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Wehrle CJ, Kusakabe J, Akabane M, Maspero M, Zervos B, Modaresi Esfeh J, Whitsett Linganna M, Imaoka Y, Khalil M, Pita A, Kim J, Diago-Uso T, Fujiki M, Eghtesad B, Quintini C, Kwon CD, Pinna A, Aucejo F, Miller C, Mazzaferro V, Schlegel A, Sasaki K, Hashimoto K. Expanding Selection Criteria in Deceased Donor Liver Transplantation for Hepatocellular Carcinoma: Long-term Follow-up of a National Registry and 2 Transplant Centers. Transplantation 2024:00007890-990000000-00780. [PMID: 38831488 DOI: 10.1097/tp.0000000000005097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND This study compares selection criteria for liver transplant (LT) for hepatocellular carcinoma (HCC) for inclusivity and predictive ability to identify the most permissive criteria that maintain patient outcomes. METHODS The Scientific Registry of Transplant Recipients (SRTR) database was queried for deceased donor LT's for HCC (2003-2020) with 3-y follow-up; these data were compared with a 2-center experience. Milan, University of California, San Francisco (UCSF), 5-5-500, Up-to-seven (U7), HALT-HCC, and Metroticket 2.0 scores were calculated. RESULTS Nationally, 26 409 patients were included, and 547 at the 2 institutions. Median SRTR-follow-up was 6.8 y (interquartile range 3.9-10.1). Three criteria allowed the expansion of candidacy versus Milan: UCSF (7.7%, n = 1898), Metroticket 2.0 (4.2%, n = 1037), and U7 (3.5%, n = 828). The absolute difference in 3-y overall survival (OS) between scores was 1.5%. HALT-HCC (area under the curve [AUC] = 0.559, 0.551-0.567) best predicted 3-y OS although AUC was notably similar between criteria (0.506 < AUC < 0.527, Mila n = 0.513, UCSF = 0.506, 5-5-500 = 0.522, U7 = 0.511, HALT-HCC = 0.559, and Metroticket 2.0 = 0.520), as was Harrall's c-statistic (0.507 < c-statistic < 0.532). All scores predicted survival to P < 0.001 on competing risk analysis. Median follow-up in our enterprise was 9.8 y (interquartile range 7.1-13.3). U7 (13.0%, n = 58), UCSF (11.1%, n = 50), HALT-HCC (6.4%, n = 29), and Metroticket 2.0 (6.3%, n = 28) allowed candidate expansion. HALT-HCC (AUC = 0.768, 0.713-0.823) and Metroticket 2.0 (AUC = 0.739, 0.677-0.801) were the most predictive of recurrence. All scores predicted recurrence and survival to P < 0.001 using competing risk analysis. CONCLUSIONS Less restrictive criteria such as Metroticket 2.0, UCSF, or U7 allow broader application of transplants for HCC without sacrificing outcomes. Thus, the criteria for Model for End-stage Liver Disease-exception points for HCC should be expanded to allow more patients to receive life-saving transplantation.
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Affiliation(s)
- Chase J Wehrle
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Jiro Kusakabe
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Miho Akabane
- Department of Surgery, Stanford University Hospital, Palo Alto, CA
| | - Marianna Maspero
- General Surgery and Liver Transplantation Unit, IRCCS Istituto Tumori, Milan, Italy
| | - Bobby Zervos
- Department of Liver Transplantation, Cleveland Clinic Weston Hospital, Weston, FL
| | | | | | - Yuki Imaoka
- Department of Surgery, Stanford University Hospital, Palo Alto, CA
| | - Mazhar Khalil
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Alejandro Pita
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Jaekeun Kim
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago-Uso
- Department of Surgery, Digestive Disease Institute, Transplantation Center, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Masato Fujiki
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghtesad
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Department of Surgery, Digestive Disease Institute, Transplantation Center, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Choon David Kwon
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Antonio Pinna
- Department of Liver Transplantation, Cleveland Clinic Weston Hospital, Weston, FL
| | - Federico Aucejo
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Vincenzo Mazzaferro
- General Surgery and Liver Transplantation Unit, IRCCS Istituto Tumori, Milan, Italy
| | - Andrea Schlegel
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Kazunari Sasaki
- Department of Surgery, Stanford University Hospital, Palo Alto, CA
| | - Koji Hashimoto
- Department of Surgery, Transplantation Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
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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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Wehrle CJ, Raj R, Maspero M, Satish S, Eghtesad B, Pita A, Kim J, Khalil M, Calderon E, Orabi D, Zervos B, Modaresi Esfeh J, Whitsett Linganna M, Diago-Uso T, Fujiki M, Quintini C, Kwon CD, Miller C, Pinna A, Aucejo F, Hashimoto K, Schlegel A. Risk assessment in liver transplantation for hepatocellular carcinoma: long-term follow-up of a two-centre experience. Int J Surg 2024; 110:2818-2831. [PMID: 38241354 PMCID: PMC11093438 DOI: 10.1097/js9.0000000000001104] [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: 09/02/2023] [Accepted: 01/08/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Liver transplantation (LT) is a well-established treatment for hepatocellular carcinoma (HCC), but there are ongoing debates regarding outcomes and selection. This study examines the experience of LT for HCC at a high-volume centre. METHODS A prospectively maintained database was used to identify HCC patients undergoing LT from 2000 to 2020 with more than or equal to 3-years follow-up. Data were obtained from the centre database and electronic medical records. The Metroticket 2.0 HCC-specific 5-year survival scale was calculated for each patient. Kaplan-Meier and Cox-regression analyses were employed assessing survival between groups based on Metroticket score and individual donor and recipient risk factors. RESULTS Five hundred sixty-nine patients met criteria. Median follow-up was 96.2 months (8.12 years; interquartile range 59.9-147.8). Three-year recurrence-free (RFS) and overall survival (OS) were 88.6% ( n =504) and 86.6% ( n =493). Five-year RFS and OS were 78.9% ( n =449) and 79.1% ( n =450). Median Metroticket 2.0 score was 0.9 (interquartile range 0.9-0.95). Tumour size greater than 3 cm ( P =0.012), increasing tumour number on imaging ( P =0.001) and explant pathology ( P <0.001) was associated with recurrence. Transplant within Milan ( P <0.001) or UCSF criteria ( P <0.001) had lower recurrence rates. Increasing alpha-fetoprotein (AFP)-values were associated with more HCC recurrence ( P <0.001) and reduced OS ( P =0.008). Chemoembolization was predictive of recurrence in the overall population ( P =0.043) and in those outside-Milan criteria ( P =0.038). A receiver-operator curve using Metroticket 2.0 identified an optimal cut-off of projected survival greater than or equal to 87.5% for predicting recurrence. This cut-off was able to predict RFS ( P <0.001) in the total cohort and predict both, RFS ( P =0.007) and OS ( P =0.016) outside Milan. Receipt of donation after brain death (DBD) grafts (55/478, 13%) or living-donor grafts (3/22, 13.6%) experienced better survival rates compared to donation after cardiac death (DCD) grafts ( n =15/58, 25.6%, P =0.009). Donor age was associated with a higher HCC recurrence ( P =0.006). Both total ischaemia time (TIT) greater than 6hours ( P =0.016) and increasing TIT correlated with higher HCC recurrence ( P =0.027). The use of DCD grafts for outside-Milan candidates was associated with increased recurrence ( P =0.039) and reduced survival ( P =0.033). CONCLUSION This large two-centre analysis confirms favourable outcomes after LT for HCC. Tumour size and number, pre-transplant AFP, and Milan criteria remain important recipient HCC-risk factors. A higher donor risk (i.e. donor age, DCD grafts, ischaemia time) was associated with poorer outcomes.
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Affiliation(s)
- Chase J. Wehrle
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Roma Raj
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Marianna Maspero
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Sangeeta Satish
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Alejandro Pita
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Jaekeun Kim
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Mazhar Khalil
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Esteban Calderon
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Danny Orabi
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Bobby Zervos
- Cleveland Clinic Weston Hospital, Department of Liver Transplantation, Weston, FL, USA
| | | | | | - Teresa Diago-Uso
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Masato Fujiki
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Cristiano Quintini
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Choon David Kwon
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Charles Miller
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Antonio Pinna
- Cleveland Clinic Weston Hospital, Department of Liver Transplantation, Weston, FL, USA
| | - Federico Aucejo
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Koji Hashimoto
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Andrea Schlegel
- Transplantation Center, Department of Surgery, Digestive Disease Institute
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, OH
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4
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Kartik A, Armstrong VL, Stucky CC, Wasif N, Fong ZV. Contemporary Approaches to the Surgical Management of Pancreatic Neuroendocrine Tumors. Cancers (Basel) 2024; 16:1501. [PMID: 38672582 PMCID: PMC11048062 DOI: 10.3390/cancers16081501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/04/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
The incidence of pancreatic neuroendocrine tumors (PNETs) is on the rise primarily due to the increasing use of cross-sectional imaging. Most of these incidentally detected lesions are non-functional PNETs with a small proportion of lesions being hormone-secreting, functional neoplasms. With recent advances in surgical approaches and systemic therapies, the management of PNETs have undergone a paradigm shift towards a more individualized approach. In this manuscript, we review the histologic classification and diagnostic approaches to both functional and non-functional PNETs. Additionally, we detail multidisciplinary approaches and surgical considerations tailored to the tumor's biology, location, and functionality based on recent evidence. We also discuss the complexities of metastatic disease, exploring liver-directed therapies and the evolving landscape of minimally invasive surgical techniques.
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Affiliation(s)
| | | | | | | | - Zhi Ven Fong
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
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5
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Soliman N, Saharia A, Abdelrahim M, Connor AA. Molecular profiling in the management of hepatocellular carcinoma. Curr Opin Organ Transplant 2024; 29:10-22. [PMID: 38038621 DOI: 10.1097/mot.0000000000001124] [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: 12/02/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to both summarize the current knowledge of hepatocellular carcinoma molecular biology and to suggest a framework in which to prospectively translate this knowledge into patient care. This is timely as recent guidelines recommend increased use of these technologies to advance personalized liver cancer care. RECENT FINDINGS The main themes covered here address germline and somatic genetic alterations recently discovered in hepatocellular carcinoma, largely owing to next generation sequencing technologies, and nascent efforts to translate these into contemporary practice. SUMMARY Early efforts of translating molecular profiling to hepatocellular carcinoma care demonstrate a growing number of potentially actionable alterations. Still lacking are a consensus on what biomarkers and technologies to adopt, at what scale and cost, and how to integrate them most effectively into care.
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Loosen SH, Leyh C, Neumann UP, Bock H, Weigel C, Luedde T, Roderburg C. Liver transplantation meets gastrointestinal cancer. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:62-72. [PMID: 38195110 DOI: 10.1055/a-2226-0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Liver transplantation (LT) has emerged as a standard of care for patients with end-stage liver disease, providing a life-saving intervention for patients with severely compromised liver function in both the acute and chronic setting. While LT has also become a routine procedure for early-stage hepatocellular carcinoma (HCC), offering a potential cure by treating both the tumor and the underlying liver disease, its relevance in the context of other malignancies such as cholangiocellular carcinoma (CCA), combined hepatocellular-cholangiocarcinoma (cHCC-CCA) or liver metastases is still the subject of intense debate and no definite recommendations have yet been established. This review summarizes the current therapeutic standards in the context of LT for gastrointestinal malignancies and provides a reflection and outlook on current scientific and clinical developments.
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Affiliation(s)
- Sven H Loosen
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
| | - Catherine Leyh
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
| | - Ulf Peter Neumann
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
| | - Hans Bock
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
| | - Christian Weigel
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
| | - Christoph Roderburg
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
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7
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Kumar A, Acharya SK, Singh SP, Duseja A, Madan K, Shukla A, Arora A, Anand AC, Bahl A, Soin AS, Sirohi B, Dutta D, Jothimani D, Panda D, Saini G, Varghese J, Kumar K, Premkumar M, Panigrahi MK, Wadhawan M, Sahu MK, Rela M, Kalra N, Rao PN, Puri P, Bhangui P, Kar P, Shah SR, Baijal SS, Shalimar, Paul SB, Gamanagatti S, Gupta S, Taneja S, Saraswat VA, Chawla YK. 2023 Update of Indian National Association for Study of the Liver Consensus on Management of Intermediate and Advanced Hepatocellular Carcinoma: The Puri III Recommendations. J Clin Exp Hepatol 2024; 14:101269. [PMID: 38107186 PMCID: PMC10724697 DOI: 10.1016/j.jceh.2023.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/12/2023] [Indexed: 12/19/2023] Open
Abstract
Hepatocellular carcinoma (HCC) presents significant treatment challenges despite considerable advancements in its management. The Indian National Association for the Study of the Liver (INASL) first published its guidelines to aid healthcare professionals in the diagnosis and treatment of HCC in 2014. These guidelines were subsequently updated in 2019. However, INASL has recognized the need to revise its guidelines in 2023 due to recent rapid advancements in the diagnosis and management of HCC, particularly for intermediate and advanced stages. The aim is to provide healthcare professionals with evidence-based recommendations tailored to the Indian context. To accomplish this, a task force was formed, and a two-day round table discussion was held in Puri, Odisha. During this event, experts in their respective fields deliberated and finalized consensus statements to develop these updated guidelines. The 2023 INASL guidelines offer a comprehensive framework for the diagnosis, staging, and management of intermediate and advanced HCC in India. They represent a significant step forward in standardizing clinical practices nationwide, with the primary objective of ensuring that patients with HCC receive the best possible care based on the latest evidence. The guidelines cover various topics related to intermediate and advanced HCC, including biomarkers of aggressive behavior, staging, treatment options, and follow-up care.
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Affiliation(s)
- Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Kaushal Madan
- Clinical Hepatology, Max Hospitals, Saket, New Delhi, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, 400022, India
| | - Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - Anil C. Anand
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Ankur Bahl
- Department of Medical Oncology, Fortis Memorial Research Institute, Sector - 44, Opp. HUDA City Center, Gurugram, 122002, India
| | - Arvinder S. Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Bhawna Sirohi
- Medical Oncology, BALCO Medical Centre, Raipur Chattisgarh, 493661, India
| | - Debnarayan Dutta
- Radiation Oncology, Amrita Institute of Medical Sciences, Ponekkara, AIMS (P.O.), Kochi, 682041, India
| | - Dinesh Jothimani
- Department of Hepatology, Dr. Rela Institute & Medical Centre, #7, CLC Works Road, Chromepet, Chennai, 600044, India
| | - Dipanjan Panda
- Department of Medical Oncology, Apollo Cancer Centre, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110076, India
| | - Gagan Saini
- Radiation Oncology, Max Institute of Cancer Care, Max Super-Speciality Hospital, W-3, Ashok Marg, near Radisson Blu Hotel, Sector-1, Vaishali, Ghaziabad, 201012, India
| | - Joy Varghese
- Department of Hepatology & Transplant Hepatology, Gleneagles Global Health City, 439, Cheran Nagar, Perumbakkam, Chennai, Tamil Nadu, 600100, India
| | - Karan Kumar
- Department of HPB Sciences and Liver Transplantation, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302022, Rajasthan, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Manas K. Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, Odisha, India
| | - Manav Wadhawan
- Liver & Digestive Diseases Institute, Institute of Liver & Digestive Diseases, BLK Max Hospital, Delhi, 110 005, India
| | - Manoj K. Sahu
- Department of Medical Gastroenterology, IMS & SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, Odisha 751 003, India
| | - Mohamed Rela
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, #7, CLC Works Road, Chromepet, Chennai, 600044, India
| | - Naveen Kalra
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Padaki N. Rao
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, No. 6-3-661, Punjagutta Road, Somajiguda, Hyderabad, Telangana, 500 082, India
| | - Pankaj Puri
- Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Heart Institute & Research Centre, Okhla Road, New Delhi, 110025, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Premashis Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Samir R. Shah
- Department of Hepatology and Liver Intensive Care, Institute of Liver Disease, HPB Surgery and Transplant Global Hospitals, Dr E Borges Road, Parel, Mumbai, 400012, India
| | - Sanjay S. Baijal
- Diagnostic and Interventional Radiology, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shivanand Gamanagatti
- Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Heart Institute & Research Centre, Okhla Road, New Delhi, 110025, India
| | - Subash Gupta
- Centre for Liver & Biliary Sciences, Liver Transplant and Biliary Sciences, Robotic Surgery, Max Super Speciality Hospital, No. 1, 2, Press Enclave Road, Mandir Marg, Saket Institutional Area, Saket, New Delhi, Delhi, 110017, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Vivek A. Saraswat
- Department of Gastroenterology and Hepatology, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302022, Rajasthan, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
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Yu Q, Khanjyan M, Fidelman N, Pillai A. Contemporary applications of Y90 for the treatment of hepatocellular carcinoma. Hepatol Commun 2023; 7:e0288. [PMID: 37782464 PMCID: PMC10545406 DOI: 10.1097/hc9.0000000000000288] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 10/03/2023] Open
Abstract
Transarterial radioembolization (TARE) with yttrium-90 (90Y) microspheres has been widely adopted for the treatment of HCC. Recent advances in yttrium-90 (90Y) dosimetry have led to durable local responses. Radiation segmentectomy has become a viable alternative to thermal ablation for early-stage HCC (Barcelona Clinic Liver Cancer 0 and A) and has been commonly used as a bridge to transplant. TARE is also commonly used for downstaging to transplant using traditional lobar dosimetry and radiation segmentectomy techniques. Radiation lobectomy has a dual role in local tumor control and induction of contralateral liver lobe hypertrophy as a bridge to resection for patients with an inadequate future liver remnant. TARE continues to provide disease control for patients with limited vascular invasion and may be an alternative to systemic therapy for patients with localized advanced disease. The potential synergy between TARE and immunotherapy has been recognized, and prospective studies evaluating this combination are needed for patients with Barcelona Clinic Liver Cancer B and C HCC.
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Affiliation(s)
- Qian Yu
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois, USA
| | - Michael Khanjyan
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Nicholas Fidelman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Anjana Pillai
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, University of Chicago, Chicago, Illinois, USA
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9
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Nie P, Zhang J, Miao W, Duan S, Wang T, Zhang J, Gu J, Wang N, Zhang R, Wang X, Yang G, Rao W, Wang Z. Incremental value of radiomics-based heterogeneity to the existing risk criteria in predicting recurrence of hepatocellular carcinoma after liver transplantation. Eur Radiol 2023; 33:6608-6618. [PMID: 37012548 DOI: 10.1007/s00330-023-09591-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/02/2023] [Accepted: 02/17/2023] [Indexed: 04/05/2023]
Abstract
OBJECTIVES The aim of the study was to evaluate the association between the radiomics-based intratumoral heterogeneity (ITH) and the recurrence risk in hepatocellular carcinoma (HCC) patients after liver transplantation (LT), and to assess its incremental to the Milan, University of California San Francisco (UCSF), Metro-Ticket 2.0, and Hangzhou criteria. METHODS A multicenter cohort of 196 HCC patients were investigated. The endpoint was recurrence-free survival (RFS) after LT. A CT-based radiomics signature (RS) was constructed and assessed in the whole cohort and in the subgroups stratified by the Milan, UCSF, Metro-Ticket 2.0, and Hangzhou criteria. The R-Milan, R-UCSF, R-Metro-Ticket 2.0, and R-Hangzhou nomograms which combined RS and the four existing risk criteria were developed respectively. The incremental value of RS to the four existing risk criteria in RFS prediction was evaluated. RESULTS RS was significantly associated with RFS in the training and test cohorts as well as in the subgroups stratified by the existing risk criteria. The four combined nomograms showed better predictive capability than the existing risk criteria did with higher C-indices (R-Milan [training/test] vs. Milan, 0.745/0.765 vs. 0.677; R-USCF vs. USCF, 0.748/0.767 vs. 0.675; R-Metro-Ticket 2.0 vs. Metro-Ticket 2.0, 0.756/0.783 vs. 0.670; R-Hangzhou vs. Hangzhou, 0.751/0.760 vs. 0.691) and higher clinical net benefit. CONCLUSIONS The radiomics-based ITH can predict outcomes and provide incremental value to the existing risk criteria in HCC patients after LT. Incorporating radiomics-based ITH in HCC risk criteria may facilitate candidate selection, surveillance, and adjuvant trial design. KEY POINTS • Milan, USCF, Metro-Ticket 2.0, and Hangzhou criteria may be insufficient for outcome prediction in HCC after LT. • Radiomics allows for the characterization of tumor heterogeneity. • Radiomics adds incremental value to the existing criteria in outcome prediction.
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Affiliation(s)
- Pei Nie
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Juntao Zhang
- GE Healthcare, Precision Health Institution, Shanghai, China
| | - Wenjie Miao
- Department of Nuclear Medicine, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Qingdao, Shandong, 266061, China
| | - Shaofeng Duan
- GE Healthcare, Precision Health Institution, Shanghai, China
| | - Tongyu Wang
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Ju Zhang
- Department of Nuclear Medicine, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Qingdao, Shandong, 266061, China
| | - Jinyang Gu
- Department of Transplantation, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ning Wang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, Shandong, 250021, China
| | - Ran Zhang
- Huiying Medical Technology Co. Ltd, Beijing, China
| | - Ximing Wang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, Shandong, 250021, China.
| | - Guangjie Yang
- Department of Nuclear Medicine, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Qingdao, Shandong, 266061, China.
| | - Wei Rao
- Division of Hepatology, Liver Disease Center, Organ Transplantation Center, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Qingdao, Shandong, 266061, China.
| | - Zhenguang Wang
- Department of Nuclear Medicine, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Qingdao, Shandong, 266061, China.
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10
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Bezjak M, Kocman B, Jadrijević S, Filipec Kanižaj T, Antonijević M, Dalbelo Bašić B, Mikulić D. Use of machine learning models for identification of predictors of survival and tumour recurrence in liver transplant recipients with hepatocellular carcinoma. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:345. [PMID: 37675331 PMCID: PMC10477658 DOI: 10.21037/atm-22-6469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/19/2023] [Indexed: 09/08/2023]
Abstract
Background Hepatocellular carcinoma (HCC) is one of the leading indications for liver transplantation (LT) however, selection criteria remain controversial. We aimed to identify survival factors and predictors for tumour recurrence using machine learning (ML) methods. We also compared ML models to the Cox regression model. Methods Thirty pretransplant donor and recipient general and tumour specific parameters were analysed from 170 patients who underwent orthotopic liver transplantation for HCC between March 2013 and December 2019 at the University Hospital Merkur, Zagreb. Survival rates were calculated using the Kaplan-Meier method and multivariate analysis was performed using the Cox proportional hazards regression model. Data was also processed through Coxnet (a regularized Cox regression model), Random Survival Forest (RSF), Survival Support Vector Machine (SVM) and Survival Gradient Boosting models, which included pre-processing, variable selection, imputation of missing data, training and cross-validation of the models. The cross-validated concordance index (CI) was used as an evaluation metric and to determine the best performing model. Results Kaplan-Meier curves for 5-year survival time showed survival probability of 80% for recipient survival and 82% for graft survival. The 5-year HCC recurrence was observed in 19% of patients. The best predictive accuracy was observed in the RSF model with CI of 0.72, followed by the Survival SVM model (CI 0.70). Overall ML models outperform the Cox regression model with respect to their limitations. Random Forest analysis provided several relevant outcome predictors: alpha fetoprotein (AFP), donor C-reactive protein (CRP), recipient age and neutrophil to lymphocyte ratio (NLR). Cox multivariate analysis showed similarities with RSF models in identifying detrimental variables. Some variables such as donor age and number of transarterial chemoembolization treatments (TACE) were pointed out, but these were not influential in our RSF model. Conclusions Using ML methods in addition to classical statistical analysis, it is possible to develop sufficient prognostic models, which, compared to established risk scores, could help us quantify survival probability and make changes in organ utilization.
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Affiliation(s)
- Miran Bezjak
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb, Croatia
| | - Branislav Kocman
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb, Croatia
| | - Stipislav Jadrijević
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb, Croatia
| | - Tajana Filipec Kanižaj
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Merkur, Zagreb, Croatia
| | | | - Bojana Dalbelo Bašić
- Faculty of Electrical Engineering and Computing, Department of Electronics, Microelectronics, Computer and Intelligent Systems, Zagreb, Croatia
| | - Danko Mikulić
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb, Croatia
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11
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Koza A, Bhogal RH, Fotiadis N, Mavroeidis VK. The Role of Ablative Techniques in the Management of Hepatocellular Carcinoma: Indications and Outcomes. Biomedicines 2023; 11:biomedicines11041062. [PMID: 37189680 DOI: 10.3390/biomedicines11041062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/18/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
The management of hepatocellular carcinoma (HCC) remains complex and will continue to rely on the multidisciplinary input of hepatologists, surgeons, radiologists, oncologists and radiotherapists. With the appropriate staging of patients and selection of suitable treatments, the outcomes for HCC are improving. Surgical treatments encompassing both liver resection and orthotopic liver transplantation (OLT) are the definitive curative-intent options. However, patient suitability, as well as organ availability, pose essential limitations. Consequently, non-surgical options, such as ablative techniques, play an increasingly important role, especially in small HCCs, where overall and disease-free survival can be comparable to surgical resection. Ablative techniques are globally recommended in recognised classification systems, showing increasingly promising results. Recent technical refinements, as well as the emerging use of robotic assistance, may expand the treatment paradigm to achieve improved oncological results. At present, in very early stage and early stage unresectable disease, percutaneous thermal ablation is considered the treatment of choice. Owing to their different features, various ablative techniques, including radiofrequency ablation, microwave ablation, cryotherapy ablation and irreversible electroporation, have been shown to confer different comparative advantages and applicability. We herein review the role of available ablative techniques in the current complex multidisciplinary management of HCC, with a main focus on the indications and outcomes, and discuss future perspectives.
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12
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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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13
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Yin C, Armstrong S, Shin R, Geng X, Wang H, Satoskar RS, Fishbein T, Smith C, Banovac F, Kim AY, He AR. Bridging and downstaging with
TACE
in early and intermediate stage hepatocellular carcinoma: Predictors of receiving a liver transplant. Ann Gastroenterol Surg 2022; 7:295-305. [PMID: 36998293 PMCID: PMC10043769 DOI: 10.1002/ags3.12622] [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: 03/20/2022] [Accepted: 09/05/2022] [Indexed: 11/27/2022] Open
Abstract
Background and Aims In patients with surgically unresectable early and intermediate stage hepatocellular carcinoma (HCC), only liver transplant (LT) offers a cure. Locoregional therapies, such as transarterial chemoembolization (TACE), are widely used to bridge patients waiting for an LT or downstage tumors beyond Milan Criteria (MC). However, there are no formal guidelines on the number of TACE procedures patients should receive. Our study explores the extent to which repeated TACE might offer diminishing gains toward LT. Approach We retrospectively analyzed 324 patients with BCLC stage A and B HCC who had received TACE with the intention of disease downstaging or bridging to LT. In addition to baseline demographics, we collected data on LT status, survival, and the number of TACE procedures. Overall survival (OS) rates were estimated using the Kaplan-Meier method, and correlative studies were calculated using chi-square or Fisher's exact test. Results Out of 324 patients, 126 (39%) received an LT, 32 (25%) of whom had responded favorably to TACE. LT significantly improved OS: HR 0.174 (0.094-0.322, P < .001). However, the LT rate significantly decreased if patients received ≥3 vs < 3 TACE procedures (21.6% vs 48.6%, P < .001). If their cancer was beyond MC after the third TACE, the LT rate was 3.7%. Conclusions An increased number of TACE procedures may have diminishing returns in preparing patients for LT. Our study suggests that alternatives to LT, such as novel systemic therapies, should be considered for patients whose cancers are beyond MC after three TACE procedures.
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Affiliation(s)
- Chao Yin
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer CenterGeorgetown UniversityWashingtonDistrict of ColumbiaUSA
| | - Samantha Armstrong
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer CenterGeorgetown UniversityWashingtonDistrict of ColumbiaUSA
| | - Richard Shin
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer CenterGeorgetown UniversityWashingtonDistrict of ColumbiaUSA
| | - Xue Geng
- Department of BiostatisticsGeorgetown UniversityWashingtonDistrict of ColumbiaUSA
| | - Hongkun Wang
- Department of BiostatisticsGeorgetown UniversityWashingtonDistrict of ColumbiaUSA
| | - Rohit S. Satoskar
- MedStar Georgetown Transplant InstituteWashingtonDistrict of ColumbiaUSA
| | - Thomas Fishbein
- MedStar Georgetown Transplant InstituteWashingtonDistrict of ColumbiaUSA
| | - Coleman Smith
- MedStar Georgetown Transplant InstituteWashingtonDistrict of ColumbiaUSA
| | - Filip Banovac
- Department of RadiologyGeorgetown University Medical CenterWashingtonDistrict of ColumbiaUSA
| | - Alexander Y. Kim
- Department of RadiologyGeorgetown University Medical CenterWashingtonDistrict of ColumbiaUSA
| | - Aiwu Ruth He
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer CenterGeorgetown UniversityWashingtonDistrict of ColumbiaUSA
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14
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Kornberg A, Kaschny L, Kornberg J, Friess H. Preoperative Prognostic Nutritional Index May Be a Strong Predictor of Hepatocellular Carcinoma Recurrence Following Liver Transplantation. J Hepatocell Carcinoma 2022; 9:649-660. [PMID: 35923612 PMCID: PMC9342250 DOI: 10.2147/jhc.s366107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 06/23/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose Malnutrition is a major risk factor of immune dysfunction and poor outcome in cancer patients. The prognostic nutritional index (PNI), which is established by serum albumin level and peripheral lymphocyte count, was shown to correlate with prognosis of hepatocellular carcinoma (HCC) patients following liver resection and non-surgical interventions. The aim of this study was to analyze the predictive value of preoperative PNI in liver transplantation (LT) patients with HCC. Patients and Methods A total of 123 HCC patients that underwent LT were included in the analysis. The prognostic impact of preoperatively assessed clinical factors including the PNI on post-LT outcome was analyzed by uni- and multivariate analysis. Results Post-transplant tumor recurrence rates were 5.1% in high-PNI (> 42) and 55.6% in low-PNI (≤ 42) patients (p < 0.001). Preoperative high-PNI could be identified as a significant and independent promoter of both recurrence-free survival (hazard ratio [HR] = 10.12, 95% CI: 3.40–30.10; p < 0.001) and overall survival (HR = 1.69, 95% CI: 1.02–2.79; p = 0.004) following LT. Apart from that low-PNI proved to be a significant and independent predictor of microvascular tumor invasion (OR = 7.71, 95% CI: 3.17–18.76; p < 0.001). In contrast, no tumor morphology features including the Milan criteria revealed an independent prognostic value. Conclusion Our data indicate that preoperative PNI correlates with biological tumor aggressiveness and outcome following LT in HCC patients and may therefore be useful for refining oncologic risk stratification.
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Affiliation(s)
- Arno Kornberg
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Surgery, Munich, Germany
- Correspondence: Arno Kornberg, Technical University of Munich, Medical School, Klinikum rechts der Isar, Department of Surgery, Ismaningerstr. 22, Munich, D-81675, Germany, Tel +49 89 41405087, Fax +49 89 41404884, Email
| | - Linda Kaschny
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Surgery, Munich, Germany
| | - Jennifer Kornberg
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Surgery, Munich, Germany
| | - Helmut Friess
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Surgery, Munich, Germany
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15
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Ahmed O, Vachharajani N, Croome KP, Tabrizian P, Agopian V, Halazun K, Hong JC, Dageforde LA, Chapman WC, Doyle MM. Are Current National Review Board Downstaging Protocols for Hepatocellular Carcinoma Too Restrictive? J Am Coll Surg 2022; 234:579-588. [PMID: 35290278 DOI: 10.1097/xcs.0000000000000140] [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: 11/26/2022]
Abstract
BACKGROUND Liver transplantation (LT) is an effective strategy for patients with unresectable hepatocellular carcinoma (HCC). To qualify for standardized LT model for end-stage liver disease exception points, the United Network for Organ Sharing National Liver Review Board (NLRB) requires that the presenting and final HCC tumor burden be within the University of California San Francisco criteria, which were recently expanded (within expanded UCSF [W-eUCSF]). Current NLRB criteria may be too restrictive because it has been shown previously that the initial burden does not predict LT failure when tumors downstage to UCSF. This study aims to assess LT outcomes for HCC initially presenting beyond expanded UCSF (B-eUCSF) criteria in a large multicenter collaboration. STUDY DESIGN Comparisons of B-eUCSF and W-eUCSF candidates undergoing LT at seven academic institutions between 2001 and 2017 were made from a multi-institutional database. Survival outcomes were compared by Kaplan-Meier and Cox regression analyses. RESULTS Of 1,846 LT recipients with HCC, 86 (5%) met B-eUCSF criteria at initial presentation, with the remainder meeting W-eUCSF criteria. Despite differences in tumor burden, B-eUCSF candidates achieved comparable 1-, 5- and 10-year overall (89%, 70%, and 55% vs 91%, 74%, and 60%, respectively; p = 0.2) and disease-free (82%, 60%, and 53% vs 89%, 71%, and 59%, respectively; p = 0.07) survival to patients meeting W-eUCSF criteria after LT. Despite increased tumor recurrence in B-eUCSF vs W-eUCSF patients (24% vs 10%, p = 0.0002), post-recurrence survival was similar in both groups (p = 0.69). CONCLUSION Transplantation for patients initially presenting with HCC B-eUSCF criteria offers a survival advantage similar to those with tumors meeting W-eUCSF criteria at presentation. The current NLRB policy is too stringent, and considerations to expand criteria should be discussed.
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Affiliation(s)
- Ola Ahmed
- From the Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO (Ahmed, Vachharajani, Chapman, Doyle)
| | - Neeta Vachharajani
- From the Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO (Ahmed, Vachharajani, Chapman, Doyle)
| | - Kris P Croome
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL (Croome)
| | - Parissa Tabrizian
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY (Tabrizian)
| | - Vatche Agopian
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA (Agopian)
| | - Karim Halazun
- New York-Presbyterian Hospital, Weill Cornell, New York, NY (Halazun)
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI (Hong)
| | - Leigh Anne Dageforde
- Department of Surgery, Division of Transplantation, Massachusetts General Hospital, Boston, MA (Dageforde)
| | - William C Chapman
- From the Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO (Ahmed, Vachharajani, Chapman, Doyle)
| | - Mb Majella Doyle
- From the Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO (Ahmed, Vachharajani, Chapman, Doyle)
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16
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Muhammad H, Gurakar M, Ting PS, Alsughayer AM, Luu H, Zaffar D, Alqahtani S, Bonder A, Gurakar A, Saberi B. Long-Term Outcomes of Living Donor Versus Deceased Donor Liver Transplant for Hepatocellular Carcinoma in the United States. EXP CLIN TRANSPLANT 2022; 20:279-284. [PMID: 35352634 DOI: 10.6002/ect.2021.0479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Although living donor liver transplant has become a vital treatment option in hepatocellular carcinoma, controversy remains on whether recurrence and survival rates are different versus deceased donor recipients. Here, we compared clinical characteristics and outcomes between recipients of living and deceased donor liver transplants for hepatocellular carcinoma in the United States. MATERIALS AND METHODS Our comparisons used data from the United Network of Organ Sharing/Organ Procurement and Transplantation Network. RESULTS There were 385 living donor and 25 274 deceased donor liver transplant recipients with diagnosis of hepatocellular carcinoma. Transplant list wait times of ≥6 months were more common in deceased donor(55.9%) versus living donor recipients (45.2%; P < .001). Both recipient groups were comparable with regard to alpha-fetoprotein level <200 ng/mL (P = .18). Only a small percentage in both groups had ≥3 total tumors (P = .73); both groups had similar low transplants outside of Milan criteria (P = .45). Overall, 1-, 5-, and 10-year overall survival rates for deceased versus living donor recipients were similar (91.2% vs 92%, 74% vs 76.4%, 58.9% vs 56.5%; P = .69). On multivariate analysis, Black/African American race/ethnicity was associated with worse outcomes than White race/ethnicity as reference (P < .001), whereas Hispanic and Asian race/ethnicity were more protected. Hepatitis C virus as liver disease etiology was associated with worse outcomes than other etiologies. Tumor characteristics, ≥3 lesions, tumor size, and higher alpha-fetoprotein levels were associated with worse outcomes. Living donor transplant was not associated with higher hazard of death. Among living donor recipients only, largest tumor size was associated with higher risk of death (P = .005). CONCLUSIONS Survival was similarin between the living donor versus deceased donor recipients with hepatocellular carcinoma. With changes in Model for End-Stage Liver Disease exception policies for hepatocellular carcinoma in the United States, living donor transplant for hepatocellular carcinoma could expand the donor pool.
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Affiliation(s)
- Haris Muhammad
- From the Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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17
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Lin MT, Chiu SYH, Chang KC, Li WF, Yong CC, Liu YW, Wang JH, Kuo FY, Huang CC, Wang CC, Hsiao CC, Hu TH. Significant association between serum Wisteria floribunda agglutinin-positive Mac-2-binding protein and prognosis of hepatocellular carcinoma after surgical treatment. Am J Cancer Res 2022; 12:601-614. [PMID: 35261790 PMCID: PMC8899980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/10/2022] [Indexed: 06/14/2023] Open
Abstract
Serum Wisteria floribunda agglutinin-positive Mac-2 binding protein (WFA+-M2BP) is a novel marker for evaluating fibrosis and predicting the development of hepatocellular carcinoma (HCC). However, the role of WFA+-M2BP in the prognosis of HCC patients after curative surgery remains unknown. In this study, we aimed to evaluate the prognostic role of serum WFA+-M2BP in HCC patients after curative resection and liver transplantation. We enrolled 460 HCC patients (357 resection and 103 transplantation) to analyze the risk factors for HCC recurrence and patient's survival. We employed time-to-event models using univariate and multivariable Cox proportional hazards regression analyses and calculated the hazard ratios (HRs) and adjusted HRs with their corresponding 95% confidence intervals (CIs). The levels of WFA+-M2BP were 0.19-14.51 COI (median 1.08) in patients of hepatectomy and 0.47-19.90 COI (median 6.0) in transplant patients. The levels of WFA+-M2BP in liver transplant patients is much higher than that of hepatectomy patients. Overall, liver fibrotic stage was positively correlated to WFA+-M2BP levels (P<0.0001). This study demonstrated that elevated WFA+-M2BP level (COI ≥0.75) was associated with a higher HCC recurrence rate in the resection group (P<0.001). Survival analysis showed that an elevated WFA+-M2BP level (COI ≥1.43) is associated with a higher mortality risk after surgical resection (P=0.0088) in the univariate analysis only. In liver transplant patients, WFA+-M2BP level (COI ≥3.81) did not predict HCC recurrence at all, but was associated poor survival after transplantation, with a borderline significance (P=0.0943). Serum WFA+-M2BP is a reliable marker for liver fibrosis in the present study. It is also reliable marker to predict prognosis of HCC after surgical resection. However, the prognostic role of WFA+-M2BP in HCC related transplants is equivocal, which is different from that of surgical resection.
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Affiliation(s)
- Ming-Tsung Lin
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung UniversityTaoyuan 33302, Taiwan
| | - Sherry Yueh-Hsia Chiu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
- Department of Health Care Management, College of Management and Healthy Aging Research Center, Chang Gung UniversityTaoyuan 33302, Taiwan
| | - Kuo-Chin Chang
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Wei-Feng Li
- Department of Surgery, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Chee-Chien Yong
- Department of Surgery, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Yueh-Wei Liu
- Department of Surgery, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Jing-Houng Wang
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Fang-Ying Kuo
- Department of Pathology, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Chao-Cheng Huang
- Department of Pathology, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Chih-Chi Wang
- Department of Surgery, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Chang-Chun Hsiao
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung UniversityTaoyuan 33302, Taiwan
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Tsung-Hui Hu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
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Lang SA, Bednarsch J, Czigany Z, Joechle K, Kroh A, Amygdalos I, Strnad P, Bruns T, Heise D, Ulmer F, Neumann UP. Liver transplantation in malignant disease. World J Clin Oncol 2021; 12:623-645. [PMID: 34513597 PMCID: PMC8394155 DOI: 10.5306/wjco.v12.i8.623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/15/2021] [Accepted: 07/23/2021] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation for malignant disease has gained increasing attention as part of transplant oncology. Following the implementation of the Milan criteria, hepatocellular carcinoma (HCC) was the first generally accepted indication for transplantation in patients with cancer. Subsequently, more liberal criteria for HCC have been developed, and research on this topic is still ongoing. The evident success of liver transplantation for HCC has led to the attempt to extend its indication to other malignancies. Regarding perihilar cholangiocarcinoma, more and more evidence supports the use of liver transplantation, especially after neoadjuvant therapy. In addition, some data also show a benefit for selected patients with very early stage intrahepatic cholangiocarcinoma. Hepatic epithelioid hemangioendothelioma is a very rare but nonetheless established indication for liver transplantation in primary liver cancer. In contrast, patients with hepatic angiosarcoma are currently not considered to be optimal candidates. In secondary liver tumors, neuroendocrine cancer liver metastases are an accepted but comparability rare indication for liver transplantation. Recently, some evidence has been published supporting the use of liver transplantation even for colorectal liver metastases. This review summarizes the current evidence for liver transplantation for primary and secondary liver cancer.
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Affiliation(s)
- Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen 52074, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen 52074, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen 52074, Germany
| | - Katharina Joechle
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen 52074, Germany
| | - Andreas Kroh
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen 52074, Germany
| | - Iakovos Amygdalos
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen 52074, Germany
| | - Pavel Strnad
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen 52074, Germany
| | - Tony Bruns
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen 52074, Germany
| | - Daniel Heise
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen 52074, Germany
| | - Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen 52074, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen 52074, Germany
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State-of-the-art surgery for hepatocellular carcinoma. Langenbecks Arch Surg 2021; 406:2151-2162. [PMID: 34405284 DOI: 10.1007/s00423-021-02298-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the most commonly diagnosed primary liver tumor with an increasing incidence worldwide. Management of patients with HCC is largely dictated by the presence of cirrhosis, disease stage, underlying liver function, and patient performance status. PURPOSE We provide an update on key aspects of surgical treatment options for patients with HCC. RESULTS & CONCLUSIONS: Liver resection and transplantation remain cornerstone treatment options for patients with early-stage disease and constitute the only potentially curative options for HCC. Selection of patients for surgical treatment should include a thorough evaluation of tumor characteristics and biology, as well as evidence-based use of various available treatment options to achieve optimal long-term outcomes for patients with HCC.
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Zhang EL, Cheng Q, Huang ZY, Dong W. Revisiting Surgical Strategies for Hepatocellular Carcinoma With Microvascular Invasion. Front Oncol 2021; 11:691354. [PMID: 34123861 PMCID: PMC8190326 DOI: 10.3389/fonc.2021.691354] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/06/2021] [Indexed: 12/12/2022] Open
Abstract
Although liver resection (LR) and liver transplantation (LT) are widely considered as potentially curative therapies for selected patients with hepatocellular carcinoma (HCC); however, there is still high risk of tumor recurrence in majority of HCC patients. Previous studies demonstrated that the presence of microvascular invasion (MVI), which was defined as the presence of tumor emboli within the vessels adjacent to HCC, was one of the key factors of early HCC recurrence and poor surgical outcomes after LR or LT. In this review, we evaluated the impact of current MVI status on surgical outcomes after curative therapies and aimed to explore the surgical strategies for HCC based on different MVI status with evidence from pathological examination. Surgical outcomes of HCC patients with MVI have been described as a varied range after curative therapies due to a broad spectrum of current definitions for MVI. Therefore, an international consensus on the validated definition of MVI in HCC is urgently needed to provide a more consistent evaluation and reliable prediction of surgical outcomes for HCC patients after curative treatments. We concluded that MVI should be further sub-classified into MI (microvessel invasion) and MPVI (microscopic portal vein invasion); for HCC patients with MPVI, local R0 resection with a narrow or wide surgical margin will get the same surgical results. However, for HCC patients with MI, local surgical resection with a wide and negative surgical margin will get better surgical outcomes. Nowadays, MVI status can only be reliably confirmed by histopathologic evaluation of surgical specimens, limiting its clinical application. Taken together, preoperative assessment of MVI is of utmost significance for selecting a reasonable surgical modality and greatly improving the surgical outcomes of HCC patients, especially in those with liver cirrhosis.
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Affiliation(s)
- Er-Lei Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Qi Cheng
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Zhi-Yong Huang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Wei Dong
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
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