Effect of autotransfusion system on tumor recurrence and survival in hepatocellular carcinoma patients

AIM:To investigate the therapeutic efficacy and safety of continuous autotransfusion system(CATS) during liver transplantation of hepatocellular carcinoma patients.METHODS:Eighty-three hepatocellular carcinoma(HCC) patients who underwent liver transplantation with intraoperative CATS(n = 24,CATS group) and without(n = 59,non-CATS group) between April 2006 and November 2011 at the Liver Transplant Institute of Inonu University were analyzed retrospectively.Postoperative HCC recurrence was monitored by measuring alpha-fetoprotein(AFP) levels at 3-mo intervals and performing imaging analysis by thoracoabdominal multidetector computed tomography at 6-month intervals.Inter-group differences in recurrence and correlations between demographic,clinical,and pathological data were assessed by ANOVA and χ 2 tests.Overall and disease-free survivals were calculated by the univariate Kaplan-Meier method.RESULTS:Of the 83 liver transplanted HCC patients,89.2% were male and the overall mean age was 51.3 ± 8.9 years(range:18-69 years).The CATS and nonCATS groups showed no statistically significant differences in age,sex ratio,body mass index,underlying disease,donor type,graft-to-recipient weight ratio,Child-Pugh and Model for End-Stage Liver Disease scores,number of tumors,tumor size,AFP level,Milan and University of California San Francisco selection criteria,tumor differentiation,macrovascular invasion,median hospital stay,recurrence rate,recurrence site,or mortality rate.The mean follow-up time of the nonCATS group was 17.9 ± 12.8 mo,during which systemic metastasis and/or locoregional recurrence developed in 25.4% of the patients.The mean follow-up time for the CATS group was 25.8 ± 15.1 mo,during which systemic metastasis and/or locoregional recurrence was detected in 29.2% of the patients.There was no significant difference between the CATS and non-CATS groups in recurrence rate or site.Additionally,no significant differences existed between the groups in overall or disease-free survival.CONCLUSION:CATS is a safe procedure and may decrease the risk of tumor recurrence in HCC patients.

Liver transplantation for hepatocellular carcinoma:Historical evolution of transplantation criteria

Liver transplantation(LT) for hepatocellular carcinoma is still a hot topic,and the main factor that is associated with the success of treatment is to determine the patients who will benefit from LT.Milan criteria have been defined 25 years ago and still is being used for patient selection for LT.However,in living donor LT,the Milan criteria is being extended.Current criteria for patient selection do not only consider morphologic characteristics such as tumor size and number of tumor nodules but also biologic markers that show tumor aggressiveness is also being considered.In the present review article,we have summarized all the criteria and scoring systems regarding LT for hepatocellular carcinoma.All criteria have 5-year overall survival rates that were comparable to the Milan Criteria and ranged between 60%-85%.On the other hand,it was seen that the recurrence rates had increased as the Milan criteria were exceeded;the 5-year recurrence rates ranged between 4.9% to 39.9%.Treatment of hepatocellular carcinoma needs a multidisciplinary approach.Ideal selection criteria are yet to be discovered.The same is true for treatment modalities.The goal will be achieved by a harmonic interplay between basic science researchers and clinicians.

Liver transplant for large hepatocellular carcinoma in Malatya: Therole of gamma glutamyl transferase and alpha-fetoprotein, aretrospective cohort study

BACKGROUND There is increasing interest in transplanting patients with hepatocellularcarcinoma (HCC) with tumors greater than 5 cm (Milan criteria).AIM To investigate possible prognostically-useful factors for liver transplantation inHCC patients with large tumors.METHODS In this clinical study, 50 patients with HCC who were transplanted at our LiverTransplant Center between April 2006 and August 2019 and had tumors greaterthan 6 cm maximum diameter were retrospectively analyzed. Their survival andfull clinical characteristics were examined, with respect to serum alphafetoprotein(AFP) and gamma glutamyl transpeptidase (GGT) levels. Kaplan-Meier survival estimates were used to determine overall survival and disease-freesurvival in these patients. The inclusion criterion was evidence of HCC. Exclusioncriteria were the presence of macroscopic portal vein thrombosis or metastasisand a follow-up period of less than 90 d.RESULTS Using receiver operating characteristic curve (ROC) analysis, cutoff values of AFP200 ng/mL and GGT 104 IU/L were identified and used in this study.Significantly longer overall survival (OS) and disease-free-survival (DFS) were found in patients who had lower values of either parameter, compared withhigher values. Even greater differences in survival were found when the 2parameters were combined. Two tumor size bands were identified, in searchingfor the limits of this approach with larger tumors, namely 6-10 cm and > 10 cm.Combination parameters in the 6-10 cm band reflected 5-year OS of 76.2% inpatients with low AFP plus low GGT vs 0% for all other groups. Patients withtumors greater than 10 cm, did not have low AFP plus low GGT. The mostconsistent clinical correlates for longer survival were degree of tumordifferentiation and absence of microscopic portal venous invasion.CONCLUSION Serum levels of AFP and GGT, both alone and combined, represent a simpleprognostic identifier in patients with large HCCs undergoing liver transplantation.

Impact of COVID-19 pandemic on clinicopathological features of transplant recipients with hepatocellular carcinoma:A case-control study

BACKGROUND The coronavirus disease 2019(COVID-19)pandemic had a significant impact on the management of all diseases.Various diseases such as cancer have a higher risk of COVID-19-related death.Despite this fact,any delay or alteration in treatment of cancer may have fatal consequences.Hepatocellular carcinoma(HCC)is an aggressive liver cancer that requires multimodality treatment to improve survival.AIM To evaluate the impact of COVID-19 on the management of patients with HCC by determining changes in demographic,clinical and histopathological variables.METHODS Demographic,clinical and pathological variables of patients with HCC who had undergone liver transplantation between March 2020 and June 2021(Pandemic group,n=48)were retrospectively compared with that of the patients with HCC transplanted between November 2018 and March 2020(Pre-pandemic group,n=61).RESULTS The median age of the patients in the study was 56(interquartile range=15).Ninety-seven patients(89%)were male and 12 were female(11%).The most common etiology of liver disease was hepatitis B virus(n=52,47.7%).According to our results,there was a 21.3% drop in the number of patients transplanted for HCC.There was no difference in the demographic,clinical and pathological characteristics of the patients except blood alkaline phosphatase levels(P=0.029),lymphovascular invasion(P=0.019)and type of the liver graft that was transplanted(P=0.017).CONCLUSION It is important to develop a surveillance strategy for liver transplant centers.The liver transplantation for HCC is justified and safe provided that strict surveillance protocols are applied.

Discordance among aggressiveness characteristics of hepatocellular carcinoma:Portal vein thrombosis and multifocality,related to tumor size,but not to serum alpha-fetoprotein level

Background and aims:Hepatocellular carcinoma(HCC)is characterized by several clinically important prognostic parameters,including portal vein thrombosis(PVT),tumor multifocality,and serum alphafetoprotein(AFP)levels,in addition to maximum tumor diameter(MTD).However,associations among these parameters have not been thoroughly examined.Thus,the study aimed to investigate the correlations among these HCC characteristics in a prospectively collected database.Methods:An 8080 HCC patient database derived from our weekly HCC council meeting was examined with respect to the correlations at baseline patient presentation between increases in MTD and changes in the percentage of patients with PVT,multifocality,or AFP levels.Results:The percentage of patients with PVT and with multifocality(tumor nodule numbers≥3)significantly increased with enlarging MTD,regardless of the serum AFP level,showing the independence of PVT and multifocality on AFP.The percentage of patients with multifocality increased with enlarging MTD,in the presence or absence of PVT,showing the independence of multifocality from PVT.Therefore,discordance was found between different tumor parameters.Conclusions:A statistically significant association was found between PVT and MTD and between multifocality and MTD,all three of which are independent of AFP.PVT and multifocality appeared to be independent of each other.Although PVT and multifocality were independent of AFP,they were also augmented with high serum AFP levels.The results suggest the possibility of multiple pathways of tumor progression in the later stages of HCC development.

Comparison of patients with hepatitis B virus-associated hepatocellular carcinoma:Data from two hospitals from Turkey and China

Aims:There are many studies on the incidence of hepatitis B virus(HBV)-associated hepatocellular carcinoma(HCC),but very little is known about the HCC features in different populations.The study aimed to compare characteristics in two cohorts of patients with HBV-associated hepatocellular carcinoma from Turkey and China.Methods:Data on patients with HBV-associated HCC diagnosed by imaging or liver biopsy were retrospectively collected from Shandong Provincial Hospital(n=578)and Inonu University Hospital(n=359)between January 2002 and December 2020,and the liver function and HCC characteristics were compared.Continuous variables were compared using Student's t-test or Mann-Whitney U test and categorical variables were compared using the χ^(2) test or Fisher's exact test.Results:The patients in the Turkish cohort had significantly worse Child-Pugh scores(Child-Pugh A:38.3%vs.87.9%;Child-Pugh B:40.3%vs.11.1%;Child-Pugh C:21.4%vs.1.0%;p<0.001)and significantly higher levels of aspartate aminotransferase(66.5[38.0−126.0]vs.36.0[27.0-50.0]IU/L;p<0.001),alanine aminotransferase(47.5[30.0−87.3]vs.33.0[24.0−45.0]IU/L;p<0.001),total bilirubin(20.8[13.7−39.3]vs.17.9[13.8−24.0]mg/dL;p<0.001),and lower albumin levels(32.0[26.0-39.0]vs.40.0[36.1-43.8]g/L;p<0.001)than patients in Chinese cohort.The tumor characteristics showed the Barcelona Clinic Liver Cancer(BCLC)score(BCLC 1:5.1%vs.71.8%;BCLC 2:48.7%vs.24.4%;BCLC 3:24.4%vs.3.8%;BCLC 4:21.8%vs.0;all p<0.001),maximum tumor diameter(5.0[3.0-9.0]vs.3.5[2.5−6.0]cm;p<0.001),alpha-fetoprotein values(27.7 vs.13.2 ng/mL;p<0.001),and percentage of patients with portal vein tumor thrombus(33%vs.6.1%;p<0.001)were all significantly worse in the Turkish cohort compared with Chinese cohort.Conclusions:HBV-associated HCC from the Turkish cohort had worse liver function and more aggressive clinical characteristics than patients from the Chinese cohort.