Downstaging Outcomes for Hepatocellular Carcinoma: Results From the Multicenter Evaluation of Reduction in Tumor Size before Liver Transplantation (MERITS-LT) Consortium

Liver transplantation (LT) is the first-line treatment for patients diagnosed with unresectable early-stage hepatocellular carcinoma (HCC) in the setting of cirrhosis. It is well known that HCC patients within the Milan criteria (solitary tumour ≤ 5 cm or ≤3 tumours, each <3 cm) could undergo LT with excellent results. However, there is a growing tendency to enlarge inclusion criteria since the Milan criteria are nowadays considered too restrictive and may exclude patients who would benefit from LT. On the other hand, there is a persistent shortage of donor organs. In this scenario, there is consensus about the role of loco-regional therapy (LRT) during the waiting list to select patients who would benefit more from LT, reducing the risk of drop off from the waiting list as well as decreasing tumour dimension to meet acceptable criteria for LT. In this review, current evidence on the safety, efficacy and utility of LRTs as neoadjuvant therapies before LT are summarized.

Section: Treatments For Bridging and Downstagingmentioning

confidence: 99%

Section: Treatments For Bridging and Downstagingmentioning

confidence: 99%

Locoregional Treatments for Bridging and Downstaging HCC to Liver Transplantation

Crocetti

Bozzi

Scalise

et al. 2021

“…Studies reporting outcomes after SIRT segmentectomy have reported significant improvements in time-to-progression, complete response rate, local tumor control, and PFS compared to TACE [ 112 , 203 , 204 , 205 ]. More recently, a multiregional study comparing SIRT with TACE found no significant difference between the two in downgrading the disease prior to liver transplantation [ 206 ]. The outcomes of radiation segmentectomy have been shown to be similar to ablation and surgical resection in patients with tumors of 3 cm or smaller [ 203 ].…”

Section: Discussionmentioning

confidence: 99%

Intraarterial Therapies for the Management of Hepatocellular Carcinoma

Garg

Shrigiriwar

Habibollahi

et al. 2022

Image-guided locoregional therapies play a crucial role in the management of patients with hepatocellular carcinoma (HCC). Transarterial therapies consist of a group of catheter-based treatments where embolic agents are delivered directly into the tumor via their supplying arteries. Some of the transarterial therapies available include bland embolization (TAE), transarterial chemoembolization (TACE), drug-eluting beads–transarterial chemoembolization (DEBs–TACE), selective internal radioembolization therapy (SIRT), and hepatic artery infusion (HAI). This article provides a review of pre-procedural, intra-procedural, and post-procedural aspects of each therapy, along with a review of the literature. Newer embolotherapy options and future directions are also briefly discussed.

“…Furthermore, the UNOS database, as a national experience of the US, showed that the 3-year survival rate post-transplantation was 83.2% in the group that always met the Milan criteria (n = 3276), while 79.1% were in the successfully down-staged group whose HCC initially met the UCSF inclusion criteria (n = 422, p = 0.17 vs. who always met the Milan criteria), and 71.4% were in the successfully down-staged patients who initially had not met the UCSF inclusion criteria (n = 121, p = 0.04 vs. who always met the Milan criteria) [ 15 ]. More recently, a prospective multiregional study (7 centers, 4 UNOS regions) also showed that over 80% of patients successfully underwent down-staging to meet the Milan criteria, with a low HCC recurrence rate (7.9%) following the UCSF down-staging protocol [ 115 ]. The findings described above support the value of the UCSF down-staging protocol as a national policy in the US.…”

Section: Down-staging or Bridging To Liver Transplantationmentioning

confidence: 99%

Liver Transplantation for Hepatocellular Carcinoma: How Should We Improve the Thresholds?

Shimamura

Goto

Watanabe

et al. 2022

Hepatocellular carcinoma (HCC) is the third highest cause of cancer-related mortality, and liver transplantation is the ideal treatment for this disease. The Milan criteria provided the opportunity for HCC patients to undergo LT with favorable outcomes and have been the international gold standard and benchmark. With the accumulation of data, however, the Milan criteria are not regarded as too restrictive. After the implementation of the Milan criteria, many extended criteria have been proposed, which increases the limitations regarding the morphological tumor burden, and incorporates the tumor’s biological behavior using surrogate markers. The paradigm for the patient selection for LT appears to be shifting from morphologic criteria to a combination of biologic, histologic, and morphologic criteria, and to the establishment of a model for predicting post-transplant recurrence and outcomes. This review article aims to characterize the various patient selection criteria for LT, with reference to several surrogate markers for the biological behavior of HCC (e.g., AFP, PIVKA-II, NLR, 18F-FDG PET/CT, liquid biopsy), and the response to locoregional therapy. Furthermore, the allocation rules in each country and the present evidence on the role of down-staging large tumors are addressed.