Liver Transplant vs Liver Resection in patients with Multifocal hepatocellular Carcinoma

BACKGROUND

The optimal surgical option in patients with Multifocal hepatocellular Carcinoma (MHCC) is an area of active research. The preference varies based on geographic variations and institutional policies. We sought to determine long-term outcomes in patients with MHCC based on surgical treatment - Liver transplant (LT) vs resection (LR).

METHODS

We performed a retrospective analysis of NCDB (2004-2015) and identified patients with MHCC within Milan criteria. Patients with αfetoprotein ≥1000 nanograms/milliliter and those who underwent ablation were excluded. The primary outcome measure was long-term survival in patients undergoing LT vs. LR. The secondary aim of our study was to determine clinicodemographic factors associated with the receipt of LT and LR.

RESULTS

1,546 patients were included, of whom 1,211 received LT and 335 underwent LR. Patients who were non-Hispanic White (70.8% vs.54.9% p <0.01), privately insured (53.7% vs. 36.7%, p <0.01), and treated at academic centers (85.4% vs. 71.6%, p<0.01) were more likely to receive an LT. Multivariable Cox analysis revealed LT was associated with improved survival compared to LR ( HR= 0.34, 95% CI= 0.28-0.42).

CONCLUSION

We described clinical and sociodemographic differences in LT and LR patients and found LT to be associated with a decreased mortality risk compared to LR. The study's findings should be interpreted in the context of several limitations, including the selection of MHCC criteria within Milan criteria.

The Usefulness of Fine Needle Aspiration Cytology in the Management of Parotid Gland Masses at a Tertiary Academic Hospital

Background

Fine needle aspiration cytology (FNAC) is an integral part of the preoperative work-up of parotid tumours.

Aim

To determine the rate of concordance between FNAC and histology following parotidectomy.

Methods

A review of records of patients who had parotidectomy which was preceded FNAC was done. Data collected included patients' demography, presenting symptoms and clinical signs; cytology and post-operative histology results.

Results

Seventy-seven records were found and 14 were excluded. Forty-five (71%: 45/63) of the tumours were benign, 21% (13/63) malignant and 8% (5/63) inflammatory lesions. Forty-one (91.1%: 41/45) of the benign tumours had concordance between FNAC and final histology. Seven (63.6%: 7/11) of FNAC diagnosed malignancies were confirmed on histology.

Conclusion

Around 71% of parotid masses were benign. Painful masses are more likely to be malignant and FNAC is more reliable for the diagnosis of pleomorphic adenoma than rare benign and malignant tumours of the parotid gland.

National Experience on Waitlist Outcomes for Down-Staging of Hepatocellular Carcinoma: High Dropout Rate in All-Comers

BACKGROUND & AIMS

The United Network for Organ Sharing (UNOS) grants priority listing for liver transplant for patients with hepatocellular carcinoma after successful down-staging to Milan criteria. We evaluated the national experience on down-staging by comparing 2 down-staging groups: tumor burden meeting UNOS down-staging (UNOS-DS) inclusion criteria, and all-comers (AC)-DS with initial tumor burden beyond UNOS-DS criteria vs patients always within Milan criteria.

METHODS

We performed a retrospective analysis of the UNOS database of 23,398 patients listed for liver transplant who had submitted a hepatocellular carcinoma Model for End-Stage Liver Disease exception application from 2010 to 2019, classified as always within Milan (n = 20,579), UNOS-DS (n = 2151), and AC-DS (n = 668).

RESULTS

The 2-year cumulative probabilities of dropout were 19% for Milan, 25% for UNOS-DS (P < .001), and 30% for AC-DS (P < .001). In multivariate analysis of the down-staging groups, factors predicting dropout included Model for End-Stage Liver Disease at listing (hazard ratio [HR], 1.06; P < .001) and initial total tumor diameter (HR, 1.04; P = .002). Compared with α-fetoprotein (AFP) level ≤20 ng/mL, AFP levels of 21 to 100, 101 to 1000, and greater than 1000 ng/mL were associated with a higher risk of dropout (HRs, 1.63, 2.06, and 4.58, respectively; P < .001). A subset of all-comers with AFP levels greater than 100 ng/mL had a 2-year probability of dropout of 52% vs 26% for all others beyond Milan criteria (P < .001).

CONCLUSIONS

All-comers had a significantly higher risk for waitlist dropout compared with the UNOS-DS and Milan groups after initial successful down-staging to Milan criteria. In particular, the subgroup of AC-DS with an AFP level greater than 100 ng/mL had a greater than 50% probability of dropout in the next 2 years. These observations suggest a high likelihood of failure when expanding the indications for down-staging.

Stick to Milan: Infeasibility of the Brazil-Milan Criteria in recommending patients with hepatocellular carcinoma for liver transplantation

This article discusses the infeasibility of adhering to the Brazil-Milan Criteria for determining whether patients with hepatocellular carcinoma (HCC) should be offered liver transplantation. The Criteria are currently used widely in Brazil. However, since they expand the net of the transplant-eligible population, and that transplantation is shown to improve clinical outcomes in HCC patients relative to other treatments, they are inherently attractive and may be adopted by other countries in determining whether HCC patients should receive liver transplantation. I argue that the Criteria unjustifiably disregard the number of tumour nodules found in the patient. This number may be indicative of the recurrence potential of the disease, since these nodules can originate from different clonal populations. The greater the number, the higher the risk these nodules are associated with clones which contain genetic mutations conferring even greater potential for proliferation and dissemination. Clusters of tumour cells may be micro-disseminated to vascular structures surrounding the liver, as well as extrahepatic systems. This increases recurrence potential and reduces the benefit of liver transplantation in these patients. Thus, HCC patients harbouring fewer but larger tumour nodules may present with a more favourable genomic and epigenomic profile than those with more, albeit smaller, tumour nodules. Patients with more tumour nodules may reap greater clinical benefit if initiated on systemic therapy early, rather than wait for a suitable donor liver. Although the Criteria are reached by consensus, with reference to findings from recent studies, as well as scientific theory, it is ripe for review.

Impact of Brazilian expanded criteria for liver transplantation in patients with hepatocellular carcinoma: a multicenter study

INTRODUCTION AND OBJECTIVES

Hepatocellular carcinoma (HCC) is one of the main indications for orthotopic liver transplantation (OLT). In Brazil, selection criteria for HCC is an expanded version of the Milan Criteria (MC), the so-called "Brazilian Milan Criteria" (BMC). Our aims were to evaluate post-OLT outcomes in patients with HCC and analyze the BMC performance.

MATERIALS AND METHODS

We conducted a multicenter, retrospective cohort study, analyzing medical records of 1,059 liver transplant recipients with HCC. Tumor was staged according to MC and BMC and correlated with overall survival (OS) and disease-free survival (DFS). We compared the ability of MC and BMC to predict OS and DFS using Delta C-statistic.

RESULTS

Post-OLT OS were 63% in five years and HCC recurrence was observed in 8% of patients. At diagnosis, 85% of patients were within MC. Patients within MC at diagnosis and in the explant showed a higher OS and DFS than patients outside MC and within BMC and patients outside both criteria (p < 0.001). Patients outside MC in the explant had an increased risk of tumor recurrence (HR: 3.78; p < 0.001) and poor survival (HR:1.77; p = 0.003). The BMC presented a lower performance than MC in properly classifying patients regarding recurrence risk.

CONCLUSIONS

In a large Brazilian cohort of HCC patients submitted to liver transplantation, we observed satisfactory overall survival and recurrence rates. However, patients transplanted within the Brazilian expanded criteria had lower OS and DFS when compared to patients within MC, which may generate future discussions regarding the criteria currently used.

Liver transplantation for hepatocellular carcinoma: Where do we stand?

Hepatocellular carcinoma represents an important cause of morbidity and mortality worldwide. It is the sixth most common cancer and the fourth leading cause of cancer death. Liver transplantation is a key tool for the treatment of this disease in human therefore hepatocellular carcinoma is increasing as primary indication for grafting. Although liver transplantation represents an outstanding therapy for hepatocellular carcinoma, due to organ shortage, the careful selection and management of patients who may have a major survival benefit after grafting remains a fundamental question. In fact, only some stages of the disease seem amenable of this therapeutic option, stimulating the debate on the appropriate criteria to select candidates. In this review we focused on current criteria to select patients with hepatocellular carcinoma for liver transplantation as well as on the strategies (bridging) to avoid disease progression and exclusion from grafting during the stay on wait list. The treatments used to bring patients within acceptable criteria (down-staging), when their tumor burden exceeds the standard criteria for transplant, are also reported. Finally, we examined tumor reappearance following liver transplantation. This occurrence is estimated to be approximately 8%-20% in different studies. The possible approaches to prevent this outcome after transplant are reported with the corresponding results.

Utility of Tumor Burden Score to Stratify Prognosis of Patients with Hepatocellular Cancer: Results of 4759 Cases from ITA.LI.CA Study Group

BACKGROUND

Dichotomous models like Milan Criteria represent the routinely used tools for predicting the outcome of patients with hepatocellular carcinoma (HCC). However, a paradigm shift from a dichotomous to continuous prognostic stratification should represent a good strategy for improving the prediction process. Recently, the tumor burden score (TBS) has been proposed for selecting patients with colorectal liver metastases. To date, TBS has not been validated in a large HCC population. The main objective of this study was to evaluate the prognostic power of TBS in an HCC population treated with different curative and palliative modalities.

METHODS

Prospectively collected data from consecutive HCC patients managed in 24 institutions participating in the ITA.LI.CA group between Jan 2002 and Mar 2015 were analyzed (n = 4759). A sub-analysis focused on 3909 patients with the radiological evidence of vascular invasion or metastatic disease was also performed.

RESULTS

TBS demonstrated the best discriminative ability when compared to MC and other tumor-specific scores. At multivariable Cox regression analysis, TBS was an independent risk factor of overall survival, with a 6% increased risk for patient death for each point increase in TBS. At survival analysis, when TBS ≥ 8 was connected with MELD ≥ 15 and alpha-fetoprotein ≥ 1000 ng/mL, patients presenting all these three risk factors presented the worst results (p value < 0.0001).

CONCLUSIONS

Survival prediction of HCC patients was very well done using TBS model, even stratifying the population in relation to the presence of metastases and/or vascular invasion. TBS model was the best in terms of discriminatory ability and goodness of fit when compared with other continuous or binary variables. Its incorporation in a model composed by tumor- and liver function-related variables further increases its survival prediction.

Impact of remnant vital tissue after locoregional treatment and liver transplant in hepatocellular cancer patients, a multicentre cohort study

The role of pathological findings after locoregional treatments as predictors of hepatocellular cancer recurrence after liver transplantation has been poorly addressed. The aim of the study was to identify the role of remnant vital tissue (RVT) of the target lesion in predicting hepatocellular cancer recurrence. Two hundred and seventy-six patients firstly undergoing locoregional treatment and then transplanted between January 2010 and December 2015 in four European Transplant Centres (i.e. Rome Tor Vergata, Birmingham, Brussels and Ancona) were enrolled in the study to investigate the role of pathological response at upfront locoregional treatment. At multivariable Cox regression analysis, RVT ≥2 cm was a strong independent risk factor for post-LT recurrence (HR = 5.6; P < 0.0001). Five-year disease-free survival rates were 60.8%, 80.9% and 95.0% in patients presenting a RVT ≥2 cm vs. 0.1-1.9 vs. no RVT, respectively. When only Milan Criteria-IN patients were analysed, similar results were reported, with 5-year disease-free survival rates of 58.1%, 79.0% and 94.0% in patients presenting a RVT ≥2 cm vs. 0.1-1.9 vs. no RVT, respectively. RVT is an important determinant of tumour recurrence after liver transplantation performed for hepatocellular cancer. Its discriminative power looks to be evident also in a Milan-IN setting, suggesting to more liberally use locoregional treatments also in these patients.

Preoperative Albumin-Bilirubin Score for Postoperative Solitary Hepatocellular Carcinoma within the Milan Criteria and Child-Pugh A Cirrhosis

Surgical resection remains the initial treatment of choice for the majority of early stage hepatocellular carcinoma (HCC) patients. Although the factors that influence the prognosis of postoperative HCC patients have been well elucidated, there are a limited number of simple, objective, and distinct methods for estimating survival for postoperative patients with solitary HCC within the Milan criteria and Child-Pugh (C-P) A cirrhosis. The Albumin-Bilirubin (ALBI) score is a new evidence-based approach to assess liver function. The ALBI score eliminates subjective variables, such as ascites and encephalopathy which are the requirements for the conventional C-P grading system. This study enrolled 654 patients to determine whether the ALBI score can predict the outcomes of postoperative solitary HCC patients within the Milan criteria and C-P A cirrhosis. Our results showed the ALBI score significantly influenced the overall survival and cumulative recurrence rates. Furthermore, the ALBI score was significantly related to the degree of liver cirrhosis and serum γ-glutamyl transpeptidase (GGT) concentration in solitary HCC cases within the Milan criteria and C-P A cirrhosis. Additionally, the combination of the ALBI score and serum GGT concentration contributed to the prognosis prediction in this cohort. In conclusion, we externally validated the ALBI grade as a novel biomarker to predict prognosis for solitary HCC within the Milan Criteria and C-P A cirrhosis.

When to consider liver transplantation in hepatocellular carcinoma patients?

Orthotopic liver transplantation (LT) has been regarded as the best cure among the three curative treatment modalities. However, when to consider LT in hepatocellular carcinoma (HCC) patients remains a complicated clinical question. In this article, we will look into the recent updates in the context of LT for HCC, including the timing of orthotopic LT (primary or salvage LT), patient selection criteria, newer prognostic markers and scoring systems, down-staging and bridging therapy, salvage LT and treatment option of post-LT HCC recurrence. Evolution of immunosuppressive therapy and future development of the LT for HCC will also be discussed.

Hepatocellular carcinoma: A comprehensive review

Hepatocellular carcinoma (HCC) is rapidly becoming one of the most prevalent cancers worldwide. With a rising rate, it is a prominent source of mortality. Patients with advanced fibrosis, predominantly cirrhosis and hepatitis B are predisposed to developing HCC. Individuals with chronic hepatitis B and C infections are most commonly afflicted. Different therapeutic options, including liver resection, transplantation, systemic and local therapy, must be tailored to each patient. Liver transplantation offers leading results to achieve a cure. The Milan criteria is acknowledged as the model to classify the individuals that meet requirements to undergo transplantation. Mean survival remains suboptimal because of long waiting times and limited donor organ resources. Recent debates involve expansion of these criteria to create options for patients with HCC to increase overall survival.

Transplant versus resection for the management of hepatocellular carcinoma meeting Milan Criteria in the MELD exception era at a single institution in a UNOS region with short wait times

BACKGROUND

Management of hepatocellular carcinoma (HCC) in the Model for End-Stage Liver Disease (MELD) exception era remains regionally variable. Outcomes were compared for patients undergoing transplant versus resection at a single institution in a UNOS region with short wait times for organ availability.

METHODS

All patients who underwent resection of HCC from January 2000 to August 2012 and patients who underwent transplant post-January 2006, during the Milan Criteria (MC)-based MELD exception policy for HCC, were identified. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS).

RESULTS

Two hundred fifty-seven patients were analyzed, of whom 131 underwent transplant and 126 underwent resection. All transplant patients met MC; 45 (36%) resection patients met MC. Median follow-up time was 30 months. Median wait time to transplant was 55 days; no patients dropped off the waitlist while awaiting an organ. Among patients meeting MC, transplant demonstrated significantly greater 5-year OS (65.7% vs. 43.8%; P = 0.005) and RFS (85.3% vs. 22.7%; P < 0.001) versus resection. For patients with hepatitis C, transplant (n = 87) demonstrated significantly improved 5-year outcomes compared to patients meeting MC who underwent resection (n = 21; OS: 63.5% vs. 23.3%; P = 0.001; RFS: 83.5% vs. 23.7%; P < 0.001).

CONCLUSION

In a region with short waitlist times for organ availability, liver transplant is associated with improved survival compared to resection for HCC within MC and should be considered for all patients meeting MC, particularly those with hepatitis C.

Poorer survival in patients whose explanted hepatocellular carcinoma (HCC) exceeds Milan or UCSF Criteria. An analysis of liver transplantation in HCC in Australia and New Zealand

BACKGROUND

Milan and University of California San Francisco (UCSF) Criteria have been used for selection of patients with hepatocellular carcinoma (HCC) for liver transplantation (LTx). The aims of this study were to analyse the results of LTx for HCC in Australia and New Zealand with emphasis on the effects of discordance between pre-LTx radiological and post-LTx pathological staging.

METHODS

A total of 186 LTx for HCC carried out between July 1985 and August 2003 were included. Patients were categorized according to the Milan and UCSF Criteria.

RESULTS

The median follow-up was 6.55 years (range 2.96-20.93 years). Pre-LTx factors associated with better survival include tumour size < or = 5 cm, number of tumours < or = 3, staging within Milan and UCSF Criteria and more recent transplantation (1996-2003). In all, 14 patients had a pre-LTx stage outside the Milan but within the UCSF Criteria. One- and 5-year patient survival rates were, respectively, 88% and 74% within the Milan Criteria, and 87% and 73% within the UCSF Criteria. Vascular invasion, capsular invasion, lymph node invasion and pathological stage outside UCSF Criteria were associated with poor outcome. Of patients within the Milan and UCSF Criteria pre-LTx, 24% and 18%, respectively, were outside the same criteria post-LTx. These patients had poorer survival rates.

CONCLUSIONS

The use of the UCSF Criteria in this cohort increased the number of patients eligible for LTx without compromising 5-year survival rates. Patients whose explant tumours were outside the Milan or UCSF Criteria had poorer outcomes compared with those whose explants remained within these criteria.