Hepatocellular carcinoma: Can it be considered a controversial indication for liver transplantation in centers with high rates of hepatitis C?

Abstract

Hepatocellular carcinoma (HCC) is still considered a controversial indication for liver transplantation (LT), mainly because of long waiting times and underlying viral cirrhosis. The goal was to evaluate the outcome of LT in 104 patients with HCC and cirrhosis, mainly hepatitis C virus (HCV)-related, in a center with a short waiting time (median, 105 days). Four groups were formed according to the HCC and HCV status: HCV positive with HCC (group 1, n ‫؍‬ 81), HCV negative with HCC (group 2, n ‫؍‬ 23), HCV positive without HCC (group 3, n ‫؍‬ 200), and HCV negative without HCC (group 4, n ‫؍‬ 207). Predictive factors of tumor recurrence were demographics, tumor related (size or number of nodules, capsule, bilobar involvement, vascular or lymphatic invasion, clinical and pathologic TNM staging, pre-LT percutaneous ultrasound-guided ethanol injection or transarterial chemoembolization, ␣-fetoprotein levels), donor and surgery related, and year of transplantation. The same variables and "tumor recurrence (yes/no)" were applied to evaluate the effect on survival. The median follow up was 29 months (range, 0 to 104 months). Patient survival was 70% at 1 year and 59% at 5 years for group 1, 87% at 1 year and 77% at 5 years for group 2, 81% at 1 year and 64% at 5 years for group 3, and 88% at 1 year and 77% at 5 years for group 4 (P ‫؍‬ .013). Survival was significantly lower in patients with HCC than in those without (74% and 63% versus 85% and 70%, at 1 and 5 years, respectively; P ‫؍‬ .05). The causes of death in those with and without HCC were tumor recurrence (24%) and recurrent HCV (8%) versus sepsis (34%) and recurrent HCV (14%). HCC recurrence occurred in 12 patients (11.5%) at a median of 14 months (range, 3 to 60 months) with a probability increasing from 8% at 1 year to 16% at 5 years. In patients with HCC, tumor recurrence was associated with vascular invasion (P ‫؍‬ .0004) by multivariate analysis; variables predictive of survival were donor old H epatocellular carcinoma (HCC) is the most frequent primary liver cancer worldwide, responsible for more than 1 million deaths yearly. 1 Without specific interventions, the mean survival time in patients with HCC in advanced stages is approximately 1 to 2 months, and that of patients with HCC in early stages only reaches 9 to 10 months. 2 Data from our country are slightly more optimistic, with survival rates of 3 and 15 months, respectively. 3 In a large recent prospective study based on cirrhotic patients with HCC, the median survival time was 17 months, ranging from 1 to 60 months, with a cumulative survival rate at 1, 3, and 5 years of 54%, 40%, and 28%, respectively. 4 Surgical resection is the only procedure capable of achieving a complete cure of this disease, and in that sense, it is likely that liver transplantation (LT) might be the best available oncologic option. 5 During the early years of transplantation activity, transplantation was only used in patients with large tumors. Unfortunately, results were highly disappointing because of the high rates of ...

Expanded criteria for liver transplantation in patients with cirrhosis and hepatocellular carcinoma

“…10,35 Indeed, several studies have shown that the differentiation degree and microvascular invasion represent direct indicators of the biologic progression of HCC, being associated with tumor recurrence and poor long-term survival. 4,6,8,10,13,35,36 In 1 study that evaluated the results of OLT in 48 patients in which the pre-OLT pathologic examination showed only moderately or well differentiated tumors, the 5-year survival rate reached 75%, regardless of the number or size of the lesions. 10 Unfortunately, there are data suggesting that this strategy might not be adequate because the tumor degree based on the pre-OLT assessment is potentially misleading, without a direct correlation with final histopathologic features.…”

“…The etiology of cirrhosis was HCV in 188 cases (associated with alcohol abuse in 30), HBV in 17 cases, alcohol in 45 cases, and other causes in 7 cases. The median body mass index was 26 kg/m 2 (range, [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36]. According to the Child-Pugh-Turcotte classification, 118 patients corresponded to group A, 93 corresponded to group B, and 46 corresponded to group C. Two hundred thirty-one patients had tumors within the MC and 26 had tumors beyond the MC on the basis of radiology.…”

Longitudinal prospective evaluation of quality of life in adult patients before and one year after liver transplantation

“…18 On the other hand, the original indication may have an effect, sometimes long-term, on psychological status, particularly if there is a risk of recidivism of the illness as HCV hepatitis 17 or hepatocellular carcinoma. 19 Other characteristics such as alcohol abuse or tobacco addiction, or a socioprofessional situation may also influence the QOL. Gender may also be important; in this study, 73% of subjects were male.…”

Host and donor risk factors before and after liver transplantation that impact HCV recurrence

“…It is likely that both tumor-and HCVrelated recurrent diseases hamper the outcome of these patients. 30 …”