Experience With LDLT in Patients With Hepatocellular Carcinoma and Portal Vein Tumor Thrombosis Postdownstaging

Abstract

Background. Median survival in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT) is 2–6 months; conventionally liver transplantation is contraindicated. Methods. We studied outcomes following living donor liver transplantation (LDLT) post-PVTT downstaging (DS) with stereotactic body radiotherapy (SBRT), and tumor ablation (with transarterial chemo- or radio-embolization). Results. Of 2348 consecutive LDLTs, 451 were for HCC, including 25 with PVTT (mainly Vp1-3) after successful DS and 20 with Vp1/2 PVTT without previous treatment. DS was attempted in 43, was successful in 27 (63%), and 25 underwent LDLT. Median alpha fetoprotein (AFP) at diagnosis and pre-LDLT were 78.1 ng/mL (3-58 200) and 55 ng/mL (2-7320), respectively. Mean DS to LDLT time was 10.2 weeks (5–16). Excluding 2 postoperative deaths, 1- and 5-year overall survival (OS) and recurrence-free survival (RFS) were 82%, 57%, and 77%, 51%, respectively, comparable to survival in 382 HCC patients without PVTT undergoing upfront LDLT (5-y OS 65%, P = 0.06; RFS 66%, P = 0.33, respectively). There was a trend toward better OS in DS+LDLT versus non-DS LDLT group (5-y OS/RFS—48%/40%). OS was significantly better than in HCC-PVTT patients receiving no intervention or palliative Sorafenib alone (1-y OS of 0%) or Sorafenib with TARE/SBRT (2-y OS of 17%) at our center during the study period. Initial AFP <400 ng/mL and AFP fall (initial minus pre-LDLT) >2000 ng/mL predicted better RFS; Grade III/IV predicted worse OS in DS patients. Conclusions. HCC patients with PVTT can achieve acceptable survival with LDLT after successful DS. Low initial AFP level, a significant drop in AFP with DS and low tumor grade, favorably influence survival in these patients.

Post liver transplant recurrence in patients with hepatocellular carcinoma: not necessarily the end of the road!

“…During this period, 481 LDLT's were performed in HCC-cirr patients. Forty-six had segmental or lobar portal vein tumour thrombosis, and underwent downstaging before LDLT as per our Institutional protocol [18] . Those 46 patients were excluded from this study.…”

Living donor liver transplantation for patients with advanced hepatocellular carcinoma

“…HAIC: hepatic arterial infusion chemotherapy; IFN-alpha 2b: interferon alfa-2b; LT: liver transplantation; RT: radiation therapy; TACE: transarterial chemoembolization; TARE: transarterial radioembolization; 5-FU: 5-fluorouracil. *Under certain conditions; **not enough support [26,34,35,38,37,40,41] long-term survival outcomes among carefully selected patients under specific criteria such as: (a) PVTT in a segmental branch, (b) AFP level < 100ng/mL, (c) low AP score, and (d) patients with HCC and PVTT who were successfully downstaged [36,42,43] .…”

“…The authors found tumor thrombus extension into the main portal vein, elevated AFP, and tumor size greater than 7 cm to be independent risk factors for recurrence. In the largest study to date, 46 patients with PVTT underwent LDLT after a downstaging protocol using stereotactic body radiation in combination with transarterial chemo-embolization or transarterial radio-embolization [42] . Five-year recurrence free survival and overall survival rates were 51% and 57%, respectively.…”

Comment on experience with LDLT in patients with hepatocellular carcinoma and portal vein tumor thrombosis postdownstaging

“…However, recent studies showing successful results with TARE in patients with PVTT were published. We would like to share our experience about the effectiveness of LDLT after downstaging (DS) in patients with HCC and PVTT in the light of the recent paper published Soin and colleagues [ 3 ]. We also would like to emphasize some of the overlooked points we found in their study, based on the experiences we have gained from about 2750 LT including 415 patients with HCC.…”

“…The authors state that they perform liver biopsy to 2% of the patients with HCC [ 3 ]. Biopsy is not required for the diagnosis of HCC provided that multidetector computerized tomography (MDCT), magnetic resonance imaging (MRI) and alfa-feto protein (AFP) are evaluated all together.…”