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Chen XF, Wu HJ, Li T, Liu JB, Zhou WJ, Guo Q. Establishment and validation of a predictive model for peripherally inserted central catheter-related thrombosis in patients with liver cancer. World J Gastrointest Surg 2024; 16:2221-2231. [PMID: 39087116 PMCID: PMC11287695 DOI: 10.4240/wjgs.v16.i7.2221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/03/2024] [Accepted: 06/18/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Peripherally inserted central catheters (PICCs) are commonly used in hospitalized patients with liver cancer for the administration of chemotherapy, nutrition, and other medications. However, PICC-related thrombosis is a serious complication that can lead to morbidity and mortality in this patient population. Several risk factors have been identified for the development of PICC-related thrombosis, including cancer type, stage, comorbidities, and catheter characteristics. Understanding these risk factors and developing a predictive model can help healthcare providers identify high-risk patients and implement preventive measures to reduce the incidence of thrombosis. AIM To analyze the influencing factors of PICC-related thrombosis in hospitalized patients with liver cancer, construct a predictive model, and validate it. METHODS Clinical data of hospitalized patients with liver cancer admitted from January 2020 to December 2023 were collected. Thirty-five cases of PICC-related thrombosis in hospitalized patients with liver cancer were collected, and 220 patients who underwent PICC placement during the same period but did not develop PICC-related thrombosis were randomly selected as controls. A total of 255 samples were collected and used as the training set, and 77 cases were collected as the validation set in a 7:3 ratio. General patient information, case data, catheterization data, coagulation indicators, and Autar Thrombosis Risk Assessment Scale scores were analyzed. Univariate and multivariate unconditional logistic regression analyses were performed on relevant factors, and the value of combined indicators in predicting PICC-related thrombosis in hospitalized patients with liver cancer was evaluated using receiver operating characteristic (ROC) curve analysis. RESULTS Univariate analysis showed statistically significant differences (P < 0.05) in age, sex, Karnofsky performance status score (KPS), bedridden time, activities of daily living impairment, parenteral nutrition, catheter duration, distant metastasis, and bone marrow suppression between the thrombosis group and the non-thrombosis group. Other aspects had no statistically significant differences (P > 0.05). Multivariate regression analysis showed that age ≥ 60 years, KPS score ≤ 50 points, parenteral nutrition, stage III to IV, distant metastasis, bone marrow suppression, and activities of daily living impairment were independent risk factors for PICC-related thrombosis in hospitalized patients with liver cancer (P < 0.05). Catheter duration of 1-6 months and catheter duration > 6 months were protective factors for PICC-related thrombosis (P < 0.05). The predictive model for PICC-related thrombosis was obtained as follows: P predictive probability = [exp (Logit P)]/[1 + exp (Logit P)], where Logit P = age × 1.907 + KPS score × 2.045 + parenteral nutrition × 9.467 + catheter duration × 0.506 + tumor-node-metastasis (TNM) staging × 2.844 + distant metastasis × 2.065 + bone marrow suppression × 2.082 + activities of daily living impairment × 13.926. ROC curve analysis showed an area under the curve (AUC) of 0.827 (95%CI: 0.724-0.929, P < 0.001), with a corresponding optimal cut-off value of 0.612, sensitivity of 0.755, and specificity of 0.857. Calibration curve analysis showed good consistency between the predicted occurrence of PICC-related thrombosis and actual occurrence (P > 0.05). ROC analysis showed AUCs of 0.888 and 0.729 for the training and validation sets, respectively. CONCLUSION Age, KPS score, parenteral nutrition, TNM staging, distant metastasis, bone marrow suppression, and activities of daily living impairment are independent risk factors for PICC-related thrombosis in hospitalized patients with liver cancer, while catheter duration is a protective factor for the disease. The predictive model has an AUC of 0.827, indicating high predictive accuracy and clinical value.
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Affiliation(s)
- Xiao-Fei Chen
- Department of Thyroid Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
- The Second Department of General Surgery, Chengdu Shangjinnanfu Hospital, West China Hospital of Sichuan University, Chengdu 611730, Sichuan Province, China
| | - Hao-Jun Wu
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Tang Li
- Department of Hepatobiliary and Pancreatic Surgery, Chengdu Shangjinnanfu Hospital, West China Hospital of Sichuan University, Chengdu 611730, Sichuan Province, China
| | - Jia-Bin Liu
- Department of Thyroid Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wen-Jie Zhou
- The Second Department of General Surgery, Chengdu Shangjinnanfu Hospital, West China Hospital of Sichuan University, Chengdu 611730, Sichuan Province, China
| | - Qiang Guo
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
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Chan KM, Lee WC. Liver transplantation for advanced hepatocellular carcinoma: Controversy over portal vein tumor thrombosis. Biomed J 2024:100757. [PMID: 38942384 DOI: 10.1016/j.bj.2024.100757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/22/2024] [Accepted: 06/25/2024] [Indexed: 06/30/2024] Open
Abstract
Liver transplantation (LT) is considered the ideal treatment for hepatocellular carcinoma (HCC) concurrent with underlying cirrhotic liver disease. As well-known, LT for HCC based on the Milan criteria has shown satisfactory outcomes. However, numerous expanded transplantation criteria were proposed to benefit more patients for LT and showed comparable survivals as well. In addition, a modest expansion of transplantation criteria for HCC may be acceptable on the basis of the consensus within the transplantation community. Nonetheless, LT in patients with advanced HCC and portal vein tumor thrombosis (PVTT) recently has received attention and has been reported by many transplantation centers despite being contraindicated. Of those, the LT outcomes in certain HCC patients with PVTT were favorable. Additionally, the advancement of multimodality treatments and the evolution of systemic therapies have emerged as promising therapeutic options for downstaging advanced HCC prior to LT. Somehow, advanced HCC with PVTT could be downstaged to become eligible for LT through these multidisciplinary approaches. Although the available evidence of LT for HCC with PVTT is limited, it is hoped that LT may soon be more widely indicated for these patients. Nevertheless, several unknown factors associated with LT for HCC remain to be explored. Herein, this review aimed to update the developments in LT for patients with advanced HCC.
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Affiliation(s)
- Kun-Ming Chan
- Department of General Surgery and Chang Gung Transplantation Institute, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Wei-Chen Lee
- Department of General Surgery and Chang Gung Transplantation Institute, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Bhangui P. Liver transplantation and resection in patients with hepatocellular cancer and portal vein tumor thrombosis: Feasible and effective? Hepatobiliary Pancreat Dis Int 2024; 23:123-128. [PMID: 37880019 DOI: 10.1016/j.hbpd.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/27/2023] [Indexed: 10/27/2023]
Abstract
Patients with locally advanced hepatocellular cancer (HCC) and portal vein tumor thrombosis (PVTT) have a dismal prognosis since limited treatment options are available for them. In recent years, effective systemic therapy, and advances in the understanding of technicalities and effectiveness of ablative therapies especially radiotherapy, have given some hope to prolong survival in them. This review summarized recent evidence in literature regarding the possible role of liver resection (LR) and liver transplantation (LT) in patients with locally advanced HCC and PVTT with no extrahepatic disease. Downstaging therapies have helped make curative resection or LT a reality in selected patients. This review emphasizes on the key points to focus on when considering surgery in these patients, who are usually relegated to palliative systemic therapy alone. Meticulous patient selection based on tumor biology, documented downstaging based on imaging and decrease in tumor marker levels, and an adequate waiting period to demonstrate stable disease, may help obtain satisfactory long-term outcomes post LR or LT in an intention to treat strategy in patients with HCC and PVTT.
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Affiliation(s)
- Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta - The Medicity, Sector 38, Gurgaon, Delhi NCR 122001, India.
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4
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Drefs M, Schoenberg MB, Börner N, Koliogiannis D, Koch DT, Schirren MJ, Andrassy J, Bazhin AV, Werner J, Guba MO. Changes of long-term survival of resection and liver transplantation in hepatocellular carcinoma throughout the years: A meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107952. [PMID: 38237275 DOI: 10.1016/j.ejso.2024.107952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/21/2023] [Accepted: 01/03/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Hepatocellular Carcinoma (HCC) still is one of the most detrimental malignant diseases in the world. As two curative surgical therapies exist, the discussion whether to opt for liver resection (LR) or transplantation (LT) is ongoing, especially as novel techniques to improve outcome have emerged for both. The aim of the study was to investigate how the utilization and outcome of the respective modalities changed through time. METHODS We searched Medline and PubMed for relevant publications comparing LT and LR in HCC patients during the time period from 1990 to 2022, prior to March 31, 2023. A total of 63 studies involving 19,804 patients - of whom 8178 patients received a liver graft and 11,626 underwent partial hepatectomy - were included in this meta-analysis. RESULTS LT is associated with significantly better 5-year overall survival (OS) (64.83%) and recurrence-free survival (RFS) (70.20%) than LR (OS: 50.83%, OR: 1.79, p < 0.001; RFS: 34.46%, OR: 5.32, p < 0.001). However, these differences are not as evident in short-term intervals. Older cohorts showed comparable disparities between the outcome of the respective modalities, as did newer cohorts after 2005. This might be due to the similar improvement in survival rates that were observed for both, LT (15-23%) and LR (12-20%) during the last 30 years. CONCLUSION LT still outperforms LR in the therapy of HCC in terms of long-term survival rates. Yet, LR outcome has remarkably improved which is of major importance in reference to the well-known limitations that occur in LT.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany.
| | - Markus B Schoenberg
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Faculty of Medicine, LMU Munich, Germany; Medical Centers Gollierplatz and Nymphenburg, Munich, Germany
| | - Nikolaus Börner
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Dionysios Koliogiannis
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Dominik T Koch
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Malte J Schirren
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Faculty of Medicine, LMU Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Markus O Guba
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Transplantation Center Munich, LMU University Hospital, LMU Munich, Germany
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Chen CL, Dungca LBP, Yong CC, Chen ICY, Cheng YF, Cheng JY, Chen YY. Proton beam therapy for downstaging hepatocellular carcinoma with lobar portal vein tumor thrombosis to living donor liver transplantation. Hepatobiliary Surg Nutr 2023; 12:966-974. [PMID: 38115927 PMCID: PMC10727813 DOI: 10.21037/hbsn-23-410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Affiliation(s)
- Chao-Long Chen
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Leona Bettina P. Dungca
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Chee-Chien Yong
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Itsuko Chih-Yi Chen
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Yu-Fan Cheng
- Liver Transplantation Center, Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Jen-Yu Cheng
- Liver Transplantation Center, Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Yen-Yang Chen
- Liver Transplantation Center, Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
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6
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Park JW, Lee H, Hong H, Seong J. Efficacy of Radiomics in Predicting Oncologic Outcome of Liver-Directed Combined Radiotherapy in Locally Advanced Hepatocellular Carcinoma. Cancers (Basel) 2023; 15:5405. [PMID: 38001665 PMCID: PMC10670316 DOI: 10.3390/cancers15225405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/05/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
PURPOSE We investigated whether radiomic features extracted from three-phase dynamic contrast-enhanced computed tomography (CECT) can be used to predict clinical outcomes, including objective treatment response (OR) and in-field failure-free survival rate (IFFR), in patients with hepatocellular carcinoma (HCC) who received liver-directed combined radiotherapy (LD-CRT). METHODS We included 409 patients, and they were randomly divided into training (n = 307) and validation (n = 102) cohorts. For radiomics models, we extracted 116 radiomic features from the region of interest on the CECT images. Significant clinical prognostic factors are identified to predict the OR and IFFR in the clinical models. We developed clinical models, radiomics models, and a combination of both features (CCR model). RESULTS Among the radiomic models evaluated for OR, the OR-PVP-Peri-1cm model showed favorable predictive performance with an area under the curve (AUC) of 0.647. The clinical model showed an AUC of 0.729, whereas the CCR model showed better performance (AUC 0.759). For the IFFR, the IFFR-PVP-Peri-1cm model showed an AUC of 0.673, clinical model showed 0.687, and the CCR model showed 0.736. We also developed and validated a prognostic nomogram based on CCR models. CONCLUSION In predicting the OR and IFFR in patients with HCC undergoing LD-CRT, CCR models performed better than clinical and radiomics models. Moreover, the constructed nomograms based on these models may provide valuable information on the prognosis of these patients.
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Affiliation(s)
- Jong Won Park
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea;
| | - Hansang Lee
- School of Electrical Engineering, Korea Advanced Institute of Science and Technology, 291 Daehak-ro, Yuseong-gu, Daejeon 34141, Republic of Korea;
| | - Helen Hong
- Department of Software Convergence, College of Interdisciplinary Studies for Emerging Industries, 621 Hwarang-ro, Nowon-gu, Seoul 01797, Republic of Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea;
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Byun HK, Kim C, Seong J. Carbon Ion Radiotherapy in the Treatment of Hepatocellular Carcinoma. Clin Mol Hepatol 2023; 29:945-957. [PMID: 37583055 PMCID: PMC10577350 DOI: 10.3350/cmh.2023.0217] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 08/17/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a highly lethal cancer with limited treatment options and poor prognosis. Carbon ion radiotherapy (CIRT) has emerged as a promising treatment modality for HCC due to its unique physical and biological properties. CIRT uses carbon ions to target and destroy cancer cells with a high precision and efficacy. The Bragg Peak phenomenon allows precise dose delivery to the tumor while minimizing damage to healthy tissues. In addition, the high relative biological effectiveness of carbon ions can be shown against radioresistant and hypoxic tumor areas. CIRT also offers a shorter treatment schedule than conventional radiotherapy, which increases patient convenience and compliance. The clinical outcomes of CIRT for HCC have shown excellent local control rates with minimal side effects. Considering its physical and biological properties, CIRT may be a viable option for complex clinical scenarios such as patients with poor liver function, large tumors, re-irradiation cases, and tumors close to critical organs. Further research and larger studies are needed to establish definitive indications for CIRT and to compare its efficacy with that of other treatment modalities. Nevertheless, CIRT offers a potential breakthrough in HCC management, providing hope for improved therapeutic outcomes and reduced treatment-related toxicities.
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Affiliation(s)
- Hwa Kyung Byun
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Changhwan Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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Claasen MPAW, Sneiders D, Rakké YS, Adam R, Bhoori S, Cillo U, Fondevila C, Reig M, Sapisochin G, Tabrizian P, Toso C. European Society of Organ Transplantation (ESOT) Consensus Report on Downstaging, Bridging and Immunotherapy in Liver Transplantation for Hepatocellular Carcinoma. Transpl Int 2023; 36:11648. [PMID: 37779513 PMCID: PMC10533675 DOI: 10.3389/ti.2023.11648] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023]
Abstract
Liver transplantation offers the best chance of cure for most patients with non-metastatic hepatocellular carcinoma (HCC). Although not all patients with HCC are eligible for liver transplantation at diagnosis, some can be downstaged using locoregional treatments such as ablation and transarterial chemoembolization. These aforementioned treatments are being applied as bridging therapies to keep patients within transplant criteria and to avoid them from dropping out of the waiting list while awaiting a liver transplant. Moreover, immunotherapy might have great potential to support downstaging and bridging therapies. To address the contemporary status of downstaging, bridging, and immunotherapy in liver transplantation for HCC, European Society of Organ Transplantation (ESOT) convened a dedicated working group comprised of experts in the treatment of HCC to review literature and to develop guidelines pertaining to this cause that were subsequently discussed and voted during the Transplant Learning Journey (TLJ) 3.0 Consensus Conference that took place in person in Prague. The findings and recommendations of the working group on Downstaging, Bridging and Immunotherapy in Liver Transplantation for Hepatocellular Carcinoma are presented in this article.
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Affiliation(s)
- Marco Petrus Adrianus Wilhelmus Claasen
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, Netherlands
- Multi-Organ Transplant Program, University Health Network (UHN), Toronto, ON, Canada
| | - Dimitri Sneiders
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Yannick Sebastiaan Rakké
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - René Adam
- Centre Hépato-Biliaire, APHP Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Paris, France
| | - Sherrie Bhoori
- Hepatology, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Umberto Cillo
- Chirurgia Generale 2, Epato-Bilio-Pancreatica e Centro Trapianto di Fegato, Azienda Ospedale Università Padova, Padova, Italy
| | | | - Maria Reig
- BCLC Group, Liver Unit, Digestive Disease Institute, Hospital Clínic, IDIBAPS CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network (UHN), Toronto, ON, Canada
| | - Parissa Tabrizian
- Liver Transplant and Hepatobiliary Surgery, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Christian Toso
- Division of Abdominal Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Tustumi F, Coelho FF, de Paiva Magalhães D, Júnior SS, Jeismann VB, Fonseca GM, Kruger JAP, D'Albuquerque LAC, Herman P. Treatment of hepatocellular carcinoma with macroscopic vascular invasion: A systematic review and network meta-analysis. Transplant Rev (Orlando) 2023; 37:100763. [PMID: 37393656 DOI: 10.1016/j.trre.2023.100763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/11/2023] [Accepted: 05/14/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND This study aimed to evaluate the outcomes of different treatments for patients with hepatocellular carcinoma (HCC) and macroscopic vascular invasion. METHODS A systematic review and meta-analysis of comparative studies was performed to evaluate various treatment modalities for HCC with macroscopic vascular invasion, including liver resection (LR), liver transplantation (LT), transarterial chemoembolization (TACE), transarterial radioembolization (TARE), radiotherapy (RT), radiofrequency ablation (RFA), and antineoplastic systemic therapy (AnST). RESULTS After applying the selection criteria, 31 studies were included. The surgical resection (SR) group (including LR and LT) had a similar mortality rate to the non-surgical resection (NS) group (RD = -0.01; 95% CI -0.05 to 0.03). The SR group had a higher rate of complications (RD = 0.06; 95% CI 0.00 to 0.12) but a higher 3-year overall survival (OS) rate than the NS group (RD = 0.12; 95% CI 0.05 to 0.20). The network analysis revealed that the overall survival was lower in the AnST group. LT and LR had similar survival benefits. The meta-regression suggested that SR has a greater impact on the survival of patients with impaired liver function. DISCUSSION Most likely, LT has a significant impact on long-term survival and consequently would be a better option for HCC with macroscopic vascular invasion in patients with impaired liver function. LT and LR offer a higher chance of long-term survival than NS alternatives, although LR and LR are associated with a higher risk of procedure-related complications.
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Affiliation(s)
- Francisco Tustumi
- Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Fabricio Ferreira Coelho
- Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Daniel de Paiva Magalhães
- Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Sérgio Silveira Júnior
- Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Vagner Birk Jeismann
- Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gilton Marques Fonseca
- Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Jaime Arthur Pirola Kruger
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Paulo Herman
- Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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10
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Zhou XH, Li JR, Zheng TH, Chen H, Cai C, Ye SL, Gao B, Xue TC. Portal vein tumor thrombosis in hepatocellular carcinoma: molecular mechanism and therapy. Clin Exp Metastasis 2023; 40:5-32. [PMID: 36318440 DOI: 10.1007/s10585-022-10188-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022]
Abstract
Portal vein tumor thrombosis (PVTT), a common complication of advanced hepatocellular carcinoma (HCC), remains the bottleneck of the treatments. Liver cancer cells potentially experienced multi-steps during PVTT process, including cancer cells leave from cancer nest, migrate in extracellular matrix, invade the vascular barrier, and colonize in the portal vein. Accumulated evidences have revealed numerous of molecular mechanisms including genetic and epigenetic regulation, cancer stem cells, immunosuppressive microenvironment, hypoxia, et al. contributed to the PVTT formation. In this review, we discuss state-of-the-art PVTT research on the potential molecular mechanisms and experimental models. In addition, we summarize PVTT-associated clinical trials and current treatments for PVTT and suppose perspectives exploring the molecular mechanisms and improving PVTT-related treatment for the future.
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Affiliation(s)
- Xing-Hao Zhou
- Liver Cancer Institute, Fudan University, Zhongshan Hospital, 136 Yi Xue Yuan Road, Shanghai, 200032, China.,Key Laboratory of Carcinogenesis and Cancer Invasion (Ministry of Education), Fudan University, Shanghai, 200032, China.,Department of Hepatic Oncology, Fudan University, Zhongshan Hospital, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, 200032, China
| | - Jing-Ru Li
- Liver Cancer Institute, Fudan University, Zhongshan Hospital, 136 Yi Xue Yuan Road, Shanghai, 200032, China.,Key Laboratory of Carcinogenesis and Cancer Invasion (Ministry of Education), Fudan University, Shanghai, 200032, China.,Department of Hepatic Oncology, Fudan University, Zhongshan Hospital, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, 200032, China
| | - Tang-Hui Zheng
- Liver Cancer Institute, Fudan University, Zhongshan Hospital, 136 Yi Xue Yuan Road, Shanghai, 200032, China.,Department of Hepatic Oncology, Xiamen Branch, Fudan University, Zhongshan Hospital, Xiamen, 361015, China
| | - Hong Chen
- Liver Cancer Institute, Fudan University, Zhongshan Hospital, 136 Yi Xue Yuan Road, Shanghai, 200032, China.,Department of Hepatic Oncology, Xiamen Branch, Fudan University, Zhongshan Hospital, Xiamen, 361015, China
| | - Chen Cai
- Liver Cancer Institute, Fudan University, Zhongshan Hospital, 136 Yi Xue Yuan Road, Shanghai, 200032, China.,Key Laboratory of Carcinogenesis and Cancer Invasion (Ministry of Education), Fudan University, Shanghai, 200032, China.,Department of Hepatic Oncology, Fudan University, Zhongshan Hospital, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, 200032, China
| | - Sheng-Long Ye
- Liver Cancer Institute, Fudan University, Zhongshan Hospital, 136 Yi Xue Yuan Road, Shanghai, 200032, China.,Key Laboratory of Carcinogenesis and Cancer Invasion (Ministry of Education), Fudan University, Shanghai, 200032, China.,Department of Hepatic Oncology, Fudan University, Zhongshan Hospital, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, 200032, China
| | - Bo Gao
- Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai Medical College, Shanghai, 200032, China.
| | - Tong-Chun Xue
- Liver Cancer Institute, Fudan University, Zhongshan Hospital, 136 Yi Xue Yuan Road, Shanghai, 200032, China. .,Key Laboratory of Carcinogenesis and Cancer Invasion (Ministry of Education), Fudan University, Shanghai, 200032, China. .,Department of Hepatic Oncology, Fudan University, Zhongshan Hospital, Shanghai, 200032, China. .,National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, 200032, China.
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11
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Ji M, Zou H, Shu B, Liu G, Zhang B, Xu Z, Pang F, Cheng M, Sun Y, Du T, Sun C, Zhu C. Prognostic analysis of hepatocellular carcinoma with macrovascular invasion after liver resection and a successful case of conversion therapy. Front Surg 2022; 9:1042431. [PMID: 36420403 PMCID: PMC9676359 DOI: 10.3389/fsurg.2022.1042431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Objective Macrovascular invasion (MVI) is an important factor leading to poor prognosis in hepatocellular carcinoma (HCC). Liver resection may offer favorable prognosis for selected patients with HCC. This study aimed to analyze the prognostic factors of HCC with MVI after liver resection as well as demonstrate a case of conversion therapy in an HCC patient with portal vein tumor thrombus (PVTT). Methods A total of 168 HCC patients with MVI who underwent primary liver resection at the Affiliated Hospital of Qingdao University between January 2013 and October 2021 were enrolled in the study. Clinicopathological data were collected retrospectively. Univariate and multivariate regression analyses were used to investigate the risk factors influencing recurrence and overall survival. Additionally, conversion therapy with drug-eluting bead transarterial chemoembolization (D-TACE), and sorafenib plus sintilimab treatment was performed in an HCC patient with PVTT. Results Among the 168 patients with HCC, 11 were diagnosed with hepatic vein tumor thrombosis, and the rest were diagnosed with PVTT. The 1-year disease-free survival rate was 37.5%, and the 3-year overall survival rate was 52.7%. Univariate and multivariate regression analyses revealed that HBsAg positivity, alpha-fetoprotein (AFP) level ≥400 ng/ml, liver capsule invasion, and tumor number ≥2 were independent prognostic factors for tumor recurrence, whereas HBsAg positivity was an independent risk factor for overall survival. Postoperative prophylactic medication did not significantly prolong the recurrence time. The median survival time (MST) after tumor recurrence was 13.4 months. In the patient treated with conversion therapy, the tumor gradually shrank and was eventually surgically resected. Conclusions This study identified the independent prognostic and risk factors associated with recurrence and overall survival in HCC patients with MVI. Additionally, we successfully performed conversion therapy in an HCC patient with PVTT. The findings would help identify patients at high risk of recurrence and indicate that combined therapy may prolong the survival of HCC patients with PVTT.
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Affiliation(s)
- Mengling Ji
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hao Zou
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Baojun Shu
- Department of Operation Room, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guoping Liu
- Department of Interventional Radiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bingyuan Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zejiang Xu
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fanfan Pang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Mengxing Cheng
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yafei Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ting Du
- Medical Department, Yidu Cloud (Beijing) Technology Co., Ltd., Beijing, China
| | - Chuandong Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
- Correspondence: Chuan-dong Sun Cheng-zhan Zhu
| | - Chengzhan Zhu
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
- Shandong Key Laboratory of Digital Medicine and Computer Assisted Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
- Correspondence: Chuan-dong Sun Cheng-zhan Zhu
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12
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Sha M, Chen C, Shen C, Jeong S, Sun HY, Xu N, Hang HL, Cao J, Tong Y. Clinical analysis of deceased donor liver transplantation in the treatment of hepatocellular carcinoma with segmental portal vein tumor thrombus: A long-term real-world study. Front Oncol 2022; 12:971532. [PMID: 36203429 PMCID: PMC9530398 DOI: 10.3389/fonc.2022.971532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT) have conventionally been regarded as a contraindication for liver transplantation (LT). However, the outcomes of deceased donor liver transplantation (DDLT) in patients with segmental PVTT remain unknown. The aim of this study is to evaluate the feasibility and effectiveness of DDLT in the treatment of HCC with segmental PVTT. Methods We retrospectively analyzed 254 patients who underwent DDLT for HCC in our institution from January 2015 to November 2019. To assess the risks of PVTT, various clinicopathological variables were evaluated. Overall (OS) and recurrence-free survival (RFS) analyses based on different PVTT types were performed in HCC patients. Results Of the 254 patients, a total of 46 patients had PVTT, of whom 35 had lobar PVTT and 11 had segmental PVTT in second-order branches or below. Alpha-fetoprotein (AFP) level, tumor maximal diameter, histological grade, micro-vascular invasion (MVI), RFS, and OS were significantly different between the control and PVTT groups. Lobar PVTT was associated with unfavorable 5-year RFS and OS compared with MVI group (28.6% and 17.1%, respectively). Instead, no significant difference was observed between the segmental PVTT and MVI group in terms of 5-year RFS and OS (RFS: 36.4% vs. 40.4%, p=0.667; OS: 54.5% vs. 45.1%, p=0.395). Further subgroup analysis showed segmental PVTT with AFP levels ≤100 ng/ml presented significantly favorable RFS and OS rates than those with AFP level >100 ng/ml (p=0.050 and 0.035, respectively). Conclusions In summary, lobar PVTT remains a contraindication to DDLT. HCC patients with segmental PVTT and AFP level ≤100 ng/ml may be acceptable candidates for DDLT.
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Affiliation(s)
- Meng Sha
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chen Chen
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chuan Shen
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Seogsong Jeong
- Department of Biomedical Informatics, CHA University School of Medicine, CHA University, Seongnam, South Korea
- Institute of Basic Medical Sciences, School of Medicine, CHA University, Seongnam, South Korea
- Institute for Biomedical Informatics, School of Medicine, CHA University, Seongnam, South Korea
| | - Han-yong Sun
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ning Xu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hua-lian Hang
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jie Cao
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Tong
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Ying Tong,
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13
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Liver transplantation and portal vein tumour thrombus: futile enterprise? Curr Opin Organ Transplant 2022; 27:312-319. [PMID: 36354257 DOI: 10.1097/mot.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE OF REVIEW To summarize recent evidence in literature regarding liver transplantation in patients with hepatocellular carcinoma (HCC) and portal vein tumour thrombosis (PVTT) with no extrahepatic disease. In addition, in this review, we have tried to highlight the advances in downstaging with ablative therapies that have made liver transplantation a possibility, and also the key points to focus on when considering liver transplantation in these patients with locally advanced HCC. RECENT FINDINGS Advances in the understanding of technicalities and effectiveness of ablative therapies, including transarterial chemoembolization, stereotactic body radiotherapy and transarterial radioembolization on PVTT have helped successfully downstage patients with HCC and PVTT to within transplant criteria. This provides the opportunity to offer a curative liver transplantation in these patients who are generally managed with systemic or palliative therapy alone with dismal prognosis. Meticulous patient selection based on tumour biology, documented downstaging based on imaging and decrease in tumour marker levels, an adequate waiting period to demonstrate stable disease, liver transplantation with some technical modifications, and a modified immunosuppression protocol may offer long-term survival in a select group of patients treated with initial downstaging therapies in an intention to treat strategy. SUMMARY In patients with HCC, presence of PVTT is generally considered the end of the road by many. A multidisciplinary approach combining ablation and a curative liver transplantation may offer the best hope of long-term survival in a select group of patients with favourable tumour biology. Although promising, current evidence is limited, and future studies with larger number of patients, and longer follow-up may pave the way for an elaborate selection algorithm to choose the ideal candidates for such a curative strategy in patients with locally advanced HCC with PVTT.
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14
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Lee HA, Seo YS, Shin IS, Yoon WS, Lee HY, Rim CH. Efficacy and feasibility of surgery and external radiotherapy for hepatocellular carcinoma with portal invasion: A meta-analysis. Int J Surg 2022; 104:106753. [DOI: 10.1016/j.ijsu.2022.106753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
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15
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Khan AR, Wei X, Xu X. Portal Vein Tumor Thrombosis and Hepatocellular Carcinoma - The Changing Tides. J Hepatocell Carcinoma 2021; 8:1089-1115. [PMID: 34522691 PMCID: PMC8434852 DOI: 10.2147/jhc.s318070] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/13/2021] [Indexed: 12/12/2022] Open
Abstract
Portal vein involvement is considered one of the most fearful complications of hepatocellular carcinoma (HCC). Portal vein tumor thrombosis (PVTT) is associated with aggressive tumor biology (high grade), high tumor burden (number and size of lesions), high levels of serum markers (AFP), poor liver function (deranged LFT), and poor performance status of patients. The Barcelona Clinic Liver Cancer staging system places HCC patients with PVTT in advanced stage (BCLC Stage-C). This group contains a fairly heterogeneous patient population, previously considered candidates for palliative systemic therapy with sorafenib. However, this provided modest overall survival (OS) benefit. The results of a recent Phase III (IMbrave150) trial favor the combination of atezolizumab and bevacizumab over sorafenib as a standard of care in advanced unresectable HCC. While only lenvatinib proved to be non-inferior against sorafenib in a phase III (REFLECT trial), regorafenib (RESORCE trial), ramucirumab (REACH-2), and cabozantinib (CELESTIAL) have been approved second-line therapy in phase III clinical trials. Recently, the data on the prospect of other modalities in the management of HCC with PVTT is mounting with favorable results. Targeting multiple pathways in the HCC cascade using a combination of drugs and other modalities such as RT, TACE, TARE, and HAIC appear effective for systemic and loco-regional control. The quest for the ideal combination therapy and the sequence set is still widely unanswered and prospective trials are lacking. With the armament of available therapeutic options and the advances and refinements in the delivery system, down-staging patients to make them eligible for curative resection has been reported. In a rapidly evolving treatment landscape, performing surgery when appropriate, in the form of LR and even LT to achieve cure does not seem farfetched. Likewise, adjuvant therapy and prompt management of the recurrences holds the key to prolong OS and DFS. This review discusses the management options of HCC patients with PVTT.
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Affiliation(s)
- Abdul Rehman Khan
- Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People's Republic of China.,Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People's Republic of China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, 310003, People's Republic of China
| | - Xuyong Wei
- Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People's Republic of China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, 310003, People's Republic of China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, 310003, People's Republic of China
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People's Republic of China.,Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People's Republic of China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, 310003, People's Republic of China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, 310003, People's Republic of China
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16
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Beumer BR, de Wilde RF, Metselaar HJ, de Man RA, Polak WG, Ijzermans JNM. The Treatment Effect of Liver Transplantation versus Liver Resection for HCC: A Review and Future Perspectives. Cancers (Basel) 2021; 13:cancers13153730. [PMID: 34359629 PMCID: PMC8345205 DOI: 10.3390/cancers13153730] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 12/17/2022] Open
Abstract
For patients presenting with hepatocellular carcinoma within the Milan criteria, either liver resection or liver transplantation can be performed. However, to what extent either of these treatment options is superior in terms of long-term survival is unknown. Obviously, the comparison of these treatments is complicated by several selection processes. In this article, we comprehensively review the current literature with a focus on factors accounting for selection bias. Thus far, studies that did not perform an intention-to-treat analysis conclude that liver transplantation is superior to liver resection for early-stage hepatocellular carcinoma. In contrast, studies performing an intention-to-treat analysis state that survival is comparable between both modalities. Furthermore, all studies demonstrate that disease-free survival is longer after liver transplantation compared to liver resection. With respect to the latter, implications of recurrences for survival are rarely discussed. Heterogeneous treatment effects and logical inconsistencies indicate that studies with a higher level of evidence are needed to determine if liver transplantation offers a survival benefit over liver resection. However, randomised controlled trials, as the golden standard, are believed to be infeasible. Therefore, we suggest an alternative research design from the causal inference literature. The rationale for a regression discontinuity design that exploits the natural experiment created by the widely adopted Milan criteria will be discussed. In this type of study, the analysis is focused on liver transplantation patients just within the Milan criteria and liver resection patients just outside, hereby ensuring equal distribution of confounders.
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Affiliation(s)
- Berend R. Beumer
- Department of Surgery Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (B.R.B.); (R.F.d.W.); (W.G.P.)
| | - Roeland F. de Wilde
- Department of Surgery Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (B.R.B.); (R.F.d.W.); (W.G.P.)
| | - Herold J. Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (H.J.M.); (R.A.d.M.)
| | - Robert A. de Man
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (H.J.M.); (R.A.d.M.)
| | - Wojciech G. Polak
- Department of Surgery Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (B.R.B.); (R.F.d.W.); (W.G.P.)
| | - Jan N. M. Ijzermans
- Department of Surgery Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (B.R.B.); (R.F.d.W.); (W.G.P.)
- Correspondence: ; Tel.: +31-010-7032396
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