Comprehensive review of hepatocellular carcinoma with portal vein tumor thrombus: State of art and future perspectives

BACKGROUND

Despite advances in the diagnosis of patients with hepatocellular carcinoma (HCC), 70%-80% of patients are diagnosed with advanced stage disease. Portal vein tumor thrombus (PVTT) is among the most ominous signs of advanced stage disease and has been associated with poor survival if untreated.

DATA SOURCES

A systematic search of MEDLINE (PubMed), Embase, Cochrane Library and Database for Systematic Reviews (CDSR), Google Scholar, and National Institute for Health and Clinical Excellence (NICE) databases until December 2022 was conducted using free text and MeSH terms: hepatocellular carcinoma, portal vein tumor thrombus, portal vein thrombosis, vascular invasion, liver and/or hepatic resection, liver transplantation, and systematic review.

RESULTS

Centers of surgical excellence have reported promising results related to the individualized surgical management of portal thrombus versus arterial chemoembolization or systemic chemotherapy. Critical elements to the individualized surgical management of HCC and portal thrombus include precise classification of the portal vein tumor thrombus, accurate identification of the subgroups of patients who may benefit from resection, as well as meticulous surgical technique. This review addressed five specific areas: (a) formation of PVTT; (b) classifications of PVTT; (c) controversies related to clinical guidelines; (d) surgical treatments versus non-surgical approaches; and (e) characterization of surgical techniques correlated with classifications of PVTT.

CONCLUSIONS

Current evidence from Chinese and Japanese high-volume centers demonstrated that patients with HCC and associated PVTT can be managed with surgical resection with acceptable results.

Complex Hepatectomy Under Total Vascular Exclusion of the Liver Preserving the Caval Flow with Portal Hypothermic Perfusion and Temporary Portacaval Shunt: A Proof of Concept

BACKGROUND

Hypothermic liver perfusion decreases ischemia/reperfusion injury during hepatectomy under standard total vascular exclusion (TVE) of the liver. This surgery needs venovenous bypass and is hampered by high morbi-mortality. TVE preserving the inferior vena cava (IVC) flow is hemodynamically well tolerated but remains limited in duration when performed under liver normothermia. The objective of this study was to report the results of TVE preserving the caval flow, modified to allow hypothermic liver perfusion and obviate splanchnic congestion.

PATIENTS AND METHODS

The technique, indicated for tumors abutting large tributaries of the hepatic veins but sparing their roots in IVC and the latter, was applied when TVE was anticipated to last for ≥ 60 min. It combines continuous TVE preserving the IVC flow with hypothermic liver perfusion and temporary portacaval shunt (PCS). Results are given as median (range).

RESULTS

Vascular control was achieved in 13 patients with excellent hemodynamical tolerance. PCS was direct or via an interposed synthetic graft (five and eight cases, respectively). Liver temperature dropped to 16.5 (6-24) °C under perfusion of 2 (2-4) L of cold perfusate. TVE lasted 67 (54-125) min and 4.5 (0-8) blood units were transfused. Resection was major in nine cases and was complete in all cases. Five complications occurred in four patients, and the 90-day mortality rate was zero.

CONCLUSIONS

This technique maintains stable hemodynamics and combines the advantages of in situ or ex situ standard TVE with hypothermic liver perfusion, without their inherent prolongation of ischemia time and need for venovenous bypass.

Comparing indications, complexity and outcomes of laparoscopic liver resection between centers with and without a liver transplant program: a French nationwide study

BACKGROUND

There are no data to evaluate the difference in populations and impact of centers with liver transplant programs in performing laparoscopic liver resection (LLR).

METHODS

This was a multicenter study including patients undergoing LLR for benign and malignant tumors at 27 French centers from 1996 to 2018. The main outcomes were postoperative severe morbidity and mortality.

RESULTS

A total of 3154 patients were included, and 14 centers were classified as transplant centers (N = 2167 patients, 68.7 %). The transplant centers performed more difficult LLRs and more resections for hepatocellular carcinoma (HCC) in patients who more frequently had cirrhosis. A higher rate of performing the Pringle maneuver, a lower rate of blood loss and a higher rate of open conversion (all p < 0.05) were observed in the transplant centers. There was no association between the presence of a liver transplant program and either postoperative severe morbidity (<10 % in each group; p = 0.228) or mortality (1 % in each group; p = 0.915).

CONCLUSIONS

Most HCCs, difficult LLRs, and cirrhotic patients are treated in transplant centers. We show that all centers can achieve comparable safety and quality of care in LLR independent of the presence of a liver transplant program.

Rescue Liver Transplantation for Posthepatectomy Liver Failure: A Systematic Review and Survey of an International Experience

BACKGROUND

Rescue liver transplantation (LT) is the only life-saving option for posthepatectomy liver failure (PHLF) whenever it is deemed as irreversible and likely to be fatal. The goals were to perform a qualitative systematic review of rescue LT for PHLF and a survey among various international LT experts.

METHODS

A literature search was performed from 2000 to 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Population, Intervention, Comparison, Outcome framework, and to this, the authors' experience was added. The international online open survey included 6 cases of PHLF extracted from the literature and submitted to 976 LT experts. The primary outcome was whether experts would consider rescue LT for each case. Interrater agreement among experts was calculated using the free-marginal multirater kappa methodology.

RESULTS

The review included 40 patients. Post-LT mortality occurred in 8 (20%) cases (7/28 with proven cancer and 1/12 with benign disease). In the long term, 6 of 21 (28.6%) survivors with cancer died of recurrence (median = 38 mo) and 15 (71.4%) were alive with no recurrence (median = 111 mo). All 11 survivors with benign disease were alive and well (median = 39 mo). In the international survey among experts in LT, the percentage agreement to consider rescue LT was 28%-98%, higher for benign than for malignant disease ( P = 0.011). Interrater agreement for the primary endpoint was low, expected 5-y survival >50% being the strongest independent predictor to consider LT.

CONCLUSIONS

Rescue LT for PHLF may achieve good results in selected patients. Considerable inconsistencies of decision-making exist among LT experts when considering LT for PHLF.

Intraoperative indocyanine green fluorescence imaging to predict early hepatic arterial complications after liver transplantation

PURPOSE

In liver transplantation (LT) setting, to propose an innovative intraoperative criterion to judge arterial flow abnormality that may lead to early hepatic arterial occlusion, i.e. thrombosis or stenosis, when left untreated and to carry out re-anastomosis.

PATIENTS AND METHODS

After liver graft implantation, and after ensuring that there is no abnormality on the Doppler ultrasound (qualitative and quantitative assessment), we intraoperatively injected indocyanine green dye (ICG, 0.01 mg/Kg) and we quantified the fluorescence signal at the graft pedicle using ImageJ software. From the obtained images of 89 adult patients transplanted in our center between September 2017 and April 2019, we constructed fluorescence intensity curves of the hepatic arterial signal, and examined their relationship with the occurrence of early hepatic arterial occlusion (thrombosis or stenosis).

RESULTS

Early hepatic arterial occlusion occurred in seven patients (7.8%), including three thrombosis and four stenosis. Among various parameters of the flow intensity curve analyzed, the ratio of peak to plateau (RPP) fluorescence intensity and the jagged wave pattern at the plateau phase were closely associated with this dreaded event. By combining RPP at 0.275 and a jagged wave, we best predicted the occurrence of early hepatic arterial occlusion and thrombosis, with sensitivity/specificity of 0.86/0.98 and 1.00/0.94, respectively.

CONCLUSIONS

Through a simple composite parameter, indocyanine green fluorescence imaging system is an additional and promising intraoperative modality for identifying transplant recipients at high risk of developing early hepatic arterial occlusion. This tool could assist the surgeon in the decision to redo the anastomosis despite normal Doppler ultrasonography.

Early portal vein thrombosis after hepatectomy for perihilar cholangiocarcinoma: Incidence, risk factors, and management

AIM

To study the incidence, risk factors and management of portal vein thrombosis (PVT) after hepatectomy for perihilar cholangiocarcinoma (PHCC).

PATIENTS AND METHOD

Single-center retrospective analysis of 86 consecutive patients who underwent major hepatectomy for PHCC, between 2012 and 2019, with comparison of the characteristics of the groups with (PVT+) and without (PVT-) postoperative portal vein thrombosis.

RESULTS

Seven patients (8%) presented with PVT diagnosed during the first postoperative week. Preoperative portal embolization had been performed in 71% of patients in the PVT+ group versus 34% in the PVT- group (P=0.1). Portal reconstruction was performed in 100% and 38% of PVT+ and PVT- patients, respectively (P=0.002). In view of the gravity of the clinical and/or biochemical picture, five (71%) patients underwent urgent re-operation with portal thrombectomy, one of whom died early (hemorrhagic shock after surgical treatment of PVT). Two patients had exclusively medical treatment. Complete recanalization of the portal vein was achieved in the short and medium term in the six survivors. After a mean follow-up of 21 months, there was no statistically significant difference in overall survival between the two groups.

FINDINGS

Post-hepatectomy PVT for PHCC is a not-infrequent and potentially lethal event. Rapid management, adapted to the extension of the thrombus and the severity of the thrombosis (hepatic function, signs of portal hypertension) makes it possible to limit the impact on postoperative mortality. We did not identify any modifiable risk factor. However, when it is oncologically and anatomically feasible, left±extended hepatectomy (without portal embolization) may be less risky than extended right hepatectomy, and portal vein resection should only be performed if there is strong suspicion of tumor invasion.

Towards refining the utility of dual (18F-FDG / 18F-Choline) PET/CT for the management of hepatocellular carcinoma: a tertiary center study

BACKGROUND

The role of positron emission tomography/computed tomography (PET/CT) in hepatocellular carcinoma (HCC) management is not clearly defined. Our objective was to analyze the utility of dual-PET/CT (18F-FDG + 18F-Choline) imaging findings on the BCLC staging and treatment decision for HCC patients.

METHODS

Between January 2011 and April 2019, 168 consecutive HCC patients with available baseline dual-PET/CT imaging data were retrospectively analyzed. To identify potential refinement criteria for surgically-treated patients, survival Kaplan-Meier curves of various standard-of-care and dual-PET/CT baseline parameters were estimated. Finally, multivariate cox proportional hazard ratios of the most relevant clinico-biological and/or PET parameters were estimated.

RESULTS

Dual-PET/CT findings increased the score of BCLC staging in 21 (12.5%) cases. In 24.4% (N.=41) of patients, the treatment strategy was modified by the PET findings. Combining AFP levels at a threshold of 10 ng/mL with 18F-FDG or 18F-Choline N status significantly impacted DFS (P<0.05). In particular, the combined criteria of the N+ status assessed by 18F-Choline with AFP threshold of 10 ng/mL provided a highly predictive composite parameter for estimation of DFS according to multivariate analysis (HR=10.6, P<0.05).

CONCLUSIONS

The 18F-Choline / AFP composite parameter appears promising, and further prospective studies are mandatory to validate its oncological impact.

Portal Vein Thrombosis in Patients with Liver Cirrhosis: What Went Wrong?

Purpose

This study aimed to explore inflammatory biomarkers, stool's functional bacterial groups and their possible link to portal vein thrombosis (PVT) in patients with liver cirrhosis (LC).

Materials and Methods

An observational study of 300 participants: 200 inhospital cirrhotic patients, who met inclusion criteria, equally assigned into two groups, based on the presence or absence of PVT and 100 healthy controls was carried out.

Results

The PVT group displayed significant differences related to older age, cigarettes smoking history, emergency admission, higher Child-Pugh score, metabolic related disorders and nonalcoholic fatty liver disease, as well as non-obstructive aspects, with chronic thrombi. The PVT group exhibited significant differences related to biomarkers such as tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP), D-dimers (D-D), as well as gut overall dysbiosis (DB) and alteration of different functional bacterial groups of the gut microbiota. Strong positive correlations were observed between PVT severity, and TNF-alpha, CRP, D-D as well as lipopolysaccharide (LPS) positive bacteria. Esophageal varices, age and abdominal pain were independent predictors for PVT severity as well as CRP, TNF-alpha and D-D.

Conclusion

Patients with LC and PVT displayed elevation of TNF-alpha, CRP, D-D alterations of the functional gut microbiota, as well as several morphological and clinical particularities. Although the LPS positive gut microbiota was linked to inflammatory biomarkers and PVT severity, it was not proven to be an independent predictor of the PVT severity like CRP, TNF-alpha and D-D.

Evidence for Alloimmune Sinusoidal Injury in De Novo Nodular Regenerative Hyperplasia After Liver Transplantation

Posttransplant nodular regenerative hyperplasia (NRH) mostly remains unexplained. Microvascular injury due to antibody-mediated rejection (AMR) is suspected, but lack of donor specific antibody (DSA) testing makes it difficult to prove. Centered around a 1-year period of routine DSA testing, concomitant protocol, and indicated posttransplant liver biopsies (LB), recipients with NRH (n = 18) were compared with a matched control group (n = 36). All index, previous, and subsequent LB were reviewed. Both groups were similar in terms of demographics, timing of index LB, and DSA. In the index LB, the NRH group had higher sinusoidal C4d positivity (p = 0.029) and perisinusoidal fibrosis (p = 0.034), both independently associated with NRH (p = 0.038 and 0.050, respectively). Features of "possible" chronic AMR were detected in 28.5% of the NRH group without a known cause and 0% of the control group (p = 0.009). The NRH group had more preceding indicated LB with increased incidence of rejection and biliary obstruction pattern. In the follow-up histology, overall, sinusoidal and portal C4d positivity, sinusoidal microvasculitis, and perisinusoidal fibrosis were also higher (all p < 0.050). In conclusion, we provide evidence towards the hypothesis that some cases of posttransplant NRH are related to preceding active and persistent AMR. Large multicenter studies with protocol DSA testing are required to confirm.

Features Importance in Acute Kidney Injury After Liver Transplant: Which Predictors Are Relevant?

OBJECTIVES

Acute kidney injury after liver transplant results from several interconnected factors related to graft, recipient, intraoperative, and postoperative events. The random decision forest model enables an appreciation of each factor's contribution, which may be helpful in setting up a preventive strategy. This study aimed to evaluate the importance of covariates at different times (pretransplant, end of surgery, postoperative day 7) with a random forest permutation algorithm.

MATERIALS AND METHODS

We used a retrospective singlecenter cohort of patients, without preoperative renal failure, who underwent primary liver transplants from deceased donors (N =1104). Significant covariates for stage 2-3 acute kidney injurywere included in a random forest model, and features importance was evaluated with mean decrease accuracy and Gini index.

RESULTS

Stage 2-3 acute kidney injury occurred in 200 patients (18.1%) and was associated with lower patient survival, even after exclusion of early graftloss. At univariate analysis, recipient factors (serum creatinine level, Model for End-Stage Liver Disease score, body weight, body mass index), graft variables (weight, macrosteatosis), intraoperative factors (number of red blood cells, duration of surgery, cold ischemia time), and postoperative event (graft dysfunction) were associated with kidney failure. The pretransplant model found that macrosteatosis and graft weight contributed to acute kidney injury. The postoperative model indicated that graft dysfunction and the number of intraoperative packed red blood cells were ranked as the 2 most essential factors in posttransplant renal failure.

CONCLUSIONS

The application of a random forestfeature identified graft dysfunction, even transient and reversible, and the number of intraoperative packed red blood cells as the 2 most crucial contributors to acute kidney injury,thus indicating that prevention of graft dysfunction and bleeding are key points to limit the risk of renal failure after liver transplant.

TACE and conformal radiotherapy vs. TACE alone for hepatocellular carcinoma: A randomised controlled trial

Background & Aims

Transcatheter arterial chemoembolisation (TACE) is recommended for patients with hepatocellular carcinoma devoid of macrovascular invasion or extrahepatic spread but not eligible for curative therapies. We compared the efficacy and safety of the combination of a single TACE and external conformal radiotherapy (CRT) vs. classical TACE.

Methods

TACERTE was an open-labelled, randomised controlled trial with a 1:1 allocation rate to two or three TACE (arm A) or one TACE + CRT (arm B). Participants had a mean age of 70 years, and 86% were male. The aetiology was alcohol in 85%. The primary endpoint was liver progression-free survival (PFS) in the intention-to-treat population. The typical CRT schedule was 54 Gy in 18 sessions of 3 Gy.

Results

Of the 120 participants randomised, 64 were in arm A and 56 in arm B; 100 participants underwent the planned schedule and defined the 'per-protocol' group. In intention-to-treat participants, the liver PFS at 12 and 18 months were 59% and 19% in arm A and 61% and 36% in arm B (hazard ratio [HR] 0.69; 95% CI 0.40-1.18; p = 0.17), respectively. In the per-protocol population, treated liver PFS tended to be better in arm B (HR 0.61; 95% CI 0.34-1.06; p = 0.081) than in arm A. Liver-related grade III-IV adverse events were more frequent in arm B than in arm A. Median overall survival reached 30 months (95% CI 23-35) in arm A and 22 months (95% CI 15.7-26.2) in arm B.

Conclusions

Although TACE + CRT tended to improve local control, this first Western randomised controlled trial showed that the combined strategy failed to increase PFS or overall survival and led more frequently to liver-related adverse effects.

Impact and implications

Hepatocellular carcinoma is frequently treated by arterial embolisation of the tumour and more recently by external radiotherapy. We tried to determine whether combination of the two treatments (irradiation after embolisation) might produce interesting results. Our results in this prospective randomised study were not able to demonstrate a beneficial effect of combining embolisation and irradiation in these patients. On the contrary, we observed more adverse effects with the combined treatment.

Clinical Trials Registration

NCT01300143.

Resectable and transplantable hepatocellular carcinoma: Integration of liver stiffness assessment in the decision-making algorithm

BACKGROUND

Liver resection is a curative treatment for hepatocellular carcinoma (HCC) and an alternative to liver transplantation (LT). However, post-liver resection recurrence rates remain high. This study aimed to determine whether liver stiffness measurement (LSM) correlated with recurrence and to propose a method for predicting HCC recurrence exclusively using pre-liver resection criteria.

METHODS

This retrospective monocentric study included patients who had undergone LR liver resection for HCC between 2015 and 2018 and who had (1) preoperative alpha-fetoprotein scores indicating initial transplant viability and (2) available preoperative LSM data. We developed a predictive score for recurrence over time using Cox univariate regression and multivariate analysis with a combination plot before selecting the optimal thresholds (receiver operating characteristic curves + Youden test).

RESULTS

Sixty-six patients were included. After an average follow-up of 40 months, the recurrence rate was 45% (n = 30). Three-year overall survival was 88%. Four preoperative variables significantly impacted the time to recurrence: age ≥70 years, LSM ≥11 kPa, international normalized ratio (INR) ≥1.2, and maximum HCC diameter ≥3 cm. By assigning 1 point per positive item, patients with a score <2 (n = 22) demonstrated greater mean overall survival (69.7 vs 54.8 months, P = .02) and disease-free survival (52.2 vs 34.7 months, P = .02) than those with a score ≥2. Patients experiencing early recurrence (<1 year) presented a significantly higher preoperative LSM (P = .06).

CONCLUSION

We identified a simple preoperative score predictive of early hepatocellular carcinoma recurrence after liver resection, highlighting the role of liver stiffness. This score could help physicians select patients and make decisions concerning perioperative medical treatment.

The rex shunt for left portal vein reconstruction during hepatectomy for malignancy using of rex-shunt in adults for oncoliver surgery

BACKGROUND

Immediate portal reperfusion is mandatory following hepatectomy combined with portal vein (PV) resection. This retrospective study analyzes the feasibility and the outcomes of the Rex shunt (RS) for reconstruction of the left portal vein (LPV) and reperfusion of the remnant left liver or lobe following hepatectomy for cancer combined with resection of the PV in adult patients.

METHODS

From 2018 to 2021, an RS was used in the above setting to achieve R0 resection or when the standard LPV reconstruction failed or was deemed technically impossible.

RESULTS

There were 6 male and 5 female patients (median age, 58 years) with perihilar cancer (5 cases) or miscellaneous cancers invading the PV (6 cases). A major hepatectomy was performed in 10/11 patients. The RS was indicated to achieve R0 resection or for technical reasons in 8 and 3 cases, respectively, and was feasible in all consecutive attempts with (10 cases) or without an interposed synthetic graft (1 case). Two fatal complications (PV thrombosis and pulmonary embolism) and three non-severe complications occurred in four patients within 90 days of surgery. Two patients died of tumor recurrence with a patent RS at 13 and 29 months, and 7 were recurrence free with a patent shunt with a follow-up of 1 to 37 months (median, 15 months).

CONCLUSION

In case of remnant left liver or lobe following hepatectomy combined with resection of the PV, the RS may help to achieve R0 resection and is a valuable option to perform technically satisfying portal reperfusion of the remnant left liver or lobe.

Incidental finding of elevated pulmonary arterial pressures during liver transplantation and postoperative pulmonary complications

BACKGROUND

In patients with end stage liver disease (ESLD) scheduled for liver transplantation (LT), an intraoperative incidental finding of elevated mean pulmonary arterial pressure (mPAP) may be observed. Its association with patient outcome has not been evaluated. We aimed to estimate the effects of an incidental finding of a mPAP > 20 mmHg during LT on the incidence of pulmonary complications.

METHODS

We examined all patients who underwent a LT at Paul-Brousse hospital between January 1,2015 and December 31,2020. Those who received: a LT due to acute liver failure, a combined transplantation, or a retransplantation were excluded, as well as patients for whom known porto-pulmonary hypertension was treated before the LT or patients who underwent a LT for other etiologies than ESLD. Using right sided pulmonary artery catheterization measurements made following anesthesia induction, the study cohort was divided into two groups using a mPAP cutoff of 20 mmHg. The primary outcome was a composite of pulmonary complications. Univariate and multivariable logistic regression analyses were performed to identify variables associated with the primary outcome. Sensitivity analyses of multivariable models were also conducted with other mPAP cutoffs (mPAP ≥ 25 mmHg and ≥ 35 mmHg) and even with mPAP as a continuous variable.

RESULTS

Of 942 patients who underwent a LT, 659 met our inclusion criteria. Among them, 446 patients (67.7%) presented with an elevated mPAP (mPAP of 26.4 ± 5.9 mmHg). When adjusted for confounding factors, an elevated mPAP was not associated with a higher risk of pulmonary complications (adjusted OR: 1.16; 95%CI 0.8-1.7), nor with 90 days-mortality or any other complications. In our sensitivity analyses, we observed a lower prevalence of elevated mPAP when increasing thresholds (235 patients (35.7%) had an elevated mPAP when defined as ≥ 25 mmHg and 41 patients (6.2%) had an elevated mPAP when defined as ≥ 35 mmHg). We did not observe consistent association between a mPAP ≥ 25 mmHg or a mPAP ≥ 35 mmHg and our outcomes.

CONCLUSION

Incidental finding of elevated mPAP was highly prevalent during LT, but it was not associated with a higher risk of postoperative complications.

Surgery for T4 Colorectal Cancer in Older Patients: Determinants of Outcomes

Background: This study aimed to compare the outcomes of older and younger patients with T4 colorectal cancer (CRC) treated with surgery. Methods: Consecutive patients with T4 CRC treated surgically at Henri Mondor Hospital between 2008 and 2016 were retrospectively analyzed in age subgroups (1) 50−69 years and (2) ≥70 years for overall and relative survival. The multivariable analyses were adjusted for adjusted for age, margin status, lymph node involvement, CEA level, postoperative complications (POC), synchronous metastases, and type of surgery. Results: Of 106 patients with T4 CRC, 57 patients (53.8%) were 70 years or older. The baseline characteristics were generally balanced between the two age groups. Older patients underwent adjuvant therapy less commonly (42.9 vs. 57.1%; p = 0.006) and had a longer delay between surgery and chemotherapy (median 40 vs. 34 days; p < 0.001). A higher trend for POC was reported among the older patients but did not impact the survival outcomes. After adjusting for confounding factors, the overall survival was shorter among the older patients (HR = 3.322, 95% CI 1.49−7.39), but relative survival was not statistically correlated to the age group (HR = 0.873, 95% CI 0.383−1.992). Conclusions: Older patients with CRC were more prone to severe POC, but age did not impact the relative survival of patients with T4 colorectal cancer. Older patients should not be denied surgery based on age alone.

[CASE REPORT: LEGAL, PSYCHOLOGICAL AND ETHICAL ASPECTS OF THE DYING PATIENT ACT]

We present a patient with amyotrophic lateral sclerosis (ALS), dependent on noninvasive ventilation, whose advance directives precluded life-prolonging measures. The patient was found in cardiac arrest and in accordance with the directives of her surrogate decision maker, underwent intubation and mechanical ventilation. Later, an additional surrogate decision maker disapproved of ventilation and when the ventilator was disconnected for bronchial suctioning, she asked the nurse not to reconnect the patient to the ventilator. We discuss the legal, psychological and ethical aspects of implementation of Israeli law in this complex patient.

Tumors located in the central column of the liver are associated with increased surgical difficulty and postoperative complications following open liver resection for colorectal metastases

BACKGROUND

To assess the impact of difficult location (based on preoperative computed tomography) of liver metastases from colorectal cancer (LMCRC) on surgical difficulty, and occurrence of severe postoperative complications (POCs).

METHODS

A retrospective single-centre study of 911 consecutive patients with LMCRC who underwent hepatectomy by the open approach between 1998 and 2011, before implementation of laparoscopic surgery to obviate approach selection bias. LMCRC with at least one of the following four features on preoperative imaging: tumor invading the hepatocaval confluence or retro-hepatic inferior vena cava, centrally located (Segments 4,5,8) and >10 cm in diameter, abutting the supra-hilar area, or involving the paracaval portion or caudate process of Segment 1; were considered as topographically difficult (top-diff). Independent predictors of surgical difficulty assessed by number of blood units transfused, duration of ischemia, and number of sessions of pedicle clamping during surgery and of severe POCs were identified by multivariate analysis before, and after propensity score matching.

RESULTS

Top-diff tumor location independently predicted surgical difficulty. Severe POCs were associated with the tumor location [top-diff vs. topographically non difficult (non top-diff)], preoperative portal vein embolization, and variables related to surgical difficulty.

CONCLUSION

LMCRC in difficult location independently predicts surgical difficulty and severe POCs.

Current indications of ex-situ liver resection: A systematic review

BACKGROUND

Ex situ liver resection and autotransplantation, a surgical technique introduced for managing advanced and unresectable malignant tumors, never became a popular surgical procedure, due mainly to the high incidence of adverse events and postoperative recurrences. This study aims to assess the clinical outcomes of ex situ liver resection and autotransplantation in the currently available literature.

METHODS

The PubMed electronic database was used to retrieve studies that meet the inclusion criteria for the topic.

RESULTS

Twenty-nine studies were included. The mean (range) 90-day mortality rate was 11.6% (0%-50%) and the mean overall survival was 55.8% (12.5%-100.0%). R0 resection was achieved in 100% of cases. In the overall study sample, the maximum tumor size was found to be positively correlated with the 90-day mortality rate (P = .047) and negatively correlated with the overall survival (P = .048). The mean number of total resected segments appeared to be positively correlated with the length of hospital stay (P = .039). In the malignant tumor sample, there was a significant relationship between the maximum tumor size and postoperative liver failure, 90-day mortality rate (P = .027 and P = .034, respectively), and between the mean length of anhepatic phase and mean length of hospital stay (P = .0092).

CONCLUSION

The ex situ liver resection and autotransplantation appears to be a valuable option in selected patients with conventionally unresectable hepatic tumors and normal liver function. However, it was not possible to provide clear and unequivocal recommendations about this procedure. To rectify this, an international database to help surgeons in their decision-making process ought to be established.

Optimal cytoreductive LIVER surgery for unresectable colorectal liver metastases: A prospective observational study

3570

Background: Patients with multiple colorectal liver metastases (CLM) involving all the hepatic segments are currently not eligible for potentially curative liver surgery. Transplantation is a promising alternative but graft shortage and stringent selection criteria limit its accessibility. Owing to the improving efficacy of chemotherapy, the impossibility to resect all the initial metastatic sites could lead to revisit the role of optimal cytoreductive liver surgery (CLS) aiming to treat by resection ± radiofrequency, all the macroscopic residual tumors after a good response to chemotherapy. Although validated for ovarian cancer and peritoneal carcinomatosis, this strategy remains unexplored in CLM. Our objective was to evaluate the outcome of this strategy in patients with definitively unresectable CLM. Methods: Within a prospective monocentric study, we enrolled for debulking surgery, between 2017 and 2021, all consecutive patients with multinodular unresectable CLM involving all segments on initial imaging and consequently ineligible for a curative surgery either after a one or two-stage hepatectomy. These patients should have a strong response to chemotherapy ( > 50 % on RECIST criteria) for at least a 3-month period and no or limited extrahepatic disease, to be included. End-points of the analysis were overall and disease-free survival at 3 years. Results: Among 26 patients considered for this strategy, optimal CLS could be achieved in 21 patients after a median interval of 10 months from CLM diagnosis. The median number of lesions was 11 (7 - 26) on initial imaging. Four patients (19%) had synchronous lung metastases. Liver-first strategy was undertaken in 19 patients (90%). Postoperative complications (Grade ≥ III) occured in 5 patients (24%). One patient died within 90-day after operation from intra-abdominal hemorrage while on anticoagulation therapy. After a median follow-up of 25 months from hepatectomy, the 3-year OS rates was 85%. Median survival was not reached at the time of the analysis. Of the 4 (19%) patients with complete pathological response on the liver specimen, 3 developed recurrence. A total of 17 patients (81%) developed recurrence after a median time of 10,5 months from hepatectomy. Among them, repeat hepatectomy could be undertaken in four patients. The survival time to surgical failure (recurrence untreatable with curative intent) was 32% and 16% at 2 and 3 years. At last follow-up, seven patients (33%) are alive and recurrence-free. Conclusions: The promising results of this prospective series suggest that CLS may be worthy in patients with diffuse CLM non curatively treatable by surgery but responding well to chemotherapy. This strategy should however be reserved to hyperselected patients, super responders, eligible for an optimal resection of all the macroscopic residual tumors, and confimed by other expert centers, to be definitively validated.

Is cure possible for breast cancer metastatic to the liver?

1099

Background: Metastatic breast cancer (MBC) is a lethal disease and is generally only amenable to systemic treatment. Although increasingly recommended on selected patients, local treatments, and particularly surgery, are seldom used in the therapeutic armamentarium for MBC and their long-term survival benefit is unknown. We hypothesized that combining surgery to systemic treatment for selected patients with breast cancer liver metastases could lead to long-term survival or even an option of cure. Methods: A retrospective study of prospectively gathered data from a surgical series of liver resections for MBC was conducted. Patients with no or limited and stable extra-hepatic disease were offered surgery after multidisciplinary discussion, if the liver metastases were responding to systemic treatment and were amenable to complete macroscopic resection. Five- and ten-year actual survivors were identified and their characteristics were explored. Results: From 1984 to 2020, 207 female patients underwent liver resections for MBC in our institution. There was no postoperative mortality. Postoperative complication rate was 23.3% and liver-specific complication rate was 19.0%. There was a total of 48 repeat hepatectomies. Median disease-free interval between initial breast cancer and liver metastasis was 36 ± 90.1 months. There was a median of 2 ± 1.8 liver metastases at diagnosis with a median size of 33.0 ± 18.3 mm and 73.1% of patients had radiological response before resection. Five- and ten-year overall survivals (OS) as well as 5- and 10-year disease-free survivals (DFS) were 39.6% and 12.7% as well as 14.2% and 6.4%, respectively. Median OS was 44.0 ± 47.2 months in the whole series. Focusing on the 5- and 10-year survivors, median OS were 89.5 ± 44.7 months and 144.0 ±42.6 months, respectively. In the 10-year survivors’ group, median DFS was 98 ±62.3 months. Observed survivals in this study underestimate true actual survivals owing to censoring of patients lost to follow-up. Conclusions: Long-term survival (≥ 5 years) as well as a curative perspective (≥ 10 years survival) are achievable for selected patients with breast cancer liver metastases by combining surgery to systemic treatment. Considering the recent improvements in the results of systemic treatments, introducing surgical resection in the treatment sequences of MBC could play an even more beneficial role.

The impact of advanced patient age in liver transplantation: a European Liver Transplant Registry propensity-score matching study

BACKGROUND

The futility of liver transplantation in elderly recipients remains under debate in the HCV eradication era.

METHODS

The aim was to assess the effect of older age on outcome after liver transplantation. We used the ELTR to study the relationship between recipient age and post-transplant outcome. Young and elderly recipients were compared using a PSM method.

RESULTS

A total of 10,172 cases were analysed. Recipient age >65 years was identified as an independent risk factor associated with reduced patient survival (HR:1.42 95%CI:1.23-1.65,p < 0.001). After PSM, 2124 patients were matched, and the same association was found between elderly recipients and patient survival and graft survival (p < 0.001). As hepatocellular carcinoma and alcoholic cirrhosis were independent prognostic factors for patient and graft survival a propensity score-matching was performed for each. Patient and graft survival were significantly worse (p < 0.05) in the alcoholic cirrhosis elderly group. However, patient and graft survival in the hepatocellular carcinoma cohort were similar (p > 0.05) between groups.

CONCLUSION

Liver transplantation is an acceptable and safe curative option for elderly transplant candidates, with worse long-term outcomes compare to young candidates. The underlying liver disease for liver transplantation has a significant impact on the selection of elderly patients.

Subjective Difficulty Scale in Liver Transplantation: A Prospective Observational Study

The predictive value of a subjective difficulty scale (DS) after surgical procedures is unknown. The objective of this study was to evaluate the prognostic value of a DS after liver transplantation (LT) and to identify predictors of difficulty. Surgeons prospectively evaluated the difficulty of 441 consecutive liver transplantations from donation after brain death at the end of the surgery by using a DS from 0 to 10 (“the easiest to the hardest you can imagine”). DS was associated with severe morbidity. The risk of graft loss at 1 year remained unchanged from 0 to 6 but increased beyond 6. Graft survival and patient survival of group with DS 7–10 was significantly impaired compared to groups with DS: 0–3 or DS: 4–6 but were significantly impaired for the group with DS: 7–10. Independent predictors of difficult LT (DS ≥ 7) were annular segment 1, transjugular intrahepatic portosystemic shunt, retransplantation beyond 30 days, portal vein thrombosis, and ascites. Of them, ascites was a borderline non-significant covariate (p = .04). Vascular complications occurred more often after difficult LT (20.5% vs. 5.9%), whereas there was no difference in the other types of complications. DS can be used to tailor monitoring and anticipate early complications. External validation is needed.

State of the Art, Current Perspectives, and Controversies of Budd-Chiari Syndrome: A Review

Background

Methods

Results

Conclusions

A systematic review of auxiliary liver transplantation of small for size grafts in patients with chronic liver disease

Background & Aims

The shortage of liver grafts continues to worsen. Because the expanded use of small-for-size grafts (SFSGs) would substantially alleviate this shortage, we aimed to analyse the available knowledge on auxiliary liver transplantation (ALT) with SFSGs in patients with chronic liver disease (CLD) to identify opportunities to develop ALT with SFSGs in patients with CLD.

Methods

This is a systematic review on ALT using SFSGs in patients with CLD. The review was completed by updates obtained from the authors of the retained reports.

Results

Heterotopic ALT was performed in 26 cases between 1980 and 2017, none for SFGS stricto sensu, and auxiliary partial orthotopic liver transplantation (APOLT) in 27 cases (from 1999 to 2021), all for SFSG. In APOLT cases, partial native liver resection was performed in most of cases, whereas the second-stage remnant native liver hepatectomy was performed in 9 cases only. The median graft-to-body weight ratio was 0.55, requiring perioperative or intraoperative portal modulation in 16 cases. At least 1 complication occurred in 24 patients following the transplant procedure (morbidity rate, 89%). Four patients (4/27, 15%) died after the APOLT procedure. At the long term, 19 (70%) patients were alive and well at 13 months to 24 years (median, 4.5 years) including 18 with the APOLT graft in place and 1 following retransplantation.

Conclusions

Despite high postoperative morbidity, and highly reported technical variability, the APOLT technique is a promising technique to use SFSGs in patients with CLD, achieving satisfactory long-term results. The results need to be confirmed on a larger scale, and a standardised technique could lead to even better results.

Lay summary

At the cost of a high postoperative morbidity, the long-term results of APOLT for small-for-size grafts are good. Standardisation of the procedure and of portal modulation remain needed.

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Using a small-for-size graft is a risk factor of small-for-size syndrome.

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Auxiliary liver transplantation can be orthotopic or heterotopic.

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In auxiliary transplantation, the remnant native liver prevents small-for-size syndrome.

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Transplantation with a small-for-size graft requires individually tailored portal modulation.

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Auxiliary liver transplantation might substantially increase the number of available grafts.

Understanding out-of-pocket spending and financial hardship among patients who succumb to cancer and their caregivers

BACKGROUND

In most countries, including those with national health insurance or comprehensive public insurance, some expenses for cancer treatment are borne by the ill and their families.

OBJECTIVES

This study aims to identify the areas of out-of-pocket (OOP) spending in the last half-year of the lives of cancer patients and examine the extent of that spending; to examine the probability of OOP spending according to patients' characteristics; and to examine the financial burden on patients' families.

METHODS

491 first-degree relatives of cancer patients (average age: 70) who died 3-6 months before the study were interviewed by telephone. They were asked about their OOP payments during the last-half year of the patient's life, the nature of each payment, and whether it had imposed a financial burden on them. A logistic regression and ordered logit models were used to estimate the probability of OOP expenditure and the probability of financial burden, respectively.

RESULTS

Some 84% of cancer patients and their relatives incurred OOP expenses during the last half-year of the patient's life. The average levels of expenditure were US$5800on medicines, $8000 on private caregivers, and $2800 on private nurses. The probability of paying OOP for medication was significantly higher among patients who were unable to remain alone at home and those who were less able to make ends meet. The probability of spending OOP on a private caregiver or private nurse was significantly higher among those who were incapacitated, unable to remain alone, had neither medical nor nursing-care insurance, and were older. The probability of a financial burden due to OOP was higher among those unable to remain alone, the incapacitated, and those without insurance, and lower among those with above-average income, those with better education, and patients who died at home.

CONCLUSIONS

The study yields three main insights. First, it is crucial that oncology services provide cancer patients with detailed information about their entitlements and refer them to the National Insurance Institute so that they can exercise those rights. Second, oncologists should relate to the financial burden associated with OOP care at end of life. Finally, it is important to sustain the annual increase in budgeting for technologies and pharmaceuticals in Israel and to allocate a significant proportion of those funds to the addition new cancer treatments to the benefits package; this can alleviate the financial burden on patients who need such treatments and their families.

Novel Composite Endpoint for Assessing Outcomes in Liver Transplantation: Arterial and Biliary Complication-Free Survival

Transplant and patient survival are the validated endpoints to assess the success of liver transplantation (LT). This study evaluates arterial and biliary complication-free survival (ABCFS) as a new metric. ABC, considered as an event, was an arterial or biliary complication of Dindo-Clavien grade ≥III complication dated at the interventional, endoscopic, or surgical treatment required to correct it. ABCFS was defined as the time from the date of LT to the dates of first ABC, death, relisting, or last follow-up (transplant survival is time from LT to repeat LT or death). Following primary whole LT (n = 532), 106 ABCs occurred and 99 (93%) occurred during the first year after LT. An ABC occurring during the first year after LT (overall rate 19%) was an independent factor associated with transplant survival (hazard ratio [HR], 3.17; P < 0.001) and patient survival (HR, 2.7; P = 0.002) in univariate and multivariate analyses. This result was confirmed after extension of the cohort to split-liver graft, donation after circulatory death, or re-LT (n = 658). Data from 2 external cohorts of primary whole LTs (n = 249 and 229, respectively) confirmed that the first-year ABC was an independent prognostic factor for transplant survival but not for patient survival. ABCFS was correlated with transplant and patient survival (ρ = 0.85 [95% CI, 0.78-0.90] and 0.81 [95% CI, 0.71-0.88], respectively). Preoperative factors known to influence 5-year transplant survival influenced ABCFS after 1 year of follow-up. The 1-year ABCFS was indicative of 5-year transplant survival. ABCFS is a reproducible metric to evaluate the results of LT after 1 year of follow-up and could serve as a new endpoint in clinical trials.

Donor HLA Class 1 Evolutionary Divergence Is a Major Predictor of Liver Allograft Rejection : A Retrospective Cohort Study

BACKGROUND

The HLA evolutionary divergence (HED), a continuous metric quantifying the peptidic differences between 2 homologous HLA alleles, reflects the breadth of the immunopeptidome presented to T lymphocytes.

OBJECTIVE

To assess the potential effect of donor or recipient HED on liver transplant rejection.

DESIGN

Retrospective cohort study.

SETTING

Liver transplant units.

PATIENTS

1154 adults and 113 children who had a liver transplant between 2004 and 2018.

MEASUREMENTS

Liver biopsies were done 1, 2, 5, and 10 years after the transplant and in case of liver dysfunction. Donor-specific anti-HLA antibodies (DSAs) were measured in children at the time of biopsy. The HED was calculated using the physicochemical Grantham distance for class I (HLA-A or HLA-B) and class II (HLA-DRB1 or HLA-DQB1) alleles. The influence of HED on the incidence of liver lesions was analyzed through the inverse probability weighting approach based on covariate balancing, generalized propensity scores.

RESULTS

In adults, class I HED of the donor was associated with acute rejection (hazard ratio [HR], 1.09 [95% CI, 1.03 to 1.16]), chronic rejection (HR, 1.20 [CI, 1.10 to 1.31]), and ductopenia of 50% or more (HR, 1.33 [CI, 1.09 to 1.62]) but not with other histologic lesions. In children, class I HED of the donor was also associated with acute rejection (HR, 1.16 [CI, 1.03 to 1.30]) independent of the presence of DSAs. There was no effect of either donor class II HED or recipient class I or class II HED on the incidence of liver lesions in adults and children.

LIMITATION

The DSAs were measured only in children.

CONCLUSION

Class I HED of the donor predicts acute or chronic rejection of liver transplant. This novel and accessible prognostic marker could orientate donor selection and guide immunosuppression.

PRIMARY FUNDING SOURCE

Institut National de la Santé et de la Recherche Médicale.

The prognostic significance of serum aspartate transaminase and gamma-glutamyl transferase in liver deceased donors

The impact of aspartate transaminases (AST) and gamma-glutamyl transferase (GGT) in serum of deceased donors on outcomes after liver transplantation (LT) is unclear. This study aimed to explore the relationship between donor highest AST value or first donor GGT value and graft survival. All consecutive patients who underwent a primary LT in a single center with available donor AST (N=1253) and GGT value (N=1152) were included. There was no significant association between donor AST and 90-day graft survival. We found a moderate association between GGT and 90-day graft survival. We found a significant interaction with a donor history of alcohol abuse (HAA). The risk of graft loss was associated with AST and GGT in donors with an HAA but remains unchanged in donors without HAA. There was no difference in graft survival according to donor AST or GGT with a cutoff ≥ 95^th percentile (475 UI/L for AST and 170 UI/L for GGT). However, graft survival was significantly decreased when donors combined GGT ≥ 170 UI/L and HAA (61% at one year). Hepatic grafts from donors with high AST or high GGT but without alcohol history and no additional risk factors can be transplanted in low-risk recipient.

The Impact of Establishing a Dedicated Liver Surgery Program at a University-affiliated Hospital on Workforce, Workload, Surgical Outcomes, and Trainee Surgical Autonomy and Academic Output

Objective

To detail the implementation of a dedicated liver surgery program at a university-affiliated hospital and to analyze its impact on the community, workforce, workload, complexity of cases, the short-term outcomes, and residents and young faculties progression toward technical autonomy and academic production.

Background

Due to the increased burden of liver tumors worldwide, there is an increased need for liver centers to better serve the community and facilitate the education of trainees in this field.

Methods

The implementation of the program is described. The 3 domains of workload, research, and teaching were compared between 2-year periods before and after the implementation of the new program. The severity of disease, complexity of procedures, and subsequent morbidity and mortality were compared.

Results

Compared with the 2-year period before the implementation of the new program, the number of liver resections increased by 36% within 2 years. The number of highly complex resections, the number of liver resections performed by residents and young faculties, and the number of publications increased 5.5-, 40-, and 6-fold, respectively. This was achieved by operating on more severe patients and performing more complex procedures, at the cost of a significant increase in morbidity but not mortality. Nevertheless, operations during the second period did not emerge as an independent predictor of severe morbidity.

Conclusions

A new liver surgery program can fill the gap between the demand for and supply of liver surgeries, benefiting the community and the development of the next generation of liver surgeons.

De novo hepatocellular carcinoma in a non-cirrhotic allograft 27 years after liver transplantation: A case report

Hepatocellular carcinoma recurrence after liver transplantation is a well-known complication but the development of de novo hepatocellular carcinoma in non-cirrhotic allograft with no previous history of hepatic malignancy either in the donor or the recipient is extremely rare. A 33-year-old man underwent deceased donor liver transplantation due to HBV-HDV cirrhosis in 1991. The donor was healthy, with negative viral serology. Pretransplant assessment and explant liver pathology revealed no tumor. He developed an 8 cm mediastinal thymus cancer in 2014, a chronic myeloid leukemia in 2015 and a 16 mm renal cell carcinoma in 2017. After 27 years, in 2018, his routine follow-up sonography showed incidentally a 37 mm hepatic nodule in segment VII which revealed after percutaneous liver guided biopsy a hepatocellular carcinoma. As no extra hepatic metastasis was noted, segmentectomy was done. The pathological report confirmed a moderately differentiated hepatocellular carcinoma nodule of 50 mm diameter with absence of microvascular invasion and the non-tumoral liver showed histological features of NASH (SAF score: S1A2F3, NAS score: A3F3 and LAFSc:5) with absence of HBsAg and HBcAg. This case emphasizes the importance of long-term close surveillance by imaging of the graft even in the absence of viral recurrence and graft cirrhosis.

Initial piggyback technique facilitates late liver retransplantation - a retrospective monocentric study

Optimal management of inferior vena cava (IVC) is crucial to ensure safety in late liver retransplantation (ReLT). The aim of this study was to evaluate different surgical strategies with regard to IVC in late ReLT. All consecutive late ReLT (≥90 days from the previous transplant) from 2013 to 2018 in a single center was reviewed (n = 66). Of them, 46 (69.7%) were performed without venovenous bypass (VVB) including 29 with caval preservation (CP) and 17 with caval replacement (CR). The remaining 20 cases (30.3%) required the use of VVB. Among ReLT without VVB, CP was associated with a lower number of packed red blood cells (median 4 vs. 7; P = 0.016) and a lower incidence of post-transplant acute kidney injury (6.9% vs. 47.1%; P = 0.003). The feasibility of CP was 95% (14/15) in patients with previous 3-vein piggyback caval anastomosis versus 48.3% (15/31) after other techniques (P = 0.003). Indirect signs of portal hypertension (PHT) before retransplantation were predictive of VVB requirement. Early and long-term outcomes were similar across the three groups (CP without VVB, CR without VVB, and VVB). Preserving the IVC in late ReLT is associated with better postoperative renal function and is facilitated by a previous 3-vein piggyback. Routine CR is not justified in late ReLT.

Impact on Oncological Outcomes and Intent-to-Treat Survival of Resection Margin for Transplantable Hepatocellular Carcinoma in All-Comers and in Patients with Cirrhosis: A Multicenter Study

BACKGROUND

The outcomes of liver resection (LR) with a narrow margin in patients with transplantable hepatocellular carcinoma (HCC) have not been studied. The aim was to assess whether narrow margin following up-front LR impacts the incidence, timing, pattern, and transplantability of tumor recurrence in patients with initially transplantable HCC.

METHODS

All initially transplantable HCC patients undergoing hepatectomy with either narrow (<10 mm) or wide (≥10 mm) margins from 2007 to 2016 at four Western university centers were compared in terms of recurrence, transplantability of recurrence, recurrence-free survival (RFS), and intention-to-treat overall survival (ITT-OS). Independent predictors of non-transplantability of recurrence were assessed.

RESULTS

This study included 187 patients (narrow group, n = 107 vs. wide group, n = 80). Recurrence was significantly more frequent in the narrow margin group (44% vs. 26%; p = 0.01) with a shorter RFS (p = 0.03). The transplantability of recurrence and ITT-OS were, however, not different between the two groups. The presence of satellite nodules on the resected specimens emerged as the sole independent predictor of non-transplantability of tumor recurrence. The stratification of the analysis according to the presence of cirrhosis achieved essentially the same results as in the whole study population.

CONCLUSIONS

Narrow margin was associated with a higher tumor recurrence rate and a shorter RFS for patients with initially transplantable HCC. However, transplantability of recurrence and long-term ITT-OS were not impaired.

Liver resection for hepatocellular carcinoma in patients with clinically significant portal hypertension

Background & Aims

Liver resection (LR) in patients with hepatocellular carcinoma (HCC) and clinically significant portal hypertension (CSPH) defined as a hepatic venous pressure gradient (HVPG) ≥10 mmHg is not encouraged. Here, we reappraised the outcomes of patients with cirrhosis and CSPH who underwent LR for HCC in highly specialised liver centres.

Methods

This was a retrospective multicentre study from 1999 to 2019. Predictors for postoperative liver decompensation and textbook outcomes were identified.

Results

In total, 79 patients with a median age of 65 years were included. The Child-Pugh grade was A in 99% of patients, and the median model for end-stage liver disease (MELD) score was 8. The median HVPG was 12 mmHg. Major hepatectomies and laparoscopies were performed in 28% and 34% of patients, respectively. Ninety-day mortality and severe morbidity rates were 6% and 27%, respectively. Postoperative and persistent liver decompensation occurred in 35% and 10% of patients at 3 months. Predictors of liver decompensation included increased preoperative HVPG (p = 0.004), increased serum total bilirubin (p = 0.02), and open approach (p = 0.03). Of the patients, 34% achieved a textbook outcome, of which the laparoscopic approach was the sole predictor (p = 0.004). The 5-year overall survival and recurrence-free survival rates were 55% and 43%, respectively.

Conclusions

Patients with cirrhosis, HCC and HVPG ≥10 mmHg can undergo LR with acceptable mortality, morbidity, and liver decompensation rates. The laparoscopic approach was the sole predictor of a textbook outcome.

Lay summary

Patients with cirrhosis, hepatocellular carcinoma, and clinically significant portal hypertension (defined as a hepatic venous pressure gradient ≥10 mmHg) can undergo resection with acceptable mortality, morbidity, liver decompensation rates, and a textbook outcome. These results can be achieved in selected patients with preserved liver function, good general status, and sufficient remnant liver volume.

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Patients with HCC and CSPH can undergo resection, with mortality of 6% and severe morbidity of 27%.

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Postoperative and persistent liver decompensation occurred in 35% and 10% of patients, respectively.

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Textbook outcome was achieved in 34% of patients.

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The laparoscopic approach was identified as a predictor of postoperative liver decompensation and textbook outcome.

Survival-Inferred Fragility Index of Phase 3 Clinical Trials Evaluating Immune Checkpoint Inhibitors

IMPORTANCE

In science and medical research, extreme and dichotomous conclusions may be drawn based on whether the P value falls above or below the threshold. The fragility index (ie, the minimum number of changes from nonevents to events resulting in loss of statistical significance) captures the vulnerability of statistics in trials with binary outcomes. There are a growing number of clinical trials of immune checkpoint inhibitors (ICIs), as well as expanding eligibility for patients to receive them. The robustness of survival outcomes in randomized clinical trials (RCTs) should be evaluated using the fragility index extended to time-to-event data.

OBJECTIVE

To calculate the fragility of survival data in RCTs evaluating ICIs.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, data on phase 3 prospective RCTs investigating ICIs included in PubMed from inception until January 1, 2020, were extracted. Two- or three-group studies reporting results for overall survival were eligible for the survival-inferred fragility index (SIFI) calculation, which is the minimum number of reassignments of the best survivors from the interventional group to the control group resulting in loss of significance (defined as P < .05 by log-rank test). For nonsignificant results, a negative SIFI was calculated by reversing the direction of reassignment (from the control group to the interventional group).

MAIN OUTCOMES AND MEASURES

Survival-inferred fragility index.

RESULTS

A total of 45 phase 3 prospective RCTs (4 of which had 3 groups, for a total of 49 groups) were identified, of which 6 (13%) investigated anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) agents, 25 (56%) investigated anti-programmed cell death 1 (PD-1) agents, 12 (27%) investigated anti-programmed cell death 1 ligand 1 agents, and 3 (7%) investigated the combination of anti-CTLA-4 and anti-PD-1 agents. The median SIFI was 5 (interquartile range, -4 to 12) for the intention-to-treat analysis; for these trials, the SIFI was 1% or less of the total sample size in 17 of 49 populations (35%). In 25 of the 49 intention-to-treat populations (51%), the SIFI was less than the number of censored patients in the intervention group shortly after randomization (defined as <5% of the follow-up time).

CONCLUSIONS AND RELEVANCE

This study suggests that many phase 3 RCTs evaluating ICI therapies have a low SIFI for overall survival, resulting in uncertainty regarding their potential clinical benefit. Although not a definitive solution for the problems arising from dichotomization, SIFI provides an additional means of assessing and communicating the strength of statistical conclusions.

Identification of Four Immune Subtypes Characterized by Distinct Composition and Functions of Tumor Microenvironment in Intrahepatic Cholangiocarcinoma

BACKGROUND AND AIMS

Intrahepatic cholangiocarcinoma (ICC) is a severe malignant tumor in which the standard therapies are mostly ineffective. The biological significance of the desmoplastic tumor microenvironment (TME) of ICC has been stressed but was insufficiently taken into account in the search for classifications of ICC adapted to clinical trial design. We investigated the heterogeneous tumor stroma composition and built a TME-based classification of ICC tumors that detects potentially targetable ICC subtypes.

APPROACH AND RESULTS

We established the bulk gene expression profiles of 78 ICCs. Epithelial and stromal compartments of 23 ICCs were laser microdissected. We quantified 14 gene expression signatures of the TME and those of 3 functional indicators (liver activity, inflammation, immune resistance). The cell population abundances were quantified using the microenvironment cell population-counter package and compared with immunohistochemistry. We performed an unsupervised TME-based classification of 198 ICCs (training set) and 368 ICCs (validation set). We determined immune response and signaling features of the different immune subtypes by functional annotations. We showed that a set of 198 ICCs could be classified into 4 TME-based subtypes related to distinct immune escape mechanisms and patient outcomes. The validity of these immune subtypes was confirmed over an independent set of 368 ICCs and by immunohistochemical analysis of 64 ICC tissue samples. About 45% of ICCs displayed an immune desert phenotype. The other subtypes differed in nature (lymphoid, myeloid, mesenchymal) and abundance of tumor-infiltrating cells. The inflamed subtype (11%) presented a massive T lymphocyte infiltration, an activation of inflammatory and immune checkpoint pathways, and was associated with the longest patient survival.

CONCLUSION

We showed the existence of an inflamed ICC subtype, which is potentially treatable with checkpoint blockade immunotherapy.

Should we use liver grafts repeatedly refused by other transplant teams?

Background & Aims

In France, liver grafts that have been refused at least 5 times can be “rescued” and allocated to a centre which chooses a recipient from its own waiting list, outside the patient-based allocation framework. We explored whether these “rescued” grafts were associated with worse graft/patient survival, as well as assessing their effect on survival benefit.

Methods

Among 7,895 candidates, 5,218 were transplanted between 2009 and 2014 (336 centre-allocated). We compared recipient/graft survival between patient allocation and centre allocation, considering a selection bias and the distribution of centre-allocation recipients among the transplant teams. We used a propensity score approach and a weighted Cox model using the inverse probability of treatment weighting method. We also explored the survival benefit associated with centre-allocation grafts.

Results

There was a significantly higher risk of graft loss/death in the centre allocation group compared to the patient allocation group (hazard ratio 1.13; 95% CI 1.05–1.22). However, this difference was no longer significant for teams that performed more than 7% of the centre-allocation transplantations. Moreover, receiving a centre-allocation graft, compared to remaining on the waiting list and possibly later receiving a patient-allocation graft, did not convey a poorer survival benefit (hazard ratio 0.80; 95% CI 0.60–1.08).

Conclusions

In centres which transplanted most of the centre-allocation grafts, using grafts repeatedly refused for top-listed candidates was not detrimental. Given the organ shortage, our findings should encourage policy makers to restrict centre-allocation grafts to targeted centres.

Lay summary

“Centre allocation” (CA) made it possible to save 6 out of 100 available liver grafts that had been refused at least 5 times for use in the top-listed candidates on the national waiting list. In this series, the largest on this topic, we showed that, in centres which transplanted most of the CA grafts, using grafts repeatedly refused for top-listed candidates did not appear to be detrimental. In the context of organ shortage, our results, which could be of interest for any country using this CA strategy, should encourage policy makers to reassess some aspects of graft allocation by restricting CA grafts to targeted centres, fostering the “best” matching between grafts and candidates on the waiting list.

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Centre allocation (CA) made it possible to save 6 out of 100 liver grafts.

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13% higher graft loss/death for CA patients.

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In transplant centres performing most CA transplants, survival was not impacted.

Laparoscopic Liver Resection for Hepatocellular Carcinoma in Child-Pugh A Patients With and Without Portal Hypertension: A Multicentre Study

BACKGROUND

Laparoscopic liver resection (LLR) may improve outcomes for cirrhotic patients with hepatocellular carcinoma (HCC) and portal hypertension (PHT). The aim of this study was to compare the short-term outcomes after LLR for HCC in cirrhotic patients with and without PHT.

METHODS

This multicentric study included 96 HCC patients who underwent LLR. Clinically significant portal hypertension (CSPH) was defined by a hepatic venous pressure gradient ≥10 mmHg. Short-term outcomes and liver-specific complications including post-hepatectomy liver failure (PHLF), ascites and encephalopathy were compared between patients with and without CSPH.

RESULTS

Thirty-one patients (32%) had CSPH. The CSPH group had higher post-operative morbidity (52% vs. 15%; p < 0.001), PHLF (10% vs. 0%; p = 0.03) and encephalopathy (10% vs. 0%; p = 0.03). There was no difference in terms of post-operative ascites between the two groups (CSPH: 16% vs. no CPSH: 8%, p = 0.28). The length of stay was longer in patients with CSPH than in those without CSPH (6 vs. 4 days; p < 0.001).

CONCLUSIONS

The laparoscopic approach is feasible in selected HCC patients with CSPH, at the price of significant increases in liver-specific complications and length of stay.

Radio-Pathological Correlations in Patients with Liver Metastases for Colorectal Cancer

BACKGROUND

Colorectal cancer (CRC) is the most frequent gastrointestinal cancer. The liver is the organ most commonly affected by CRC metastases. Synchronous CRC liver metastases (CRCLM) are present in 15-25% at diagnosis, and metastases are confined to the liver in 70-80% of these cases. The aim of the present study was to investigate the existence of significant correlations between the pathological features and computed tomography scan morpho-densitometric findings.

SUMMARY

A retrospective study of prospectively collected data has been performed; all patients underwent curative-intent hepatic resection from January 2004 to December 2012 and had histologically confirmed CRCLM. Key Messages: Thirty-four (57%) patients were males; the mean age was 64.4 (±10.2) years. Statistically significant differences have been found with the percentages of intra-tumoral fibrosis (p = 0.038) and necrosis (p = 0.007); the values of fibrosis are higher in the absence of a peri-lesional ring, while those of necrosis are higher in the presence of a peri-lesional ring.There was a correlation between the histopathological response to treatments and the global attenuation levels observed in the computed tomography scan of CRCLM. Furthermore, the presence of a radiologically evidenced peripheral ring was associated with the amount of viable tumor cells in the periphery of the tumor, and with responses predominated by necrosis. More studies are needed to clarify the radiological and histological correlation and to be able to better select patients who are going to undergo surgery.