyon, France
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Hassan Demian
- Department of General Surgery and Liver Transplantation, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Thomas Schulz
- Department of Intensive Care, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Tessa Mazard
- Department of Intensive Care, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Kerstin Hartig-Lavie
- Cancer Research Center of Lyon (CRCL), INSERM U1052, Centre National de la Recherche Scientifique UMR5286, Lyon, France
| | - Teresa Antonini
- Cancer Research Center of Lyon (CRCL), INSERM U1052, Centre National de la Recherche Scientifique UMR5286, Lyon, France
| | - Jean-Yves Mabrut
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Department of General Surgery and Liver Transplantation, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Kayvan Mohkam
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Department of General Surgery and Liver Transplantation, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Agnès Rode
- Department of Radiology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Philippe Merle
- Cancer Research Center of Lyon (CRCL), INSERM U1052, Centre National de la Recherche Scientifique UMR5286, Lyon, France
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
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Koh B, Tan DJH, Lim WH, Wong JSL, Ng CH, Chan KE, Wang M, Yong WP, Dan YY, Wang LZ, Tan N, Muthiah M, Kow A, Syn NL, Huang DQ, Yau T. Trial watch: immunotherapeutic strategies on the horizon for hepatocellular carcinoma. Oncoimmunology 2023; 12:2214478. [PMID: 37284696 PMCID: PMC10241000 DOI: 10.1080/2162402x.2023.2214478] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 06/08/2023] Open
Abstract
The use of immune checkpoint inhibitors (ICIs) targeting PD-L1/PD-1 and CTLA-4 has transformed the oncology practice of hepatocellular carcinoma. However, only 25-30% of the patients with advanced HCC treated with atezolizumab-bevacizumab or tremelimumab-durvalumab (STRIDE) respond initially, and mechanistic biomarkers and novel treatment strategies are urgently needed for patients who present with or acquire resistance to first-line ICI-based therapies. The recent approval of the STRIDE regimen has also engendered new questions, such as patient selection factors (e.g. portal hypertension and history of variceal bleed) and biomarkers, and the optimal combination and sequencing of ICI-based regimens. Triumphs in the setting of advanced HCC have also galvanized considerable interest in the broader application of ICIs to early- and intermediate-stage diseases, including clinical combination of ICIs with locoregional therapies. Among these clinical contexts, the role of ICIs in liver transplantation - which is a potentially curative strategy unique to HCC management - as a bridge to liver transplant in potential candidates or in the setting of post-transplant recurrence, warrants investigation in view of the notable theoretical risk of allograft rejection. In this review, we summarize and chart the landscape of seminal immuno-oncology trials in HCC and envision future clinical developments.
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Affiliation(s)
- Benjamin Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Jeffrey S L Wong
- Department of Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Special Administrative Region, China
- State Key Laboratory for Liver Disease, University of Hong Kong, Hong Kong, Special Administrative Region, China
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Kai En Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Meng Wang
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Wei Peng Yong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Yock Young Dan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Louis Z Wang
- SingHealth Internal Medicine Residency Programme, Singapore General Hospital, Singapore, Singapore
| | - Nigel Tan
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, University Surgical Cluster, Singapore, Singapore
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Alfred Kow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, University Surgical Cluster, Singapore, Singapore
| | - Nicholas L Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
- Department of Pathology, National University Hospital, Singapore, Singapore
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Thomas Yau
- Department of Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Special Administrative Region, China
- State Key Laboratory for Liver Disease, University of Hong Kong, Hong Kong, Special Administrative Region, China
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Montano-Loza AJ, Rodríguez-Perálvarez ML, Pageaux GP, Sanchez-Fueyo A, Feng S. Liver transplantation immunology: Immunosuppression, rejection, and immunomodulation. J Hepatol 2023; 78:1199-1215. [PMID: 37208106 DOI: 10.1016/j.jhep.2023.01.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/30/2022] [Accepted: 01/30/2023] [Indexed: 05/21/2023]
Abstract
Outcomes after liver transplantation have continuously improved over the past decades, but long-term survival rates are still lower than in the general population. The liver has distinct immunological functions linked to its unique anatomical configuration and to its harbouring of a large number of cells with fundamental immunological roles. The transplanted liver can modulate the immunological system of the recipient to promote tolerance, thus offering the potential for less aggressive immunosuppression. The selection and adjustment of immunosuppressive drugs should be individualised to optimally control alloreactivity while mitigating toxicities. Routine laboratory tests are not accurate enough to make a confident diagnosis of allograft rejection. Although several promising biomarkers are being investigated, none of them is sufficiently validated for routine use; hence, liver biopsy remains necessary to guide clinical decisions. Recently, there has been an exponential increase in the use of immune checkpoint inhibitors due to the unquestionable oncological benefits they provide for many patients with advanced-stage tumours. It is expected that their use will also increase in liver transplant recipients and that this might affect the incidence of allograft rejection. Currently, the evidence regarding the efficacy and safety of immune checkpoint inhibitors in liver transplant recipients is limited and cases of severe allograft rejection have been reported. In this review, we discuss the clinical relevance of alloimmune disease, the role of minimisation/withdrawal of immunosuppression, and provide practical guidance for using checkpoint inhibitors in liver transplant recipients.
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Affiliation(s)
- Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, AB, Canada.
| | - Manuel L Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Universidad de Córdoba, IMIBIC, Córdoba, Spain; CIBER de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - George-Philippe Pageaux
- Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France
| | - Alberto Sanchez-Fueyo
- Institute of Liver Studies, King's College London University and King's College Hospital, London, United Kingdom
| | - Sandy Feng
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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Kuo FC, Chen CY, Lin NC, Liu C, Hsia CY, Loong CC. Optimizing the Safe Washout Period for Liver Transplantation Following Immune Checkpoint Inhibitors with Atezolizumab, Nivolumab, or Pembrolizumab. Transplant Proc 2023:S0041-1345(23)00232-4. [PMID: 37127513 DOI: 10.1016/j.transproceed.2023.03.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/28/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Using immune checkpoint inhibitors (ICIs) as a downstaging therapy for liver transplantation (LT) has improved outcomes for patients with advanced hepatocellular carcinoma (HCC). However, this therapy carries a risk of post-transplant graft rejection. The washout (WO) period between the last ICI dose and LT seems critical in preventing postoperative rejection. This study aimed to optimize the WO period by balancing tumor burden suppression and rejection prevention using ICIs before LT. METHODS We reviewed published case reports or series from March 2020 to December 2022 regarding LT for HCC after downstaging or bridge therapy with ICIs and included 4 of our cases. Most patients received atezolizumab, nivolumab, or pembrolizumab; these ICIs shared a half-life of around 28 days. Therefore, we excluded cases without definite WO period data and those using non-atezolizumab/nivolumab/pembrolizumab ICIs and ultimately enrolled 22 patients for analysis. We compared their clinical outcomes and estimated the rejection-free survival for every 0.5 half-life interval. RESULTS Most study subjects received nivolumab (n = 25). Six patients had severe rejections (nivolumab group, n = 5) and needed rescue management. Of the 6 cases, 1 patient died after rejection, and 2 underwent re-transplantation. The median WO period in these 6 patients was 22 days (IQR: 9-35 days). In addition, we found that a 1.5 half-life (42 days) was the shortest safe WO period associated with significant rejection-free survival (P = .005). CONCLUSIONS Our results showed that 42 days was the safest WO period before LT for HCC after ICI with atezolizumab, nivolumab, or pembrolizumab.
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Affiliation(s)
- Fang-Cheng Kuo
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Yen Chen
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Niang-Cheng Lin
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chinsu Liu
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Yuan Hsia
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Che-Chuan Loong
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Rudolph M, Shah SA, Quillin R, Lemon K, Olowokure O, Latif T, Sohal D. Immune checkpoint inhibitors in liver transplant: a case series. J Gastrointest Oncol 2023; 14:1141-1148. [PMID: 37201081 PMCID: PMC10186520 DOI: 10.21037/jgo-22-922] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/02/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) in the setting of liver transplant (LT) pose a risk of rejection and hold unclear benefit in both the neoadjuvant (pre-transplant) and post-transplant salvage setting. In the pre-transplant setting, neoadjuvant ICIs may serve as a bridge to LT by downstaging disease burden to fit within transplant criteria. Outcomes in this setting include patients who had successful transplants without complications to patients who suffered severe complications, including fatal hepatic necrosis and graft failure requiring re-transplant. Some authors suggest having a period of three months between checkpoint inhibition and transplant may help mitigate adverse effects. In the post-LT setting, there are few treatment options if there is a recurrence of disease, which forces treatment teams to reconsider checkpoint inhibitors. Again, a longer period of time between transplant and checkpoint inhibition may reduce risk of rejection. Case reports of patients treated with ICIs post-transplant utilized either nivolumab or pembrolizumab. As combination atezolizumab/bevacizumab is a relatively new treatment option for unresectable hepatocellular carcinoma (HCC), there are only three reported cases using this combination in the post-LT setting. While there were no cases of rejection, all three cases had progression of disease. As immunotherapy joins transplantation as a mainstay of treatment for HCC, it remains unclear how to best navigate when the treatment course involves both immune activation and immunosuppression. CASE DESCRIPTION Patients who had an LT and were treated with ICIs (pre or post LT) at the University of Cincinnati were included in this retrospective chart review. CONCLUSIONS Fatal rejection remains a significant risk even 4 years after LT. Neoadjuvant ICIs also pose a risk for acute cellular rejection; however, this may not always be clinically significant. Graft versus host disease (GVHD) may be an additional, previously unreported risk of ICIs in the setting of LT. Prospective studies are needed to understand benefits and risks of checkpoint inhibitors in the LT setting.
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Affiliation(s)
- Mark Rudolph
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Shimul A. Shah
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Ralph Quillin
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Kristina Lemon
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Olugbenga Olowokure
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Tahir Latif
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Davendra Sohal
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
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Abboud K, Umoru G, Esmail A, Abudayyeh A, Murakami N, Al-Shamsi HO, Javle M, Saharia A, Connor AA, Kodali S, Ghobrial RM, Abdelrahim M. Immune Checkpoint Inhibitors for Solid Tumors in the Adjuvant Setting: Current Progress, Future Directions, and Role in Transplant Oncology. Cancers (Basel) 2023; 15:1433. [PMID: 36900226 PMCID: PMC10000896 DOI: 10.3390/cancers15051433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/16/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
The rationale for administering immune checkpoint inhibitors (ICIs) in the adjuvant setting is to eradicate micro-metastases and, ultimately, prolong survival. Thus far, clinical trials have demonstrated that 1-year adjuvant courses of ICIs reduce the risk of recurrence in melanoma, urothelial cancer, renal cell carcinoma, non-small cell lung cancer, and esophageal and gastroesophageal junction cancers. Overall survival benefit has been shown in melanoma while survival data are still not mature in other malignancies. Emerging data also show the feasibility of utilizing ICIs in the peri-transplant setting for hepatobiliary malignancies. While ICIs are generally well-tolerated, the development of chronic immune-related adverse events, typically endocrinopathies or neurotoxicities, as well as delayed immune-related adverse events, warrants further scrutiny regarding the optimal duration of adjuvant therapy and requires a thorough risk-benefit determination. The advent of blood-based, dynamic biomarkers such as circulating tumor DNA (ctDNA) can help detect minimal residual disease and identify the subset of patients who would likely benefit from adjuvant treatment. In addition, the characterization of tumor-infiltrating lymphocytes, neutrophil-to-lymphocyte ratio, and ctDNA-adjusted blood tumor mutation burden (bTMB) has also shown promise in predicting response to immunotherapy. Until additional, prospective studies delineate the magnitude of overall survival benefit and validate the use of predictive biomarkers, a tailored, patient-centered approach to adjuvant ICIs that includes extensive patient counseling on potentially irreversible adverse effects should be routinely incorporated into clinical practice.
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Affiliation(s)
- Karen Abboud
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Godsfavour Umoru
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Abdullah Esmail
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX 77030, USA
| | - Ala Abudayyeh
- Section of Nephrology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Humaid O. Al-Shamsi
- Department of Oncology, Burjeel Cancer Institute, Burjeel Medical City, Abu Dhabi P.O. Box 92510, United Arab Emirates
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ashish Saharia
- JC Walter Jr Center for Transplantation and Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston, TX 77030, USA
| | - Ashton A. Connor
- JC Walter Jr Center for Transplantation and Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston, TX 77030, USA
| | - Sudha Kodali
- JC Walter Jr Center for Transplantation and Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston, TX 77030, USA
| | - Rafik M. Ghobrial
- JC Walter Jr Center for Transplantation and Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston, TX 77030, USA
| | - Maen Abdelrahim
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX 77030, USA
- Cockrell Center of Advanced Therapeutics Phase I Program, Houston Methodist Research Institute, Houston, TX 77030, USA
- Department of Internal Medicine, Weill Cornell Medical College, New York, NY 14853, USA
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Laschtowitz A, Roderburg C, Tacke F, Mohr R. Preoperative Immunotherapy in Hepatocellular Carcinoma: Current State of the Art. J Hepatocell Carcinoma 2023; 10:181-191. [PMID: 36789252 PMCID: PMC9922501 DOI: 10.2147/jhc.s347944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 02/01/2023] [Indexed: 02/10/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a malignancy that requires multidisciplinary evaluation to develop individualized and tailored treatment concepts. While liver resection and transplantation represent the mainstay of curative treatment in patients with early-stage HCC, disease recurrence remains an important burden. Immune checkpoint inhibitors (ICI) have become standard of care in the palliative setting, achieving promising response rates with overall good tolerability. Accordingly, ICIs are being evaluated in (neo)adjuvant concepts in order to improve survival. Nevertheless, neoadjuvant therapies are not recommended by current guidelines as they have not been proven to improve the outcome in large Phase III trials yet. Especially in the context of liver transplantation (LT), perioperative ICI usage is in need of a particularly critical risk-benefit assessment, as the immunotherapy may significantly increase the risk of rejection. In this review, we summarize available data on ICI-based perioperative treatment strategies in HCC. We discuss current drawbacks and challenges of this treatment concept and specifically highlight the risk of allograft rejection when ICI are given in patients (subsequently) considered for liver transplantation.
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Affiliation(s)
- Alena Laschtowitz
- Department of Hepatology and Gastroenterology, Charité – Universitätsmedizin Berlin, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Berlin, Germany
| | - Christoph Roderburg
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité – Universitätsmedizin Berlin, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Berlin, Germany
| | - Raphael Mohr
- Department of Hepatology and Gastroenterology, Charité – Universitätsmedizin Berlin, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Berlin, Germany,Correspondence: Raphael Mohr, Department of Hepatology and Gastroenterology, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin, 13353, Germany, Email
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48
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Xu X. State of the art and perspectives in liver transplantation. Hepatobiliary Pancreat Dis Int 2023; 22:1-3. [PMID: 36528548 DOI: 10.1016/j.hbpd.2022.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 12/02/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Xiao Xu
- Institute of Organ Transplantation, Zhejiang University, Hangzhou 310003, China.
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49
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Abstract
This is a review of current practices and upcoming developments regarding hepatocellular carcinoma (HCC). This includes a contemporary review of the diagnosis, staging, and treatment of HCC. Furthermore, the authors provide a review of certain ongoing trials and future directions of various treatment modalities for HCC.
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Fung J, DiSabato D, Liao CY, Ahmed O, Pillai A. Perspective: Advances in liver transplantation for hepatocellular carcinoma - A prototype for transplant oncology. Hepatobiliary Pancreat Dis Int 2023; 22:4-6. [PMID: 36163102 DOI: 10.1016/j.hbpd.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/05/2022] [Indexed: 02/07/2023]
Affiliation(s)
- John Fung
- Liver Tumor Center, The University of Chicago Medicine, Chicago 60637, IL, USA.
| | - Diego DiSabato
- Liver Tumor Center, The University of Chicago Medicine, Chicago 60637, IL, USA
| | - Chih-Yi Liao
- Liver Tumor Center, The University of Chicago Medicine, Chicago 60637, IL, USA
| | - Osmanuddin Ahmed
- Liver Tumor Center, The University of Chicago Medicine, Chicago 60637, IL, USA
| | - Anjana Pillai
- Liver Tumor Center, The University of Chicago Medicine, Chicago 60637, IL, USA
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