Hepatocellular Carcinoma Recurrence and Death Following Living and Deceased Donor Liver Transplantation

Abstract

We examined mortality and recurrence of hepatocellular carcinoma (HCC) among 106 transplant candidates with cirrhosis and HCC who had a potential living donor evaluated between January 1998 and February 2003 at the nine centers participating in the Adult-toAdult Living Donor Liver Transplantation Cohort Study (A2ALL). Cox regression models were fitted to compare time from donor evaluation and time from transplant to death or HCC recurrence between 58 living donor liver transplant (LDLT) and 34 deceased donor liver transplant (DDLT) recipients. Mean age and calculated Model for End-Stage Liver Disease (MELD) scores at transplant were similar between LDLT and DDLT recipients (age: 55 vs. 52 years, p = 0.21; MELD: 13 vs. 15, p = 0.08). Relative to DDLT recipients, LDLT recipients had a shorter time from listing to transplant (mean 160 vs. 469 days, p < 0.0001) and a higher rate of HCC recurrence within 3 years than DDLT recipients (29% vs. 0%, p = 0.002), but there was no difference in mortality or the combined outcome of mortality or recurrence. LDLT recipients had lower relative mortality risk than patients who did not undergo LDLT after the center had more experience (p = 0.03). Enthusiasm for LDLT as HCC treatment is dampened by higher HCC recurrence compared to DDLT.

Small‐for‐size grafts increase recurrence of hepatocellular carcinoma in liver transplantation beyond milan criteria

“…Although LDLT was used as an alternative treatment for HCC in times of shortage of donor livers, high HCC recurrence rates associated with LDLT have been reported, which were attributed to the fact that SFSGs are relatively more frequently used in LDLT than in DDLT. (7)(8)(9) However, Hwang et al and Gondolesi et al reported no difference in oncologic outcomes between LDLT and DDLT. (10)(11)(12) As can be seen, controversies exist regarding the association between SFSG and HCC recurrence, and several important points have been overlooked in the previous literature.…”

“…HBV infection was found in 89.3% (n 5 293) of recipients. The median Child-Pugh score was 6 (interquartile range [IQR], [4][5][6][7][8], and the median MELD score was 11 (IQR, 9-16). With regard to T stage, T2 was the most common, observed in 58.2% (n 5 191) of the patients, followed by T1 in 23.5% (n 5 77) of the patients.…”

“…They indicated that the tumor recurrence rate increased more significantly following LDLT using partial liver grafts for HCC than deceased donor liver transplantation (DDLT) based on retrospective clinical data. (7)(8)(9) However, several reports showed no significant difference in HCC recurrence between LDLT and DDLT. (10)(11)(12) Controversy still exists regarding the association between liver graft size and HCC recurrence after LT, and findings are still unclear.…”

Should the liver transplant criteria for hepatocellular carcinoma be different for deceased donation and living donation?

“…Six published articles comparing LDLT and DDLT for HCC with CEBM level 1b evidence were identified, [1][2][3][4][5][6] and they are listed in Table 1.…”

“…However, some centers have been reluctant to offer LDLT for HCC because of concerns about higher rates of cancer recurrence and inferior patient survival after LDLT versus deceased donor liver transplantation (DDLT). [1][2][3][4][5][6] Theoretical reasons for concerns about the potential for higher rates of HCC recurrence after LDLT include the following: (1) the stimulation of residual cancer cells by growth factors in the regenerating liver 7 ; (2) the relatively brief waiting time for LDLT, which may allow transplantation for patients whose aggressive or rapidly progressive HCC tumors might progress with a longer waiting time and exclude them from transplantation 8 ; and (3) more limited oncological clearance with the inferior vena cava-sparing technique used for LDLT. Another explanation for the reports of higher recurrence rates after LDLT is the presence of programmatic biases that lead these centers to unknowingly offer LDLT to patients with a higher risk of HCC recurrence.…”