Liver transplantation for hepatocellular carcinoma: the Hangzhou experience

Over the last 25 years orthotopic liver transplantation (OLT) has been proven a durabletherapy for all forms of end stage liver

A national report from China Liver Transplant Registry: steroid avoidance after liver transplantation for hepatocellular carcinoma

Objective：We aimed to evaluate the efficacy and safety of steroid-free immunosuppression after liver transplantation（LT）for hepatocellular carcinoma（HCC）.Methods：We retrospectively analyzed HCC recipients without steroids after LT（SF group,n=368）based on the China Liver Transplant Registry（CLTR）database.These recipients were matched 1：2 with patients using steroids（S group,n=736）for the same period after LT for HCC,according to propensity scores.Results：Multivariate analysis indicates that recipients with younger age[odds ratio（OR）,1.053;P=0.011],preoperative hepatitis B virus（HBV）DNA≥1,000 copies/mL（OR,2.597;P=0.004）and beyond Milan criteria（OR,4.255;P〈0.001）were identified as the risk factors associated with tumor recurrence in steroid avoidance recipients after LT.The patients fulfilling the Milan criteria in the SF group presented higher overall and tumor-free survival rates than those in the S group（P〈0.05）.Multivariate analysis revealed that recipient beyond Milan criteria was an independent prognostic factor for overall survival（OR,1.690;P〈0.001）and tumor-free survival（OR,2.066;P〈0.001）.The incidences of new-onset diabetes mellitus（21.20% vs.33.29%,P〈0.001）,new-onset hypertension（10.05%vs.18.61%,P〈0.001）and hyperlipidemia（4.08% vs.7.20%,P=0.042）were significantly lower in the SF group.Conclusions：Steroid-free immunosuppression could be safe and feasible for HBV-related HCC patients in LT.Age,HBV DNA level and Milan criteria maybe risk factors associated with tumor recurrence in steroid avoidance recipients.Recipient beyond Milan criteria was an independent prognostic factor and recipient fulfilling Milan criteria can benefit the most from steroid-free immunosuppression.

Prognostic value of glypican-3 in patients with HBV-associated hepatocellular carcinoma after liver transplantation

BACKGROUND：Glypican-3（GPC-3）is frequently overexpressed in hepatocellular carcinoma（HCC）.Recent studies have shown that GPC-3 is a highly efficient diagnostic biomarker of HCC and an indicator of poor prognosis in HCC patients who have undergone hepatectomy.However,its prognostic value in patients with HBV-associated HCC after liver transplantation（LT）is not clear.The present study is to evaluate the prognostic value of GPC-3 in patients with HBV-associated HCC after LT.METHODS： A cohort of 104 HCC patients with HBV-associ- ated cirrhosis who had undergone LT at our hospital between 2002 and 2011 were enrolled in this study. Samples of HCC were taken from these patients. GPC-3 protein expression was detected in paraffin-embedded specimens using immunohis- tochemistry. All related clinical data were obtained from the China Liver Transplant Registry. The relationship between GPC-3 expression and clinicopathological parameters was analyzed. Univariate and multivariate Cox-regression analyses were used to identify risk factors for poor prognosis. RESULTS： GPC-3 was expressed in samples from 74 （71.2%） of the 104 patients. GPC-3 was expressed only in HCC cells. Positive staining was correlated with tumor size （P=0.004）, encapsulation （P=0.018）, pathological stage （P--0.027）, portal vein invasion （P=0.043）, tumor differentiation （P=0.002） and the Milan criteria （P=0.016）. The 5-year survival rate and dis- ease-free survival rate of patients with GPC-3-positive were lower than those （38.2% vs 75.4%, P〈0.001; 30.8% vs 69.7%, P=0.001） of patients with GPC-3-negative. Multivariate Coxregression analysis revealed that GPC-3 was an independent risk factor for 5-year survival rate （P=0.031） and disease-free survival rate （P=0.047）, together with tumor differentiation, Milan criteria and pre-operative alpha-fetoprotein.CONCLUSION： GPC-3 is a potential biomarker for poor prognosis after LT in HCC patients with HBV-associated cirrhosis.

Liver transplantation for hepatocellular carcinoma on cirrhosis:Strategies to avoid tumor recurrence

Hepatocellular carcinoma(HCC) is one of the most frequent neoplasms worldwide and in most cases it is associated with chronic liver disease.Liver transplantation(LT) is potentially the optimal treatment for those patients with HCC who have a poor functional hepatic reserve due to their underlying chronic liver disease.However,due to the limited availability of donors,only those patients whose oncologic profile is favorable can be considered for LT.Despite the careful selection of candidates based on strict rules,10 to 20%of liver transplant recipients who have HCC in the native cirrhotic liver develop tumor recurrence after transplantation.The selection criteria presently employed to minimize the risk of recurrence are based on gross tumor characteristics defined by imaging techniques;unfortunately,the accuracy of imaging is far from being optimal.Furthermore,microscopic tumor features that are strictly linked with prognosis can not be assessed prior to transplantation.Pre-transplantation tumor downstaging may allow transplantation in patients initially outside the selection criteria and seems to improve the prognosis;it also provides information on tumor biology.Themain peculiarity of the transplantation setting,when this is compared with other modalities of treatment,is the need for pharmacological immunosuppression:this is based on drugs that have been demonstrated to increase the risk of tumor development.As HCC is an aggressive malignancy,immunosuppression has to be handled carefully in patients who have HCC at the time of transplantation and new categories of immunosuppressive agents should be considered.Adjuvant chemotherapy following transplantation has failed to show any significant advantage.The aim of the present study is to review the possible strategies to avoid recurrence of HCC after liver transplantation based on the current clinical evidence and the more recent developments and to discuss possible future directions.

Current strategies for preventing the recurrence of hepatocellular carcinoma after liver transplantation

BACKGROUND：Liver transplantation is the optimal treatment for a selected group of patients with moderate to severe cirrhosis and hepatocellular carcinoma（HCC）.Despite the strict selection of candidates,post-transplant recurrence often occurs and markedly reduces the long-term survival of patients with HCC.The present review focuses on the current strategies on preventing the recurrence of HCC after liver transplantation.DATA SOURCES： Relevant articles were identified by exten- sive searching of PubMed using the keywords ＂hepatocellular carcinoma＂, ＂recurrence＂ and ＂liver transplantation＂ between January 1996 and January 2014. Additional papers were searched manually from the references in key articles. RESULTS： The current theories of HCC recurrence after liver transplantation are： （i） the growth of pre-transplant occult metastases; （ii） the engraftment of circulating tumor cells released at the time of transplantation. Pre-transplant treatment aims to control local tumor by radiofrequency ablation, transarterial embolization and transarterial chemoembolization. The main objective during the operation is to prevent tumor cell dissemination. Post-transplant treatment includes systemic anticancer therapy, antiviral therapy, and most recently, immunotherapy. These strategies concentrate on the control of the tumor when the patients are waiting for transplant, to reduce the release of HCC cells during surgical procedures and to dear the occult HCC cells after transplantation.CONCLUSIONS： Much can be done to prevent HCC recurrence after liver transplantation. In future, effort is likely to be di- rected towards combining multidisciplinary approaches and various treatment modalities.

Salvage living-donor liver transplantation to previously hepatectomized hepatocellular carcinoma patients:is it a reasonable strategy?

Salvage liver transplantation (LT) has been performed for recurred hepatocellular carcinoma(HCC) or for deterioration of liver function after resection of HCC. Controversies arise, howeverover the technical feasibility of salvage LT in patientswho underwent liver surgery,

Selection of patients with hepatocellular carcinoma before liver transplantation:need to combine alpha-fetoprotein with morphology?

Liver transplantation is the best treatment for selected patients with unresectable hepatocellular carcinoma (HCC). While candidate selection has been historically based on the restrictive Milan

A three-factor preoperative scoring model predicts risk of recurrence after liver resection or transplantation in hepatocellular carcinoma patients with preserved liver function

BACKGROUND： No staging systems of hepatocellular carcinoma（HCC） are tailored for assessing recurrence risk. We sought to establish a recurrence risk scoring system to predict recurrence of HCC patients receiving surgical curative treatment（liver resection or transplantation）.METHODS： We retrospectively studied 286 HCC patients with preserved liver function receiving liver resection（n=184） or transplantation（n=102）. Independent risk factors were identified to construct the recurrence risk scoring model. The recurrence free survival and discriminatory ability of the model were analyzed. RESULTS： Total tumor volume, HBs Ag status, plasma fibrinogen level were included as independent prognostic factors for recurrence-free survival and used for constructing a 3-factor recurrence risk scoring model. The scoring model was as follows： 0.758×HBs Ag status（negative： 0; positive： 1）＋0.387×plasma fibrinogen level（≤3.24 g/L： 0; 〉3.24 g/L： 1）＋0.633×total tumor volume（≤107.5 cm3： 0; 〉107.5 cm3： 1）. The cutoff value was set to 1.02, and we defined the patients with the score ≤1.02 as a low risk group and those with the score 〉1.02 as a high risk group. The 3-year recurrence-free survival rate was significantly higher in the low risk group compared with that in the high risk group（67.9% vs 41.3%, P〈0.001）. In the subgroup analysis, liver transplantation patients had a better3-year recurrence-free survival rate than the liver resection patients in the low risk group（80.0% vs 64.0%, P〈0.01）. Additionally for patients underwent liver transplantation, we compared the recurrence risk model with the Milan criteria in the prediction of recurrence, and the 3-year recurrence survival rates were similar（80.0% vs 79.3%, P=0.906）.CONCLUSION： Our recurrence risk scoring model is effective in categorizing recurrence risks and in predicting recurrencefree survival of HCC before potential surgical curative treatment.

Liver transplantation for hepatocellular carcinoma： is zero recurrence theoretically possible？

BACKGROUND： Hepatocellular carcinoma（HCC） recurrence remains a key issue after liver transplantation. This study aimed to determine a subgroup of HCC patients within the Milan criteria who could achieve a theoretical goal of zero recurrence rates after liver transplantation.METHODS： Between 1999 and 2009, 179 patients who received liver transplantation for HCC within the Milan criteria were retrospectively included. Analysis of the factors associated with HCC recurrence was performed to determine the subgroup of patients at the lowest risk of recurrence.RESULTS： Seventy-two percent of the patients received a bridging therapy, including 54 liver resections. Eleven（6.1%） patients recurred within a delay of 19±22 months and ultimately died. Factors associated with recurrence were serum alpha-fetoprotein level 〉400 ng/m L, satellite nodules, poor differentiation, microvascular invasion and cholangiocarcinoma component. Recurrence rates decreased from 6.1% to 3.1% in patients without any of these factors.CONCLUSIONS： Among HCC patients within the Milan criteria, selecting patients with factors based on histology would allow tending towards zero recurrence, and prior histological assessment by liver biopsy or resection may be essential to rule out poorly differentiated tumors, microvascular invasion,and cholangiocarcinoma component.

Survivals after liver transplantation for hepatocellular carcinoma:Granular data for a better allocation process?

To the Editor:A large international study has been recently published focusing on the combination of morphological aspects and alpha-fetoprotein(AFP)as predictors of survival in patients with hepatocellular cancer(HCC)treated with liver transplantation(LT)[1].As a matter of fact,morphology and biology represent the two sides of the same

Adjuvant chemotherapy after liver transplantation for hepatocellular carcinoma

In this issue, Lin et al presented a well-written meta- analysis regarding the use of adjuvant chemotherapy in orthotopic liver transplant （OLT） recipients withhepatoceUular carcinoma （HCC）. They highlighted the need for further investigation about the post-OLT management of HCC. The treatment of advanced HCC remains a difficult challenge as there is limited response to chemotherapeutics even after resection and limited literature is available to support the use of chemotherapy after OLT for HCC. This study delves into the impor- tance of preventing HCC recurrence and prolonging survival after transplantation. The conclusions claim that chemotherapy may be useful in increasing survival and prolonging disease-free survival; however the findings that it does not prevent recurrence remain troublesome. Perhaps one of the greatest limitations is that cytotoxic agents have never been shown to improve survival in ad- vanced disease and therefore it is difficult to see a role in the early/adjuvant setting.

Loss of membranous carcinoembryonic antigen-related cell adhesion molecule 1 expression is related to decreased relapse-free survival of hepatocellular carcinoma following liver transplantation

Background Loss of carcinoembryonic antigen-related cell adhesion molecule 1 （CEACAM1） expression is an adverse prognostic factor in hepatocellular carcinoma （HCC）. The purpose of this study was to investigate the expression of CEACAM1 and its effect on relapse-free survival （RFS） following liver transplantation （LT） for HCC. Methods Expression of CEACAM1 was immunohistochemically detected in HCC specimens from 48 patients. The relationship between CEACAM1 expression and clinicopathologic variables, as well as tumor recurrence, was further analyzed. Results Of the 48 HCC specimens, membranous CEACAM1 expression was detected in 25 specimens and cytoplasmic CEACAM1 expression was detected in 19 specimens. Four specimens had loss of CEACAM1 expression. Loss of membranous CEACAM1 expression was significantly associated with tumor size, tumor number, and serum （z-fetoprotein levels （all P 〈0.05）. Patients with loss of membranous CEACAM1 had significantly poorer RFS than patients with membranous expression, determined via Kaplan-Meier analysis （P=0.027）. Multivariate analysis revealed that loss of membranous CEACAM1 expression might be an independent prognostic factor of RFS for HCC patients after liver transplantation （P=0.037）. Conclusion Loss of membranous CEACAM1 expression in HCC was closely associated with aggressive tumor biology and might be a relapsing biomarker of HCC treated with LT.

Validation of novel Japanese indication criteria and biomarkers among living donor liver transplantation recipients with hepatocellular carcinoma - a single center retrospective study

Aim:To validate a novel Japanese indication criteria for liver transplantation(LT)for hepatocellular carcinoma(HCC),i.e.,the 5-5-500 criteria(nodule size≤5 cm in diameter,nodule number≤5,and alfa-fetoprotein(AFP)value≤500 ng/mL)and the Japanese double eligibility criteria(DEC)(patients meeting the Milan or the 5-5-500 criteria)in the University of Tokyo cohort.The usefulness of biomarkers in predicting the recurrence of HCC was also verified.Methods:The overall survival and recurrence rates of patients meeting the Milan,5-5-500,and the Japanese DEC were compared among 153 patients who underwent living donor LT(LDLT)between 1996 and 2019.A receiver-operating characteristics curve analysis was conducted to evaluate the usefulness of AFP,lens culinaris agglutinin-reactive fraction of AFP,des-gamma-carboxy prothrombin,neutrophil-lymphocyte ratio,and the platelet-lymphocyte ratio to detect recurrence.Results:The 5-year recurrence rate for all patients,those meeting the Japanese DEC,5-5-500 criteria,and the Milan criteria was 10.9%,9.2%,7.4%,and 7.6%,respectively.Compared with the conventional Milan criteria,the 5-5-500 criteria and the Japanese DEC could increase the number of eligible LDLT candidates by 6.1%and 11.4%.Among five biomarkers,the area under the curve value of AFP was the highest(0.852).Conclusion:The results suggest that the 5-5-500 criteria and the Japanese DEC are the appropriate selection criteria for patients with HCC in LDLT.Among five biomarkers investigated,AFP was most reliable to predict HCC recurrence,which justified the utilization of AFP in the 5-5-500 criteria and the Japanese DEC.