Recurrent hepatocellular carcinoma after liver transplantation - an emerging clinical challenge

Evaluation of surgical strategies and long-term outcomes in pediatric hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC), the second most common pediatric malignant liver tumor after hepatoblastoma, represents 1% of all pediatric tumors.

METHODS

A retrospective study was conducted on children with HCC treated at our center from March 2002 to October 2022, excluding those with inadequate follow-up or records. Demographic data, initial complaints, alpha-fetoprotein (AFP) values, underlying disease, size and histopathological features of the masses, chemotherapy, and long-term outcomes were analyzed.

RESULTS

Fifteen patients (8 boys, 7 girls) with a mean age of 11.4 ± 4.1 years (0.8-16.4 years) were analyzed. The majority presented with abdominal pain, with a median AFP of 3.9 ng/mL. Hepatitis B cirrhosis in one patient (6.6%) and metabolic disease (tyrosinemia type 1) in two patients (13.3%) were the underlying diseases. Histopathological diagnoses were fibrolamellar HCC (n:8; 53.3%), HCC (n:6; 40%). Four of the 15 patients underwent liver transplantation, and 9 underwent surgical resection. Due to late diagnosis, two patients were considered inoperable (13.3%). The survival rate for the four patients who underwent liver transplantation was found to be 75%.

CONCLUSION

Surgical treatment of various variants of HCC can be safely performed in experienced centers with a multidisciplinary approach, and outcomes are better than in adults.

Induction Immunosuppression Does Not Worsen Tumor Recurrence After Liver Transplantation for Hepatocellular Carcinoma

BACKGROUND

Prior studies are inconsistent regarding the impact of antibody induction therapy on outcomes after liver transplantation (LT) for hepatocellular carcinoma (HCC).

METHODS

Adults transplanted with HCC exception priority were identified from February 27, 2002, to March 31, 2019, using the United Network for Organ Sharing database. Time-to-event analyses evaluated the association of antibody induction therapy (none, nondepleting induction [NDI], depleting induction [DI]) with overall post-LT patient survival and HCC recurrence. Separate multivariable models adjusted for tumor characteristics on either last exception or on explant. The interaction of induction and maintenance regimen at LT discharge was investigated.

RESULTS

Among 22 535 LTs for HCC, 17 688 (78.48%) received no antibody induction, 2984 (13.24%) NDI, and 1863 (8.27%) DI. Minimal differences in patient and tumor characteristics were noted between induction groups, and there was significant center variability in practices. NDI was associated with improved survival, particularly when combined with a calcineurin inhibitor (CNI) and antimetabolite (hazard ratio [HR] 0.73 versus no induction plus 3-drug therapy in the last exception model [ P  < 0.001]; HR 0.64 in the explant model [ P  = 0.011]). The combination of DI with CNI alone was also protective (HR 0.43; P  = 0.003). Neither NDI nor DI was associated with tumor recurrence (all P  > 0.1). However, increased HCC recurrence was observed with no induction plus CNI monotherapy (HR 1.47, P  = 0.019; versus no induction plus 3-drug therapy).

CONCLUSIONS

In conclusion, induction immunosuppression was not associated with worse post-LT outcomes in patients transplanted with HCC exception priority. An improvement in survival was possibly observed with NDI.

Predicting Overall Survival with Deep Learning from 18F-FDG PET-CT Images in Patients with Hepatocellular Carcinoma before Liver Transplantation

Positron emission tomography and computed tomography with 18F-fluorodeoxyglucose (18F-FDG PET-CT) were used to predict outcomes after liver transplantation in patients with hepatocellular carcinoma (HCC). However, few approaches for prediction based on 18F-FDG PET-CT images that leverage automatic liver segmentation and deep learning were proposed. This study evaluated the performance of deep learning from 18F-FDG PET-CT images to predict overall survival in HCC patients before liver transplantation (LT). We retrospectively included 304 patients with HCC who underwent 18F-FDG PET/CT before LT between January 2010 and December 2016. The hepatic areas of 273 of the patients were segmented by software, while the other 31 were delineated manually. We analyzed the predictive value of the deep learning model from both FDG PET/CT images and CT images alone. The results of the developed prognostic model were obtained by combining FDG PET-CT images and combining FDG CT images (0.807 AUC vs. 0.743 AUC). The model based on FDG PET-CT images achieved somewhat better sensitivity than the model based on CT images alone (0.571 SEN vs. 0.432 SEN). Automatic liver segmentation from 18F-FDG PET-CT images is feasible and can be utilized to train deep-learning models. The proposed predictive tool can effectively determine prognosis (i.e., overall survival) and, thereby, select an optimal candidate of LT for patients with HCC.

Machine Learning Models for Prediction of Posttreatment Recurrence in Early-Stage Hepatocellular Carcinoma Using Pretreatment Clinical and MRI Features: A Proof-of-Concept Study

BACKGROUND. Posttreatment recurrence is an unpredictable complication after liver transplant for hepatocellular carcinoma (HCC) that is associated with poor survival. Biomarkers are needed to estimate recurrence risk before organ allocation. OBJECTIVE. This proof-of-concept study evaluated the use of machine learning (ML) to predict recurrence from pretreatment laboratory, clinical, and MRI data in patients with early-stage HCC initially eligible for liver transplant. METHODS. This retrospective study included 120 patients (88 men, 32 women; median age, 60.0 years) with early-stage HCC diagnosed who were initially eligible for liver transplant and underwent treatment by transplant, resection, or thermal ablation between June 2005 and March 2018. Patients underwent pretreatment MRI and posttreatment imaging surveillance. Imaging features were extracted from postcontrast phases of pretreatment MRI examinations using a pretrained convolutional neural network. Pretreatment clinical characteristics (including laboratory data) and extracted imaging features were integrated to develop three ML models (clinical model, imaging model, combined model) for predicting recurrence within six time frames ranging from 1 through 6 years after treatment. Kaplan-Meier analysis with time to recurrence as the endpoint was used to assess the clinical relevance of model predictions. RESULTS. Tumor recurred in 44 of 120 (36.7%) patients during follow-up. The three models predicted recurrence with AUCs across the six time frames of 0.60-0.78 (clinical model), 0.71-0.85 (imaging model), and 0.62-0.86 (combined model). The mean AUC was higher for the imaging model than the clinical model (0.76 vs 0.68, respectively; p = .03), but the mean AUC was not significantly different between the clinical and combined models or between the imaging and combined models (p > .05). Kaplan-Meier curves were significantly different between patients predicted to be at low risk and those predicted to be at high risk by all three models for the 2-, 3-, 4-, 5-, and 6-year time frames (p < .05). CONCLUSION. The findings suggest that ML-based models can predict recurrence before therapy allocation in patients with early-stage HCC initially eligible for liver transplant. Adding MRI data as model input improved predictive performance over clinical parameters alone. The combined model did not surpass the imaging model's performance. CLINICAL IMPACT. ML-based models applied to currently underutilized imaging features may help design more reliable criteria for organ allocation and liver transplant eligibility.

Improving Liver Transplant Outcomes for Hepatitis C Virus Hepatocellular Carcinoma in the Direct-Acting Antiviral Therapy Era

BACKGROUND

Direct-acting antiviral (DAA) therapy has transformed the outcomes of liver transplant (LT) with hepatitis C virus (HCV). This study aimed to analyze the effects of DAA treatment for HCV-associated hepatocellular carcinoma (HCC) in LT.

METHODS

We included patients confirmed with HCC on explant, analyzed data from United Network for Organ Sharing, and defined the pre-DAA era (2012-2013) and DAA era (2014-2016).

RESULTS

HCV-associated HCC cases totaled 4778 (62%) during the study period. In the DAA era, the median recipient age was older and the median days on the waiting list were longer. For the donor, median age, body mass index, and the rate of HCV significantly increased in the DAA era. In pathology, the median largest tumor size was significantly higher; however, the rate of completed tumor necrosis was significant higher in the DAA era. The 3-year graft/patient survival had significantly improved in the DAA era. In multivariable analysis, the DAA era (hazard ratio, 0.79; 95% confidence interval, 0.68-0.91) had significantly affected the 3-year graft survival.

CONCLUSIONS

DAA has a significant beneficial effect on LT. In the DAA era, graft survival for HCV-associated HCC has been significantly improving.

Different Models to Predict the Risk of Recurrent Hepatocellular Carcinoma in the Setting of Liver Transplantation

Simple Summary

Liver transplantation is considered the first-choice curative therapy for hepatocellular carcinoma in the early phase of the disease, when surgical resection is not possible. Even when implementing restrictive criteria to select patients for liver transplantation, there is a risk of recurrence in the transplanted liver, influencing the long-term outcome and prognosis. As it is challenging to predict the individual risk of recurrence, there is a need for validated and predictive scoring systems to use to stratify patients before and/or after liver transplantation. Most of the proposed scorings include biological markers for tumour behavior, in addition to the number and size of tumoral nodules. In this review, we discuss different published models to assess the risk of recurrent hepatocellular carcinoma after transplantation. Our aim is to refine clinical decisions about prioritization and listing for liver transplantation, to better inform patients and provide an appropriate surveillance strategy to influence their prognosis.

Abstract

Liver transplantation is the preferred therapeutic option for non-resectable hepatocellular carcinoma in early-stage disease. Taking into account the limited number of donor organs, liver transplantation is restricted to candidates with long-term outcomes comparable to benign indications on the waiting list. Introducing the morphometric Milan criteria as the gold standard for transplant eligibility reduced the recurrence rate. Even with strict patient selection, there is a risk of recurrence of between 8 and 20% in the transplanted liver, and this is of even greater importance when using more expanded criteria and downstaging protocols. Currently, it remains challenging to predict the risk of recurrence and the related prognosis for individual patients. In this review, the recurrence-risk-assessment scores proposed in the literature are discussed. Currently there is no consensus on the optimal model or the implications of risk stratification in clinical practice. The most recent scorings include additional biological markers for tumour behavior, such as alfa-foetoprotein, and the response to locoregional therapies, in addition to the number and diameter of tumoral nodules. The refinement of the prediction of recurrence is important to better inform patients, guide decisions about prioritization and listing and implement individualized surveillance strategies. In the future, this might also provide indications for tailored immunosuppressive therapy or inclusion in trials for adjuvant treatment.

Liver transplantation for patients with hepatocellular carcinoma: Its current status and advances

Liver transplantation is one of the best treatment options for selected patients with hepatocellular carcinoma (HCC). The Milan criteria (a single tumor with a maximum size of 5 cm or two or three tumors with a maximum size of 3 cm without evidence of vascular or extrahepatic involvement or metastasis) are one of the most common criteria to select patients with HCC for transplantation, though they are considered too restrictive. A moderate expansion of the criteria has been found to yield comparable recurrence-free survival rates. HCC will recur in approximately 10% of patients, and mostly within the first 2 years after transplantation. The preoperative level of alpha-fetoprotein, macrovascular invasion, tumor size, and tumor number are prognostic factors for recurrence. Recurrence of HCC after transplantation results in a poor prognosis.

Reduced calcineurin inhibitor exposure with antibody induction and recurrent hepatocellular carcinoma after liver transplantation

BACKGROUND

Hepatocellular carcinoma (HCC) is a common indication for liver transplantation (LT), but post-LT tumor recurrence remains a concern. Early post-LT immunosuppression is suggested to affect recurrence risk. We evaluated the impact on HCC recurrence of an immunosuppression protocol introduced in 2010 with interleukin-2 receptor antibody (IL-2RA) induction and delayed-introduction of reduced-dose tacrolimus with mycophenolate.

METHODS

We included consecutive HCC patients transplanted 2000-2017 in Gothenburg. The impact on HCC recurrence of IL-2RA induction and mean tacrolimus trough concentration during the first 20 post-LT days was analyzed by multivariable Cox regression and propensity score-adjusted analyses.

RESULTS

The study comprised 235 patients (mean age 57 yrs, men 80%, mean MELD 13, within Milan criteria 57%). The cumulative 5-yr HCC recurrence rate among patients transplanted before and after 2010 were 28.6% and 19.7%, respectively. IL-2RA induction had no independent effect on HCC recurrence. High tacrolimus exposure (mean 20-day tacrolimus concentration ≥8ng/mL) was associated with increased HCC recurrence risk on univariable analysis (HR 2.22, 95% CI 1.23-4.01, p = .008), but was non-significant on multivariable analysis (p = .17). Outside Milan criteria, high tacrolimus exposure was significant for HCC recurrence (HR 3.68, 95% CI 1.34-10.11, p = .012) independently of tumor characteristics and AFP level. This was confirmed on multivariable propensity score-adjusted analysis.

CONCLUSIONS

Reduced early tacrolimus exposure, facilitated by IL-2RA induction, was associated with reduced risk for HCC recurrence among patients outside Milan criteria. Prospective studies are needed to confirm if early tacrolimus-minimization strategies can help reduce HCC recurrence rates and help extend transplant criteria.

Liver Transplant Imaging prior to and during the COVID-19 Pandemic

Background

The suspension of the surgical activity, the burden of the infection in immunosuppressed patients, and the comorbidities underlying end-stage organ disease have impacted transplant programs significantly, even life-saving procedures, such as liver transplantation.

Methods

A review of the literature was conducted to explore the challenges faced by transplant programs and the adopted strategies to overcome them, with a focus on indications for imaging in liver transplant candidates.

Results

Liver transplantation relies on an appropriate imaging method for its success. During the Coronavirus Disease 2019 (COVID-19) pandemic, chest CT showed an additional value to detect early signs of SARS-CoV-2 infection and other screening modalities are less accurate than radiology.

Conclusion

There is an emerging recognition of the chest CT value to recommend its use and help COVID-19 detection in patients. This examination appears highly sensitive for liver transplant candidates and recipients, who otherwise would have not undergone it, particularly when asymptomatic.

Clinical stages of recurrent hepatocellular carcinoma: A retrospective cohort study

BACKGROUND

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death worldwide, and has relatively high recurrence rates. Few studies have been published on the clinical stages of recurrent HCC.

AIM

To assess the applicability of the Barcelona Clinic Liver Cancer (BCLC) staging for recurrent HCC and the need to establish clinical stage criteria for recurrent HCC.

METHODS

The clinicopathological data of 81 patients with recurrent HCC who were admitted to the Hospital of Guangxi Zhuang Autonomous Region from January 2013 to December 2017 were collected. The patients were divided into three groups according to the BCLC staging system as follows: (1) Group A with BCLC stage A, 51 patients; (2) Group B with BCLC stage B, 14 patients; and (3) Group C with BCLC stage C, 16 patients. The median time to tumor recurrence and the median overall survival were compared.

RESULTS

The median time to tumor recurrence in groups A, B, and C was 16 ± 1.5 mo, 10 ± 2.8 mo, and 6 ± 0.5 mo, respectively, with a statistically significant difference among them (χ² = 70.144, P < 0.05); no statistically significant difference was noted between group A and group B (χ² = 2.659, P > 0.05), although there were statistically significant differences between group A and group C and between group B and group C (χ² = 62.110, and 19.972, P < 0.05). The median overall survival in groups A, B, and C were 42 ± 5.1 mo, 22 ± 3.1 mo, and 13 ± 1.8 mo, respectively, with a statistically significant difference among them (χ² = 38.949, P < 0.05); there were statistically significant differences between group A and group B, group A and group C, and group B and group C (χ² = 9.577, 37.172, and 7.183, respectively; P < 0.05).

CONCLUSION

There are different prognoses in recurrent HCC patients according to the BCLC staging. Therefore, BCLC staging is applicable to recurrent HCC and it is essential to formulate clinical stage criteria for recurrent HCC.

Investigating the value of pre-treatment 18F-FDG PET/CT in predicting the pathological characteristic of hepatocellular carcinoma and recurrence after liver transplantation

PURPOSE

The aim of this study is to investigate the value of pre-treatment ¹⁸F-FDG PET/CT in predicting the pathological characteristic of HCC and recurrence after liver transplantation (LT).

METHODS

A total of 34 patients who underwent ¹⁸F-FDG PET/CT before LT for HCC and did not receive any other treatment were retrospectively enrolled in the study. The maximal standard uptake value of the tumor (T-SUVmax), normal liver tissues (L-SUVmax), and mediastinal blood pool (B-SUVmax) were derived, followed by the calculations of the T-SUVmax/L-SUVmax (T/L) and the T-SUVmax/B-SUVmax (T/B) ratios. Combined with the post-transplantation pathological results and ROC curve, the performance in predicting the pathological characteristic and the recurrence after LT were evaluated.

RESULTS

The AUCs for T-SUVmax, T/L, and T/B in predicting the pathological grade of tumors were 0.820, 0.784, and 0.806, respectively. Alternatively, the AUCs for T-SUVmax, T/L, and T/B in predicting the recurrence after LT were 0.865, 0.899, and 0.931, respectively. The individual cutoff values were 5.0, 1.7, and 2.2, corresponding to a predication accuracy of 88.2%, 85.3%, and 88.2%, respectively. In addition, the AUCs for T/B in predicting microvascular invasion (mVI) and liver capsular invasion (LCI) were 0.825 and 0.788, respectively.

CONCLUSION

The pre-treatment ¹⁸F-FDG PET/CT is effective for predicting recurrence of HCC after LT. In addition, it demonstrates values for predicting the pathological characteristic of HCC such as pathological grade, mVI, and LCI.

Hepatocellular Carcinoma: Downstaging to Liver Transplantation as Curative Therapy

Hepatocellular carcinoma (HCC) ranks among the leading cancer-related causes of morbidity and mortality worldwide. Downstaging of HCC has prevailed as a key method to curative therapy for patients who present with unresectable HCC outside of the listing criteria for liver transplantation (LT). Even though LT paves the way to lifesaving curative therapy for HCC, perpetually severe organ shortage limits its broader application. Debate over the optimal protocol and assessment of response to downstaging treatment has fueled immense research activity and is pushing the boundaries of LT candidate selection criteria. The implicit obligation of refining downstaging protocol is to ensure the maximization of the transplant survival benefit by taking into account the waitlist life expectancy. In the following review, we critically discuss strategies to best optimize downstaging HCC to LT on the basis of existing literature.

Postoperative imaging surveillance for hepatocellular carcinoma: How much is enough?

BACKGROUND

The objective of the current study was to define trends in postoperative surveillance imaging following liver-directed treatment of hepatocellular carcinoma (HCC), and characterize the impact of high-intensity surveillance on long-term survival.

METHODS

Patients who underwent liver- directed therapy for HCC between 2004 and 2016 were identified using the SEER-Medicare database. Trends in surveillance intensity over time, factors associated with high surveillance intensity and the impact of surveillance on long-term outcomes were examined.

RESULTS

Utilization of high-intensity surveillance abdominal imaging (≥6 scans over 2 years) following liver-directed therapy of HCC decreased over time (2004-2007: n = 130, 36.1% vs. 2008-2011: n = 181, 29.5% vs. 2012-2016: n = 111, 24.5%; p_trend  < 0.001). History of chronic viral hepatitis (hepatitis B: odds ratio [OR], 1.98; 95% confidence interval [CI]: 1.15-3.43; hepatitis C: OR, 1.79; 95% CI: 1.32-2.43), presence of regional (vs. local-only) disease (OR, 1.47; 95% CI: 1.09-1.98) and receipt of transplantation (OR, 2.23; 95% CI: 1.57-3.17) were associated with higher odds of high intensity surveillance. Intensity of surveillance imaging was not associated with long-term survival (5-year overall survival: low-intensity, 48.1% vs. high-intensity, 48.9%; hazards ratio, 0.94; 95% CI: 0.78-1.13).

CONCLUSION

Utilization of posttreatment surveillance imaging decreased over time following liver-directed therapy for HCC. While utilization of high-intensity screening varied by HCC procedure performed, intensity of surveillance had no effect on survival.

Machine learning in liver transplantation: a tool for some unsolved questions?

Machine learning has recently been proposed as a useful tool in many fields of Medicine, with the aim of increasing diagnostic and prognostic accuracy. Models based on machine learning have been introduced in the setting of solid organ transplantation too, where prognosis depends on a complex, multidimensional and nonlinear relationship between variables pertaining to the donor, the recipient and the surgical procedure. In the setting of liver transplantation, machine learning models have been developed to predict pretransplant survival in patients with cirrhosis, to assess the best donor-to-recipient match during allocation processes, and to foresee postoperative complications and outcomes. This is a narrative review on the role of machine learning in the field of liver transplantation, highlighting strengths and pitfalls, and future perspectives.

Anti-Programmed Cell Death Protein 1 (PD-1) Immunotherapy for Metastatic Hepatocellular Carcinoma After Liver Transplantation: A Report of Three Cases

The treatment of recurrent hepatocellular carcinoma (HCC) after liver transplantation is difficult due to the lack of effective treatment options. The available evidence on the emerging immunotherapy in liver transplantation is based on anecdotal experiences and requires additional investigations. To determine the efficacy and safety of immunotherapy in liver transplant recipients, we report three cases of recurrent metastatic HCC after liver transplantation who were treated with nivolumab as off-label salvage therapy.

Recent developments and ongoing trials in transplant oncology

Over the past two decades since the introduction of the Milan criteria, the field of transplant oncology has undergone a rapid development with a rising proportion of liver transplantations being performed for oncological indications. For many patients with liver tumours, transplantation represents the only chance for cure. However, many challenges remain, such as the adequate patient selection, management of post-transplant recurrence and refinement of neoadjuvant treatment protocols. This review provides an overview of the current state of the art of liver transplantation for oncological indications such as hepatocellular carcinoma, cholangiocarcinoma, colorectal liver metastasis and metastatic neuroendocrine tumours. We also summarize the ongoing research and explore future trends. Clinical trials are currently studying new diagnostic modalities, innovative pharmacological treatments, novel surgical techniques, downstaging regimens and new indications for liver transplantation. These emerging results will continue to shape the field of transplant oncology and provide us with the necessary tools to better select, treat and follow patients with liver tumours qualifying for liver transplantation.

AFP ratio predicts HCC recurrence after liver transplantation

Background/aims

Hepatocellular carcinoma (HCC) is a leading indication for liver transplantation (LT) worldwide. Early identification of patients at risk for HCC recurrence is of paramount importance since early treatment of recurrent HCC after LT may be associated with increased survival. We evaluated incidence of and predictors for HCC recurrence, with a focus on the course of AFP levels.

Methods

We performed a retrospective, single-center study of 99 HCC patients who underwent LT between January 28^th, 1997 and May 11^th, 2016. A multi-stage proportional hazards model with three stages was used to evaluate potential predictive markers, both by univariate and multivariable analysis, for influences on 1) recurrence after transplantation, 2) mortality without HCC recurrence, and 3) mortality after recurrence.

Results

19/99 HCC patients showed recurrence after LT. Waiting time was not associated with overall HCC recurrence (HR = 1, p = 0.979). Similarly, waiting time did not affect mortality in LT recipients both with (HR = 0.97, p = 0.282) or without (HR = 0.99, p = 0.685) HCC recurrence. Log₁₀-transformed AFP values at the time of LT (HR 1.75, p = 0.023) as well as after LT (HR 2.07, p = 0.037) were significantly associated with recurrence. Median survival in patients with a ratio (AFP at recurrence divided by AFP 3 months before recurrence) of 0.5 was greater than 70 months, as compared to a median of only 8 months in patients with a ratio of 5.

Conclusion

A rise in AFP levels rather than an absolute threshold could help to identify patients at short-term risk for HCC recurrence post LT, which may allow intensification of the surveillance strategy on an individualized basis.

Predictors, Presentation, and Treatment Outcomes of Recurrent Hepatocellular Carcinoma After Liver Transplantation: A Large Single Center Experience

BACKGROUND

Liver transplantation (LT) is an accepted therapeutic option for hepatocellular carcinoma (HCC) in patients with cirrhosis. Despite careful candidate selection, HCC recurrence occurs. We aimed to describe the predictors of recurrence, clinical presentation, and predictors of survival after HCC recurrence post-LT.

METHODS

Patients with recurrent HCC after LT between January 1996 and December 2017 were retrospectively reviewed.

RESULTS

Of 711 patients, 96 (13.5%) patients had post-LT HCC recurrence. The median time to recurrence was 17.1 months, and the median survival was 10.1 months. Initial recurrence was more often in the graft (34.4%), and most (60.4%) had multiple recurrent lesions, and 26% were in multiple sites. In multivariate analysis, factors associated with shorter survival were poorly differentiated histology in explant (Hazard ratio [HR] = 1.96; p = 0.027), bilirubin ≥1.2 mg/dL (HR = 2.47; p = 0.025), and albumin <3.5 mg/dL (HR = 2.13; p = 0.014) at recurrence, alpha-fetoprotein at recurrence ≥ 1000 ng/mL (HR = 2.96; p = 0.005), and peritoneal disease (HR = 3.20; p = 0.022). There was an increased survival in patients exposed to sirolimus (HR = 0.32; p < 0.0001).

CONCLUSIONS

Recurrent HCC after LT is often in extrahepatic sites with a decreased survival in those with poorly differentiated explant pathology, high bilirubin, low albumin, marked elevation of alpha-fetoprotein at recurrence, and peritoneal recurrence. Sirolimus-based immunosuppression may provide benefit.

Pulmonary Resection for Metastasis of Hepatocellular Carcinoma Recurring After Liver Transplant: An Italian Multicenter Experience

Background and aim: Liver transplantation (LT) is a validated treatment for hepatocellular carcinoma (HCC). HCC recurrence occurred between 8 and 20% of patients and lung is the most frequent site. Pulmonary metastases resection (PMR) prolongs survival, however in LT-setting the impact on survival is unclear. To give new lights on this issue, we report the experience of three Italian LT Centers.

Methods: All consecutive HCC transplanted patients in three Italian LT Centers, who developed pulmonary metastasis from HCC (PM-HCC), as first metastasis, from 2008 to 2018, were included whenever treated with PMR.

Results: Twenty-five patients were enrolled (median age 58 yrs, 84% male, 3% cirrhotics). HCC recurred after 34 months (9–306) since LT and PMR was performed after 2.4 months (0–43.1). A total of 28 PMR (19 single resections; 9 multiple resections; 16 right; 2 left) have been performed on 24 patients while in one case percutaneous microwave ablation (MWA) was preferred. Four patients have been re-operated due to pulmonary HCC-recurrence after surgery. The majority of surgical resection type was wedge resection (26, 89%). Surgical access was: video-assisted thoracic surgery (VATS) in 17 cases (59%); thoracotomy in 11 (38%); MWA in 1 (3%). The 48% of nodule was in right lower lobe. Perioperative in-hospital mortality and 30 days mortality were nil; median surgical time 90 min (50–365); median post-operative overall stay 5 days (2–11). Post-operative ICU treatment was necessary in 1 case (3%) for 3 days; blood transfusions in 2 cases (7%). Overall, 5 complications (2 bleeding; 1 AKI; 1 major cardiac; 1 wound dehiscence) occurred, with an overall complications rate of 23%. Eight (32%) patients died during a follow-up after HCC recurrence of 32 months (7–213): 7 for HCC progression, 1 for severe liver failure due to chronic rejection. The 1 and 5 year cumulative probability of OS from recurrence were 100 and 43% (95%CI 12–74), respectively, with a median OS of 51 months (95%CI 24–78).

Conclusion: Selected patients with isolated pulmonary HCC-recurrence after LT and with preserved hepatic function showed that a pulmonary metastasectomy could be efficacious in managing a PM-HCC and could give an opportunity for long-term survival.

Reduction of FoxP3+ Tregs by an immunosuppressive protocol of rapamycin plus Thymalfasin and Huaier extract predicts positive survival benefits in a rat model of hepatocellular carcinoma

Background

Investigate immunoregulation and anti-tumor immunity of FoxP3⁺Tregs after treatment with rapamycin (RAPA/SRL) plus thymalfasin (Zadaxin) and Huaier extract (PS-T) in a hepatocellular carcinoma (HCC) rat model simulating HCC relapse after liver transplant (LT).

Methods

We successfully established a rat model simulating HCC relapse after LT using an optimized chemical induction method with TACROLIMUS, methylprednisolone, and diethylnitrosamine as identified by visible liver nodules and hematoxylin-eosin staining. The model rats were then treated with RAPA, Zadaxin, and PS-T. Immune status changes were analyzed by flow cytometry, and protein expression of Akt and mTOR was determined by western blotting. Cytokines were measured by ELISAs.

Results

Combined therapy by RAPA plus Zadaxin and PS-T obviously alleviated hepatic pathological changes and significantly decreased the levels of FoxP3⁺Tregs in peripheral blood, the spleen, and the liver (P<0.05) and expression of mTOR protein (P<0.01) in the liver, obviously improved survival time (P=0.02). Moreover, the levels of CD8⁺T cells were increased significantly to almost normal levels (P<0.05) in comparison with no SRL monotherapy protocols. Inhibitory cytokines were also decreased in accordance with FoxP3⁺Tregs. Significant decreases of IL-10 and TGF-β were observed after SRL-based therapy (P<0.01) in comparison with the other groups. Serum alpha fetoprotein (AFP) and vascular endothelial growth factor (VEGF) levels were also decreased significantly (P<0.05). FoxP3⁺Tregs showed a negative correlation with CD8⁺ and CD4⁺/CD8⁺T cells and a positive correlation with AFP, and VEGF (P<0.05).

Conclusions

SRL-based therapy reduces FoxP3⁺Tregs to decrease secreted inhibitory cytokines which may enhancement the viability and number of CD8⁺T cells to exert anti-tumor effects that are mainly mediated through the AKT-mTOR signaling pathway.

Risk factors for long-term prognosis of hepatocellular carcinoma patients after anatomic hepatectomy

BACKGROUND

The risk factors for patients with major postoperative complications immediately after liver resection have been identified; however, the intermediate and long-term prognoses for these patients have yet to be determined.

AIM

To evaluate the factors responsible for the long-term recurrence-free survival rate in patients with hepatocellular carcinoma (HCC) following anatomic hepatectomy.

METHODS

We performed a retrospective analysis of 74 patients with HCC who underwent precise anatomic hepatectomy at our institution from January 2013 to December 2015. The observational endpoints for this study were the tumor recurrence or death of the HCC patients. The overall follow-up duration was three years. The recurrence-free survival curves were plotted by the Kaplan-Meier method and were analyzed by the log-rank test. The value of each variable for predicting prognosis was assessed via multivariate Cox proportional hazards regression analysis.

RESULTS

The 1-year and 3-year recurrence-free survival rates of HCC patients were 68.92% and 55.41%, respectively, following anatomic liver resection. The results showed that the 3-year recurrence-free survival rate in HCC patients was closely related to preoperative cirrhosis, jaundice level, tumor stage, maximal tumor diameter, complications of diabetes mellitus, frequency of intraoperative hypotensive episodes, estimated blood loss (EBL), blood transfusion, fluid infusion, and postoperative infection (P < 0.1). Based on multivariate analysis, preoperative cirrhosis, tumor stage, intraoperative hypotension, and EBL were identified to be predictors of 3-year recurrence-free survival in HCC patients undergoing anatomic hepatectomy (P < 0.05).

CONCLUSION

Tumor stage and preoperative cirrhosis adversely affect the recurrence-free survival rate in HCC patients following anatomic hepatectomy. The long-term recurrence-free survival rate of patients with HCC is closely related to intraoperative hypotension and EBL.

Regorafenib Combined With Sirolimus Achieves Successful Treatment of Diffuse Double Lung Metastasis After Liver Transplantation in Giant Liver Cancer Beyond Transplantation Criteria: A Case Report

The treatment of hepatocellular carcinoma after liver transplantation (LT) is controversial because of its high recurrence rate and low survival rate. Here, we report a case of early diffuse bilateral lung metastasis after LT beyond the Milan transplantation criteria (d = 18 cm, α-fetoprotein >24,000 ng/mL) that successfully achieved 1-year tumor-free remission survival with sirolimus combined with regorafenib. The donor source of the liver is legal, and this study followed the guidelines of the Helsinki Congress in this LT. To the best of our knowledge, this is the first report of the use of regorafenib as a first-line agent combined with sirolimus to treat recurrent hepatocellular carcinoma after LT, and this case expands the indications for LT.

In silico identification of EP400 and TIA1 as critical transcription factors involved in human hepatocellular carcinoma relapse

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-associated mortality worldwide. Transcription factors (TFs) are crucial proteins that regulate gene expression during cancer progression; however, the roles of TFs in HCC relapse remain unclear. To identify the TFs that drive HCC relapse, the present study constructed co-expression network and identified the Tan module the most relevant to HCC relapse. Numerous hub TFs (highly connected) were subsequently obtained from the Tan module according to the intra-module connectivity and the protein-protein interaction network connectivity. Next, E1A-binding protein p400 (EP400) and TIA1 cytotoxic granule associated RNA binding protein (TIA1) were identified as hub TFs differentially connected between the relapsed and non-relapsed subnetworks. In addition, zinc finger protein 143 (ZNF143) and Yin Yang 1 (YY1) were also identified by using the plugin iRegulon in Cytoscape as master upstream regulatory elements, which could potentially regulate expression of the genes and TFs of the Tan module, respectively. The Kaplan-Meier (KM) curves obtained from KMplot and Gene Expression Profiling Interactive Analysis tools confirmed that the high expression of EP400 and TIA1 were significantly associated with shorter relapse-free survival and disease-free survival of patients with HCC. Furthermore, the KM curves from the UALCAN database demonstrated that high EP400 expression significantly reduced the overall survival of patients with HCC. EP400 and TIA1 may therefore serve as potential prognostic and therapeutic biomarkers.

Suppression of Hepatocellular Carcinoma by Mycophenolic Acid in Experimental Models and in Patients

BACKGROUND

Tumor recurrence is a major complication following liver transplantation (LT) as treatment for hepatocellular carcinoma (HCC). Immunosuppression is an important risk factor for HCC recurrence, but conceivably may depend on the type of immunosuppressive medication. Mycophenolic acid (MPA) is a currently widely used immunosuppressant. This study investigated the effects of MPA on HCC.

METHODS

Three human HCC cell lines and organoids from mouse primary liver tumor were used as experimental models. MTT, Alamar Blue assay, cell cycle analysis, colony formation, and [3H]-thymidine assays were performed. An LT database was used for retrospective analysis of the effect of mycophenolate mofetil, the prodrug of MPA, on HCC recurrence.

RESULTS

With clinically achievable concentrations, MPA effectively inhibited HCC cell proliferation and single-cell colony-forming unit. In short-term experiments, MPA effectively elicited S phase arrest in HCC cell lines. In addition, the initiation and growth of liver tumor organoids were effectively inhibited by MPA. Most importantly, the use of mycophenolate mofetil in patients with HCC-related LT was significantly associated with less tumor recurrence and improved patient survival.

CONCLUSIONS

MPA can specifically counteract HCC growth in vitro and tumor recurrence in LT patients. These results warrant prospective clinical trials into the role of MPA-mediated immunosuppression following LT of patients with HCC.

Pre-transplant alpha-fetoprotein is associated with post-transplant hepatocellular carcinoma recurrence mortality

BACKGROUND

Although liver transplantation may potentially cure hepatocellular carcinoma (HCC), the risk of HCC recurrence is 8%-20% at five years post-transplant. Pre-transplant alpha-fetoprotein (AFP) is a predictor of HCC recurrence, but it is unknown if pre-transplant AFP also predicts survival in patients with recurrence.

METHODS

We performed a retrospective cohort study using the United Network for Organ Sharing (UNOS) database between 2002 and 2016. We identified adult transplant recipients with HCC recurrence after liver transplantation for HCC and used Cox regression to compare patient survival among different maximum pre-transplant AFP levels.

RESULTS

The cohort (N = 1164) was primarily male, white, and with hepatitis C liver disease. The median time to HCC recurrence was 11.6 months (interquartile range 6.1-26.3). In Cox regression analysis, increasing pre-transplant AFP was associated with poorer survival when adjusting for age, pre-transplant model for end-stage liver disease (MELD), and time to HCC recurrence. For example, patients with pre-transplant AFP ≥500ng/mL had a 1.6-fold higher risk of death versus those with AFP ≤20ng/mL (P < 0.001).

CONCLUSION

Pre-transplant AFP is independently associated with survival in patients with HCC recurrence. These findings further contextualize the importance of pre-transplant AFP in liver transplantation and may improve prognostication for patients with HCC recurrence.

Multicenter validation of a score to predict prognosis after the development of HCC recurrence following liver transplantation

BACKGROUND

HCC recurrence after LT impacts negatively on survival. A recent study detected late recurrence (≥12 months), alpha-fetoprotein (AFP) <100 ng/mL at recurrence and being amenable for curative-intent treatments as good prognostic factors. With these variables a prognostic score was proposed. The objective of this study was to validate the prognostic score for hepatocellular carcinoma (HCC) recurrence following liver transplantation (LT).

METHODS

Data from the University of California, San Francisco, the University Hospital of Birmingham and Instituto Nazionale dei Tumori, Milan including patients with HCC recurrence after LT were analyzed. The previous reported score was applied to this cohort.

RESULTS

From June 2002-December 2014, 1328 patients had a confirmed HCC in their explanted liver. The study group comprised 130 patients (9.8%) diagnosed with HCC recurrence after LT. Overall median survival after HCC recurrence was 12.4 (95% CI 10.2-16.3) months. Application of the previously reported score showed a significantly superior survival for the good prognosis group compared to moderate and poor prognosis groups (p < 0.0001).

CONCLUSION

The score continues to identify a group of patients who would benefit from aggressive treatment and experience significant improved survival following recurrent HCC after LT.

Systematic review with meta-analysis: sirolimus- or everolimus-based immunosuppression following liver transplantation for hepatocellular carcinoma

BACKGROUND

Calcineurin-inhibitor immunosuppressants (tacrolimus and ciclosporin) have been associated with an exposure-related increase in tumour recurrence following liver transplantation for hepatocellular carcinoma (HCC). Conversely, mechanistic target of rapamycin (mTOR) inhibitors (sirolimus and everolimus) have been suggested to reduce recurrence rates and improve survival in this patient group.

AIM

To clarify the potential benefit of mTOR-inhibitors in HCC transplant patients by comparing recurrence and survival outcomes with calcineurin-inhibitor-based immunosuppression.

METHODS

A systematic review and meta-analysis was performed. The inclusion criteria were observational or interventional studies reporting the effect of early-initiated (<6 months post-transplant) mTOR-inhibitor-based immunosuppression on survival or tumour recurrence in patients transplanted with HCC, compared to a control of calcineurin-inhibitor-based therapy.

RESULTS

Meta-analysis demonstrated that compared with calcineurin-inhibitor controls, recurrence-free-survival was significantly increased with mTOR-inhibitor-based therapy at 1-year (Risk-Ratio (RR): 1.09, 95% CI: 1.01-1.18) and 3-years (RR: 1.1, 95% CI: 1.01-1.21) post-transplant, with a nonsignificant increase at 5-years (RR: 1.15, 95% CI: 0.99-1.35). Overall survival was improved at 1-year (RR: 1.07, 95% CI: 1.02-1.12), 3-years (RR: 1.1, 95% CI: 1.02-1.19), and 5-years (RR: 1.18, 95% CI: 1.08-1.29). Recurrence-rate was lower in the mTOR-inhibitor arm (RR: 0.67, 95% CI: 0.56-0.82), with no significant increase in acute rejection (RR: 1.1, 95% CI: 0.94-1.28).

CONCLUSIONS

mTOR-inhibitor-based immunosuppression may be a preferable option in patients transplanted with HCC. It improves recurrence-free-survival over at least three years and reduces the recurrence rate compared with standard calcineurin-inhibitor-based therapy, with no significant increase in the rate of acute rejection. Future research should clarify the effect in higher vs lower risk cohorts.

Obtaining Optimal Long-Term Outcomes from Liver Transplantation for Hepatocellular Cancer

Liver transplantation is the definitive treatment for patients with end-stage liver disease. Liver transplantation is also the optimal treatment for patients with hepatocellular carcinoma (HCC), especially in the setting of chronic liver disease. Unfortunately, due to the worldwide shortage of organs, this treatment is not available for all patients with HCC. Strict selection criteria have been developed in order to obtain optimal results. A surgical perspective of the preoperative selection, perioperative management, and postoperative care of patients is reviewed in depth and provides an overview for obtaining optimal long-term results from liver transplantation for HCC. With rigorous selection and patient management, excellent long-term outcomes can be obtained with liver transplantation for patients with HCC.

Long-term observation of hepatocellular carcinoma recurrence after liver transplantation at a European transplantation centre

Background

The recurrence of hepatocellular carcinoma (HCC) is the strongest survival-limiting factor after liver transplantation (LT) in patients with HCC. In the face of donor organ shortage, it is necessary to identify factors associated with HCC recurrence in order to maximize the utility of the available grafts.

Objective

To study the phenomenon of HCC recurrence after LT at a European transplantation centre over the past 20 years.

Methods

Data from 304 HCC patients who underwent LT were prospectively recorded. Clinical and pathological factors were assessed for their association with recurrence.

Results

Fifty-one patients (16.8%) had HCC recurrence after LT. Patients exceeding the Milan criteria developed HCC recurrence more frequently. The time point of recurrence did not affect survival after recurrence. Furthermore, there was no difference in survival between patients with intra- and extrahepatic recurrence. However, patients with recurrence due to needle tract seeding had a significantly better outcome than patients with other sites of recurrence.

Conclusion

Our data support a restrictive use of patient selection criteria to help identify patients who have an increased risk of HCC recurrence after LT, and highlight the need to improve patient selection before LT in order to minimize the rate of HCC recurrence.

Statin Use is Associated with Decreased Hepatocellular Carcinoma Recurrence in Liver Transplant Patients

Statins have been reported to prevent the development of hepatocellular carcinoma (HCC). We examined whether statin therapy is associated with decreased HCC recurrence in patients who underwent liver transplantation for HCC. Three hundred forty-seven patients ≥ 20 years old who underwent liver transplantation for HCC from 2006 to 2016 were enrolled in this study. Statin therapy was defined as the administration of statins for more than 30 days after liver transplantation. One hundred twelve (32.3%) patients treated with statins over 30 days were defined as the statin group, and the remaining 235 (67.7%) were defined as the non-statin group. Several risk factors reported to be associated with HCC recurrence, such as proportion of underlying liver disease, above Milan criteria, differentiation of HCC, vascular invasion, and preoperative alpha-fetoprotein level were not different between the two groups. Time-dependent Cox regression analysis showed that statin treatment was associated with significantly lower recurrence risk of HCC after adjusting for other risk factors (hazard ratio = 0.32, 95% CI = 0.11–0.89).

Achieving Complete Remission of Hepatocellular Carcinoma: A Significant Predictor for Recurrence-Free Survival after Liver Transplantation

BACKGROUND

Liver transplantation (LT) is a curative treatment for hepatocellular carcinoma (HCC) and the underlying primary liver disease; however, tumor recurrence is still a major issue. Therefore, the aim of this study was to assess predictors and risk factors for HCC recurrence after LT in patients within and outside the Milan criteria with a special focus on the impact of different bridging strategies.

METHODS

All patients who underwent LT for HCC between 07/2002 and 09/2016 at the University Hospital of Muenster were consecutively included in this retrospective study. Database research was performed and a multivariable regression analysis was conducted to explore potential risk factors for HCC recurrence.

RESULTS

A total of 82 patients were eligible for the statistical analysis. Independent of bridging strategy, achieving complete remission (CR) was significantly associated with a lower risk for tumor recurrence (p = 0.029; OR = 0.426, 95% CI 0.198-0.918). A maximal diameter of lesion < 3 cm was also associated with lower recurrence rates (p = 0.040; OR = 0.140, 95% CI 0.022-0.914). Vascular invasion proved to be an independent risk factor for HCC recurrence (p = 0.004; OR = 11.357, 95% CI 2.142-60.199).

CONCLUSION

Achieving CR prior to LT results in a significant risk reduction of HCC recurrence after LT independent of the treatment modalities applied.

Outcome of ABO-incompatible adult living-donor liver transplantation for patients with hepatocellular carcinoma

BACKGROUND & AIMS

Living-donor liver transplantation (LDLT) can simultaneously cure hepatocellular carcinoma (HCC) and underlying liver cirrhosis, improving long-term results in patients with HCC. ABO-incompatible LDLT could expand the living-donor pool, reduce waiting times for deceased-donor liver transplantation, and improve long-term survival for some patients with HCC.

METHODS

We retrospectively reviewed the medical records of patients undergoing LDLT for HCC from November 2008 to December 2015 at a single institution in Korea. In total, 165 patients underwent ABO-incompatible and 753 patients underwent ABO-compatible LDLT for HCC. ABO-incompatible recipients underwent desensitization to overcome the ABO blood group barrier, including pretransplant plasma exchange and rituximab administration (300-375 mg/m² /body surface area).

RESULTS

We performed 1:1 propensity score matching and included 165 patients in each group. 82.4% of ABO-incompatible and 83.0% of -compatible LDLT groups had HCC within conventional Milan criteria, respectively, and 92.1% and 92.7% of patients in each group had a Child-Pugh score of A or B. ABO-incompatible and -compatible LDLT groups were followed up for 48.0 and 48.7 months, respectively, with both groups showing comparable recurrence-free survival rates (hazard ratio [HR] 1.14; 95% CI 0.68-1.90; p = 0.630) and overall patient-survival outcomes (HR 1.10; 95% CI 0.60-2.00; p = 0.763).

CONCLUSIONS

These findings suggested that ABO-incompatible liver transplantation is a feasible option for patients with HCC, especially for those with compensated cirrhosis with HCC within conventional Milan criteria.

LAY SUMMARY

Despite hypothetical immunological concerns that the desensitization protocol for breaking through the ABO blood group barrier might have a negative impact on the recurrence of hepatocellular carcinoma, our experience demonstrated no significant differences in the long-term overall survival and recurrence-free survival rates between patients receiving ABO-compatible or ABO-incompatible liver transplantation. In conclusion, results from our institution indicated that ABO-incompatible living-donor liver transplantation constitutes a potentially feasible option for patients with hepatocellular carcinoma, especially those with compensated cirrhosis with hepatocellular carcinoma within conventional Milan criteria.

The search for biomarkers of hepatocellular carcinoma and the impact on patient outcome

Hepatocellular carcinoma (HCC) is the 5th most common cancer, but the 3rd leading cause of cancer death globally with approximately 700,000 fatalities annually. The severity of this cancer arises from its difficulty to detect and treat. The major etiologies of HCC are liver fibrosis or cirrhosis from chronic viral infections, as well as metabolic conditions. Since most cases arise from prior pathologies, biomarker surveillance in high-risk individuals is an essential approach for early detection and improved patient outcome. While many molecular biomarkers have been associated with HCC, there are few that have made clinical impact for this disease. Here we review some major approaches used for HCC biomarker discovery-proteomics and glycomics-and describe new methodologies being tested for biomarker development.

Sarcopenia as a predictor of post-transplant tumor recurrence after living donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria

To evaluate the association between sarcopenia and tumor recurrence after living donor liver transplantation (LDLT) in patients with advanced hepatocellular carcinoma (HCC), we analyzed 92 males who underwent LDLT for treating HCC beyond the Milan criteria. Sarcopenia was defined when the height-normalized psoas muscle thickness was <15.5 mm/m at the L3 vertebra level on computed tomography based on an optimum stratification method using the Gray’s test statistic. Survival analysis was performed with death as a competing risk event. The primary outcome was post-transplant HCC recurrence. The median follow-up time was 36 months. There was a 9% increase in recurrence risk per unit decrease in height-normalized psoas muscle thickness. Twenty-six (36.1%) of 72 sarcopenic recipients developed HCC recurrence, whereas only one (5.0%) of 20 non-sarcopenic recipients developed HCC recurrence. Recurrence risk was greater in sarcopenic patients in univariable analysis (hazard ratio [HR] = 8.06 [1.06–16.70], p = 0.044) and in multivariable analysis (HR = 9.49 [1.18–76.32], p = 0.034). Greater alpha-fetoprotein and microvascular invasion were also identified as independent risk factors. Incorporation of sarcopenia improved the model fitness and prediction power of the estimation model. In conclusion, sarcopenia appears to be one of the important host factors modulating tumor recurrence risk after LDLT for advanced HCC.

Application of a novel liquid biopsy in patients with hepatocellular carcinoma undergoing liver transplantation

Circulating tumor cells (CTCs) serves a primary function in metastasis and recurrence of hepatocellular carcinoma (HCC). In the present study, in order to evaluate the analytical performance and clinical value of the liquid biopsy-based platform, a novel integrated subtraction enrichment and immunostaining-fluorescence in situ hybridization (iFISH^®) platform was applied to analyze CTCs in patients with HCC undergoing liver transplantation (LT). In total, 30 patients with HCC undergoing LT and 10 healthy volunteers were enrolled. CTCs in peripheral blood that were obtained from each patient prior to LT and 3 months thereafter were detected using the iFISH^® platform, and CellSearch^® system was performed for each subject for comparison. Using iFISH^® and CellSearch^®, the percentage of CTCs in patients with pre-operative HCC were 70.00% and 26.67%, respectively. CTCs counted using iFISH^® (iFISH-CTCs) were increased compared with CellSearch^® (Cellsearch-CTCs) (P<0.01). A significant decrease in iFISH-CTCs was observed 3 months following LT (3.04±0.93/7.5 to 1.0±0.53/7.5 ml, P<0.05). Furthermore, patients with lower preoperative iFISH-CTCs level (<5/7.5 ml) had markedly increased recurrence-free survival compared with iFISH-CTCs (>5/7.5 ml, 15 vs. 5.5 months; P<0.01. iFISH^® platform exhibits an increased analytical sensitivity, and may be used as a dynamic monitoring tool for CTCs, and CTCs may be a good prognostic indicator for patients with HCC undergoing LT.

Contrast-enhanced ultrasound (CEUS) prediction of focal liver lesions in patients after liver transplantation in comparison to histopathology results

PURPOSE

To investigate the value of contrast-enhanced ultrasound (CEUS) in histologic prediction of focal liver lesions after liver transplantation.

MATERIALS AND METHODS

10 focal liver lesions in 10 patients after liver transplantation were scanned using CEUS and the CEUS results were compared with the histopathological results.

RESULTS

Among 10 focal liver lesions, 7 proofed to be histopathological benign and 3 lesions proofed to be histopathological malignant. All lesions (100%) were correctly report as benign or malignant in the report of the CEUS examination.

CONCLUSION

CEUS can be helpful in the differentiation of benign and malignant focal liver lesions in patients after liver transplantation and can be used in clinical management of focal liver lesions.

Donor Polymorphisms of Toll-like Receptor 4 rs1927914 Associated with the Risk of Hepatocellular Carcinoma Recurrence Following Liver Transplantation

BACKGROUND

Hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) severely restricts the long-term survival of patients. Toll-like receptor 4 (TLR4) has been considered to be involved in hepatocarcinogenesis and metastasis. Additionally, there is a study demonstrating the significant association between TLR4 gene rs1927914 polymorphism and HCC, but no study investigated the association of the TLR4 rs1927914 polymorphism with the risk of HCC recurrence following LT.

AIM

The purpose of this study was to assess the potential association between the TLR4 gene rs1927914 polymorphism of donors and recipients and hepatocellular carcinoma recurrence after LT.

METHODS

Eighty-three patients with HCC undergoing LT from July 2006-June 2015 were identified for this analysis. We genotyped a single-nucleotide polymorphism (rs1927914) in both donors and recipients and evaluated the association between the polymorphism and risk of tumor recurrence.

RESULTS

The donor TLR4 rs1927914 polymorphism was found to be significantly associated with HCC recurrence following LT. In multivariate logistic regression analysis, Milan criteria, microvascular invasion and donor TLR4 rs1927914 genotype were confirmed to be independent risk factors for HCC recurrence. Kaplan-Meier survival curves showed that patients carrying donors homozygous TT had a significantly lower recurrence-free survival and overall survival than CC/CT patients. Cox proportional hazards modeling indicated that TNM stage or Milan criteria, microvascular invasion, and donor TLR4 rs1927914 genotype were independent factors for the clinical outcomes of LT patients.

CONCLUSIONS

Donor TLR4 rs1927914 polymorphism is associated with an increased risk of HCC recurrence following LT and has a potential clinical value for the prediction of HCC recurrence after LT.

An inflammatory myofibroblastic tumor in the transplanted liver displaying quick wash-in and wash-out on contrast-enhanced ultrasound: A case report

RATIONALE

Inflammatory myofibroblastic tumor (IMT) is an uncommon mesenchymal neoplasm, and its presence in a grafted liver is exceedingly rare.

PATIENT CONCERNS

A 54-year-old woman was admitted to our hospital with a half-month history of intermittent melena. She had undergone deceased-donor liver transplantation (LT) for hepatitis B virus related liver cirrhosis without hepatocellular carcinoma 5 months previously.

DIAGNOSIS

Laboratory examination showed impaired liver and renal functions and Epstein-Barr virus (EBV) infection, but tumor markers within normal ranges. Gastroscopy showed esophageal varices. Ultrasound and computed tomography angiography revealed an ill-defined and irregular solitary lesion in the porta hepatis, encasing both the portal vein and the hepatic artery. The lesion was characterized by arterial hyper-enhancement and hypo-enhancement in the remaining phases with contrast-enhanced ultrasound (CEUS). The lesion was finally confirmed as an IMT by ultrasound-guided biopsy.

INTERVENTION

The patient received conservative treatment, including immunosuppression, endoscopic variceal ligation, antibiotics, steroids, and antiviral agents.

OUTCOME

The patient's gastrointestinal bleeding was controlled, but the symptoms associated with portal hypertension worsened. Attempts to perform a transjugular intrahepatic portosystemic shunt were unsuccessful, and she unfortunately died soon after.

LESSONS

A differential diagnosis of IMT should be considered in LT recipients presenting with EBV infection, normal tumor markers, and a de novo hepatic lesion with quick wash-in and wash-out on CEUS. Ultrasound is associated with the advantages of convenience and nonionizing radiation, and should thus be the priority approach for monitoring transplanted liver.

Comparison of repeated surgical resection and radiofrequency ablation for small recurrent hepatocellular carcinoma after primary resection

There is controversy concerning whether radiofrequency ablation (RFA) or surgical resection (SR) is a better treatment option for recurrent HCC after resection. In Kaohsiung Veteran General Hospital, from January 2002 to September 2014, a total of 100 consecutive patients who developed recurrent HCCs with a tumor size ≦ 3 cm and tumor numbers ≦ 3 after surgical resection were enrolled. Among these patients, 57 patients received RFA and 43 patients underwent repeated SR. Baseline characteristics at the time of recurrence after hepatic resection and clinical outcomes following treatment of recurrent HCC were compared between the two groups. The baseline data of initial HCC and the first recurrence of HCC were comparable in both groups. The 1-, 3-, 5-year overall survival rates following treatment of the first recurrence of HCC were 97.6%, 82.7%, 56.4% in the repeated SR group and 98.2%, 77.2%, 52.6% in the RFA group (p = 0.69). The 1-, 3-, 5-year disease-free survival rates were 57.0%, 32.1%, 28.6% in the repeated SR group and 60.8%, 26.6%, 16.6% in the RFA group ((p = 0.89). There was a trend whereby patients who underwent repeated SR had more procedure-related morbidity than patients who underwent RFA (16% vs. 7%, p = 0.14). The median total hospital days were longer in the repeated SR group than that in the RFA group (13 vs. 5 days, p < 0.05). In the small recurrent HCCs after SR, RFA achieved similar overall survival and disease-free survival than those with repeated SR as well as having a shorter hospital stay.

The role of metronomic capecitabine for treatment of recurrent hepatocellular carcinoma after liver transplantation

The management of recurrent hepatocellular carcinoma untreatable with surgical options is based on systemic therapy with sorafenib. Due to the high rates of adverse events connected to the therapy with sorafenib, metronomic capecitabine seems a promising strategy for these patients. We analyzed the data of 38 patients with hepatocellular carcinoma recurrent after liver transplantation performed at our center. We compared the outcome of 17 patients receiving metronomic capecitabine versus 20 patients experiencing best supportive care and versus the data of the literature about treatment with sorafenib. In the group treated with metronomic capecitabine we observed an increased survival after tumor recurrence at the univariate and multivariate analysis compared to the group of best supportive care (median 22 months vs. 7 months, p < 0.01). Data from the literature on the use of sorafenib showed outcomes like our study group, with similar patient and tumoral features. The episodes of acute rejection and the tumor stage at the recurrence showed a correlation with patient survival at the univariate analysis. The metronomic capecitabine for hepatocellular cancer recurrent after liver transplantation seems effective without important adverse events and comparable results to sorafenib.