Alpha-fetoprotein and 18F-FDG standard uptake value predict tumor recurrence after liver transplantation for hepatocellular carcinoma with portal vein tumor thrombosis:Preliminary experience

Background:Portal vein tumor thrombosis(PVTT)is regarded as a contraindication for liver transplantation(LT)in hepatocellular carcinoma(HCC).However,some of these patients may have a favorable prognosis after LT.In this study,we evaluated the biological behavior of HCC with PVTT using tumor biomarker(alpha-fetoprotein,AFP)and 18 F-FDG positron emission tomography(tumor standard uptake value)to identify a subset of patients who may be suitable for LT.Methods:Seventy-five HCC-PVTT liver recipients transplanted during February 2016 and June 2018 were analyzed.Different pre-transplant prognostic factors were identified by univariate and multivariate analyses.PVTT status was identified following Vp classification(Vp1-Vp4).Results:Three-year recurrence-free survival and overall survival rates were 40%and 65.4%in Vp2-Vp3 PVTT patients,21.4%and 30.6%in Vp4 PVTT patients(P<0.05).Total tumor diameter>8 cm,pretransplant AFP level>1000 ng/m L and intrahepatic tumor maximal standard uptake value(SUVmaxtumor>5)were independent risk factors for HCC recurrence and overall survival after LT in Vp2-3 PVTT patients.Low risk patients were defined as total tumor diameter≤8 cm;or if total tumor diameter more than 8 cm,with both pre-transplant AFP level less than 1000 ng/m L and intrahepatic tumor SUVmax less than 5,simultaneously.Twenty-two Vp2-3 PVTT HCC patients(46.8%)were identified as low risk patients,and their 3-year recurrence-free and overall survival rates were 67.6%and 95.2%,respectively.Conclusions:Patients with segmental or lobar PVTT and biologically favorable tumors defined by AFP and 18 F-FDG SUVmax might be suitable for LT.

Complex hepatic outflow reconstruction in domino liver transplantation

Domino liver transplantation has been accepted as a safe procedure to further expand the organ donor pool. The most important technical challenge of the procedure resides in restoring a proper hepatic venous allograft outflow in the familial amyloidotic polyneuropathy-liver recipient. To overcome this issue, combined techniques were used to perform an innovative outflow reconstruction. A domino liver transplantation was successfully performed with reconstruction of complex venous outflow. The inferior vena cava sparing hepatectomy technique in the familial amyloidotic polyneuropathy-donor was used to cut the hepatic vein to the liver parenchyma. To overcome this issue the venous outflow tract was reconstructed using a longitudinally opened iliac vein graft from a post-mortem donor to create a new outflow tract using a diamond patch between the right and middle/left hepatic veins.

Three-dimensional modeling in complex liver surgery and liver transplantation

Liver resection and transplantation are the most effective therapies for many hepatobiliary tumors and diseases.However,these surgical procedures are challenging due to the anatomic complexity and many anatomical variations of the vascular and biliary structures.Three-dimensional(3D)printing models can clearly locate and describe blood vessels,bile ducts and tumors,calculate both liver and residual liver volumes,and finally predict the functional status of the liver after resection surgery.The 3D printing models may be particularly helpful in the preoperative evaluation and surgical planning of especially complex liver resection and transplantation,allowing to possibly increase resectability rates and reduce postoperative complications.With the continuous developments of imaging techniques,such models are expected to become widely applied in clinical practice.

Gastrointestinal tract post-transplant lymphoproliferative disorder after liver transplantation

To the Editor:Post-transplant lymphoproliferative disorder（PTLD）is a rare and potentially fatal complication occurring after all types of solid organ transplantation.;PTLD accounts for 20%of all de novo post-transplant tumors.;The most important risk factors for PTLD are prolonged intense immunosuppression and Epstein-Barr virus（EBV）

Morphology does not tell us the entire story: biological behavior improves our ability to select patients with hepatocellular carcinoma waiting for liver transplantation

The Milan criteria （solitary lesion 〈5 cm or twothree lesions 〈3 cm）, published in 1996 in relation to the selection of patients harboring hepatocel-lular carcinoma （HCC） in a diseased liver are still dominating the allocation of liver allografts in all international organ allocation organisms, this despite the fact that excellent results have been reported after liver transplantation （LT） done for patients presenting HCC outside these criteria,

From portal to splanchnic venous thrombosis:What surgeons should bear in mind

The present study aims to review the evolution of surgical management of portal(PVT) and splanch-nic venous thrombosis(SVT) in the context of liver transplantation over the last 5 decades. PVT is more commonly managed by endovenous thrombectomy, while SVT requires more complex technical expedients. Several surgical techniques have been proposed, such as extensive eversion thrombectomy, anastomosis to collateral veins, reno-portal anastomosis, cavo-portal hemi-transposition, portal arterialization and combined liver-intestinal transplantation. In order to achieve satisfactory outcomes, careful planning of the surgical strategy is mandatory. The excellent results that are ob-tained nowadays confirm that, even extended, splanch-nic thrombosis is no longer an absolute contraindication for liver transplantation. Patients with advanced portal thrombosis may preferentially be referred to specialized centres, in which complex vascular approaches and even multivisceral transplantation are performed.

Hepatocellular carcinoma recurrence after acute liver allograft rejection treatment: A multicenter European experience

Background:During the last decades,several risk factors for the recurrence of hepatocellular carcinoma(HCC)after liver transplantation(LT)have been investigated.However,the impact of two important drivers of oncogenesis,namely the immunosuppression and the treatment of acute cellular rejection(ACR)have been marginally addressed.This study aimed at investigating the impact of ACR treatment on the incidence of tumor recurrence in a large European HCC-LT population.Methods:Seven hundred and eighty-one adult patients transplanted between February 1,1985 and June 30,2016 were retrospectively analyzed.After propensity score match,116 patients treated for ACR using steroid boluses were compared with 115 patients who did not present any ACR or a histologic but clinical irrelevant ACR.Results:Steroid boluses treated patients had a 18-fold higher overall incidence of HCC recurrence than those non-treated patients(16.4%vs.0.9%;P<0.0001).At multivariate Cox regression analysis,steroid boluses used to treat ACR were an independent risk factor for HCC recurrence(HR=14.2;95%CI:1.8–110.4;P=0.010).Conclusions:The decision to treat ACR as well as to reinforce immunosuppression load should be cautiously taken in view of the presented results.Prospective studies are needed to further elucidate the clinical impact of immunosuppression on HCC recurrence after transplantation.

Composite hepatocellular and hemangiosarcomatous tumor: The prognosis is determined by the sarcomatous component

Nowadays, mixed liver tumors are more frequently diagnosed due to better imaging, advanced immunohistochemistry (IHC) staining techniques and better knowledge of hepatic tumorigene- sis [1–3] . Such tumors represent a mosaic of components with dis- tinct histogenesis and carcinogenic pathways. As their occurrence in the liver is very rare, their behavior and natural history are difficult to determine, and their management remains empirical. An uncommon case of a composite tumor harboring hepatocellular carcinoma (HCC) and hepatic hemangiosarcoma (HHS) components in a liver transplant (LT) recipient is reported herein.

Portal inflow reconstruction for liver transplantation with portal vein thrombosis

Complex non-malignant portal vein thrombosis(PVT),defined as Yerdel grade 4,was previously considered as a contraindication for liver transplantation(LT)because of technical challenges followed by high morbidity and mortality(1).In complex PVT,Bhangui et al.proposed defining reconstruction of portal inflow as physiological when the splanchnic venous blood can be redirected to the graft,thus resolving the pre-existing portal hypertension(PHT)(2).Renoportal anastomosis(RPA)and coronary-portal anastomosis(CPA)are 2 main options(3).However,all reports were single case reports or small case series regarding physiological reconstruction for complex PVT,therefore,the postoperative outcomes were very heterogeneous.Herein,we introduced our experience of physiological portal inflow restoration for liver transplant in complex PVT patients,and outcomes were compared with those of patients with non-complex PVT.