Liver transplantation in malignant disease

Overall Survival Prediction by Tumor Microenvironment Lymphocyte Distribution in Hepatocellular Carcinoma After Liver Transplantation

INTRODUCTION

Our previous research demonstrated that CD8+ cell density profiling using a hexagonal grid-based digital image analysis method provides predictors of patient outcomes after liver resection due to hepatocellular carcinoma (HCC). Continuing our study, we have further investigated the applicability of the methodology to patients receiving a liver transplant for HCC.

METHODS

The retrospective study enrolled patients with HCC who underwent liver transplantation (LT) at the Vilnius University Hospital Santaros Clinics between 2007 and 2020. We determined the density profiles of CD8+ lymphocytes at the interface between HCC and stroma and the interface between the perineoplastic liver parenchyma and stroma. Both digital image analysis and the hexagonal grid-based immunogradient method were applied to CD8+ immunohistochemistry images. Survival statistics based on clinicopathological, peripheral blood analysis, and surgical data determined the prognostic value of these indicators.

RESULTS

Univariate clinicopathological predictors of worse OS after LT included: patient's age at the time of the transplantation, a higher number of HCC nodules, lower platelet count, longer activated thromboplastin time, lower serum albumin, higher serum total bilirubin, and lower serum creatinine levels. The two independent predictors of overall survival were mean CD8+ cell density at the epithelial edge of the explanted liver parenchyma-stroma interface and peripheral blood platelet count.

CONCLUSIONS

Our model discloses that preoperative peripheral blood platelet count and mean CD8+ cell density at the epithelial edge of nonmalignant interface in the explanted liver parenchyma are independent predictors of OS for HCC after LT.

Liver transplantation meets gastrointestinal cancer

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.

Surgical management of hilar cholangiocarcinoma: Controversies and recommendations

Hilar cholangiocarcinomas are highly aggressive malignancies. They are usually at an advanced stage at initial presentation. Surgical resection with negative margins is the standard of management. It provides the only chance of cure. Liver transplantation has increased the number of 'curative' procedures for cases previously considered to be unresectable. Meticulous and thorough preoperative planning is required to prevent fatal post-operative complications. Extended resection procedures, including hepatic trisectionectomy for Bismuth type IV tumors, hepatopancreaticoduodenectomy for tumors with extensive longitudinal spread, and combined vascular resection with reconstruction for tumors involving hepatic vascular structures, are challenging procedures with surgical indications expanded. Liver transplantation after the standardization of a neoadjuvant protocol described by the Mayo Clinic has increased the number of patients who can undergo operation.

Liquid Biopsy by ctDNA in Liver Transplantation for Colorectal Cancer Liver Metastasis

INTRODUCTION

Colorectal cancer is a leading cause of cancer-related death worldwide. Metastatic liver disease develops in 50% of cases and drives patient outcomes. Although the ideal treatment for colorectal cancer liver metastases (CRLM) is resection, only a third of patients are suitable for this approach. Reports of liver transplantation in selected patients with unresectable CRLM have shown encouraging results compared to conventional forms of therapy. No study to date has examined the utility of liquid biopsy circulating tumor DNA (ctDNA) for evaluation of residual disease in this cohort of patients. We report a small series of liver transplantation in patients with CRLM in whom ctDNA was assessed peri-operatively.

METHODS

Five patients underwent liver transplantation for unresectable CRLM or liver failure following CRLM treatment from 2018 to 2022. Clinical data, cross-sectional imaging, and serum biomarkers including peri-operative ctDNA were reviewed from electronic medical records.

RESULTS

All patients are alive without radiologic evidence of disease at time of this publication. Median time of follow-up was 32 months (IQR 6.6-40 months). ctDNA was assessed before (4 patients) and after transplant (6 patients). One patient experienced a pulmonary recurrence that was resected, for whom pre-recurrence ctDNA was not available; the remaining patients have not experienced recurrence. Four patients are without evidence of ctDNA following transplant, and two demonstrate persistent ctDNA positivity post-transplant. Three of four patients with positive pre-transplant ctDNA remain ctDNA-negative post-transplant.

CONCLUSIONS

Liver transplantation for liver-confined unresectable CRLM is emerging as a valid surgical option in selected patients. The significance of liquid biopsy in this population remains elusive due to lack of data. The clearance of ctDNA after transplant in these patients with metastatic disease and despite their immunosuppression is notable. The significance and usefulness of liquid biopsy in patient selection, surveillance, and as an indication for treatment warrant further investigation.

Differential diagnosis of different types of solid focal liver lesions using two-dimensional shear wave elastography

BACKGROUND

The clinical management and prognosis differ between benign and malignant solid focal liver lesions (FLLs), as well as among different pathological types of malignant FLLs. Accurate diagnosis of the possible types of solid FLLs is important. Our previous study confirmed the value of shear wave elastography (SWE) using maximal elasticity (Emax) as the parameter in the differential diagnosis between benign and malignant FLLs. However, the value of SWE in the differential diagnosis among different pathological types of malignant FLLs has not been proved.

AIM

To explore the value of two-dimensional SWE (2D-SWE) using Emax in the differential diagnosis of FLLs, especially among different pathological types of malignant FLLs.

METHODS

All the patients enrolled in this study were diagnosed as benign, malignant or undetermined FLLs by conventional ultrasound. Emax of FLLs and the periphery of FLLs was measured using 2D-SWE and compared between benign and malignant FLLs or among different pathological types of malignant FLLs.

RESULTS

The study included 32 benign FLLs in 31 patients and 100 malignant FLLs in 96 patients, including 16 cholangiocellular carcinomas (CCCs), 72 hepatocellular carcinomas (HCCs) and 12 liver metastases. Thirty-five FLLs were diagnosed as undetermined by conventional ultrasound. There were significant differences between Emax of malignant (2.21 ± 0.57 m/s) and benign (1.59 ± 0.37 m/s) FLLs (P = 0.000), and between Emax of the periphery of malignant (1.52 ± 0.39 m/s) and benign (1.36 ± 0.44 m/s) FLLs (P = 0.040). Emax of liver metastases (2.73 ± 0.99 m/s) was significantly higher than that of CCCs (2.14 ± 0.34 m/s) and HCCs (2.14 ± 0.46 m/s) (P = 0.002). The sensitivity, specificity and accuracy were 71.00%, 84.38% and 74.24% respectively, using Emax > 1.905 m/s (AUC 0.843) to diagnose as malignant and 23 of 35 (65.74%) FLLs with undetermined diagnosis by conventional ultrasound were diagnosed correctly.

CONCLUSION

Malignant FLLs were stiffer than benign ones and liver metastases were stiffer than primary liver carcinomas. 2D-SWE with Emax was a useful complement to conventional ultrasound for the differential diagnosis of FLLs.