Curative salvage liver transplantation in patients with cirrhosis and hepatocellular carcinoma: An intention‐to‐treat analysis

Abstract

The salvage liver transplantation (SLT) strategy was conceived for initially resectable and transplantable (R&T) hepatocellular carcinoma (HCC) patients, to try to obviate upfront liver transplantation, with the "safety net" of SLT in case of postresection recurrence. The SLT strategy is successful or curative when patients are recurrence free following primary resection alone, or after SLT for recurrence. The aim of the current study was to determine the SLT strategy's potential for cure in R&T HCC patients, and to identify predictors for its success. From 1994 to 2012, all R&T HCC patients with cirrhosis were enrolled in the SLT strategy. An intention-to-treat (ITT) analysis was used to determine this strategy's outcomes and predictors of success according to the above definition. In total, 110 patients were enrolled in the SLT strategy. Sixty-three patients (57%) had tumor recurrence after initial resection, and in 30 patients SLT could be performed (recurrence transplantability rate 5 48%). From the time of initial resection, ITT 5-year overall and disease-free survival rates were 69% and 60%, respectively. The SLT strategy was successful in 60 patients (56%), either by resection alone (36%), or by SLT for recurrence (19%). Preresection predictors of successful SLT strategy at multivariate analysis included Model for End-Stage Liver Disease (MELD) score >10, and absence of neoadjuvant transarterial chemoembolization (TACE). Additional postresection predictive factors were absence of postresection morbidity, and T-stage 1-2 at the resection specimen. Conclusion: The SLT strategy is curative in only 56% of cases. Higher MELD score at inception of the strategy and no pre-resection TACE are predictors of successful SLT strategy. (HEPATOLOGY 2018;67:204-215).T he salvage liver transplantation (SLT) strategy consists of primary liver resection for resectable and transplantable (R&T) hepatocellular carcinoma (HCC), followed by SLT in case of transplantable tumor recurrence. (1,2) This could help in alleviating both the graft shortage and the dropout from the transplant waiting list, which occurs in 25%-30% of cases after 12 months, mainly attributed to tumor progression. (3,4) The aforementioned definition of the SLT strategy excludes LT "de principe" (also called preemptive) after resection based on the histopathological examination of the resection specimen, (5) resection as a bridge to liver transplantation (LT) where the tumor (transplantable or not) is resected in the waiting

Does meeting the Milan criteria at the time of recurrence of hepatocellular carcinoma after curative resection have an impact on prognosis?

“…In terms of curative treatment, salvage LT was associated with best survival outcome only in the IN‐rIN group ( P = 0.000) (Fig. ), which was acceptable and comparable to the findings of other studies . However, its impact in the IN‐rOUT and OUT‐rIN groups was not significant because of the small sample size of each treatment group and possible selection bias.…”

“…However, there are no treatment guidelines for recurrence except salvage LT. In previous studies, indications for salvage LT were similar to those for primary LT and were based on the status of recurrent HCC . Referred studies of salvage LT were performed on small cohorts focused on the first recurrence.…”

Preoperative platelet-albumin–bilirubin grades predict the prognosis of patients with hepatitis B virus-related hepatocellular carcinoma after liver resection

“…[ 5 ] The PALBI score was calculated using the following equation: 2.02 × log 10 bilirubin–0.37 × (log 10 bilirubin) 2 –0.04 × albumin–3.48 × log 10 platelets + 1.01 × (log 10 platelets). [ 2 , 11 ] Serum bilirubin was expressed in μmol/L; serum albumin level was expressed in g/L; and blood platelet count was expressed in 1000/μL. [ 11 ] The PALBI score was divided into 3 grades as follows: grade 1 (≤−2.53), grade 2 (>−2.53 and ≤−2.09), grade 3 (>−2.09).…”

“…Previous investigations reported a postoperative recurrence rate of 70% at 5 years, even in patients with early stage HCC. [ 2 ]…”

Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases

“…A recent intention to treat analysis from France included 110 patients treated with resection with planned salvage transplant for recurrence or decompensation from 1994 to 2012. Only 56% were able to be cured using this protocol, with 36% of patients cured from resection alone and 19% after undergoing salvage LT following resection and recurrence, indicating that resection should be considered in transplant‐eligible patients.…”