Liver Transplantation is a Preferable Alternative to Palliative Therapy for Selected Patients with Advanced Hepatocellular Carcinoma

Abstract

Background:Patients with hepatocellular carcinoma (HCC) beyond the traditional criteria (advanced HCC) are typically offered palliation, which is associated with a 3-year survival rate lower than 30%. This study aimed to describe the outcomes for a subset of patients with advanced HCC who satisfied the Extended Toronto Criteria (ETC) and were listed for liver transplantation (LT). Materials & Methods: All patients listed in the Toronto liver transplant program with HCC beyond both the Milan and University of California, San Francisco criteria were included in this study. Data were extracted from the prospectively collected electronic database. All radiological images were reviewed by two independent radiologists. The primary endpoint was patient survival. Results: Between January 1999 and August 2014, 96 patients with advanced HCC were listed for LT, and 62 (65%) of these patients received bridging therapy while on the waiting list. Bridging therapy led to a significant reduction in tumor progression (p=0.02) and tumor burden (p <0.001). The majority of those listed underwent LT (n=69, 72%). Both tumor progression on waiting list .464], p=0.006) and peak AFP ≥400ng/ml ], p=0.003) were independently associated with waiting list dropout. Post-LT HCC recurrence occurred in 35% (n=24). Among those with HCC recurrence, survival was significantly better for those who received curative treatment (p=0.004). The overall actuarial survival rates from the listing were 76% at 1 year, 56% at 3 years, and 47% at 5 years, and the corresponding rates from LT were 93%, 71%, and 66%. Conclusion: LT provides significantly better survival rates than palliation for patients with selected advanced HCC. SYNOPSISIn most Western centers, palliation remains the only option for patients with advanced HCC with a 3-year survival <30%. This study reports an improved survival with liver transplantation (71%, 66% at 3, 5 years) of selected patients with advanced HCC.

Ischemia-reperfusion injury and the risk of hepatocellular carcinoma recurrence after deceased donor liver transplantation

“…This indicates that the clinical relevance of IRI is limited to generally low-risk populations and diminishes with increasing tumour burden. This appears to be particularly importantly because it demonstrates the possibility of using high-risk grafts to expand the donor pool for high-risk HCC candidates in the context of discussion on widening the boundaries of existing selection criteria 2 – 6 , 29 . Notably, the safe use of extended criteria allografts preferentially for patients with advanced tumours was already reported 30 .…”

Hepatocellular carcinoma: when is liver transplantation oncologically futile?

“…The Extended Toronto Criteria allow LT for patients with any number and any size of HCC lesions provided no evidence exists for vascular invasion or extrahepatic disease, no cancer-related constitutional symptoms are observed, and a targeted biopsy of the largest lesion does not show poor differentiation (39). Two studies evaluated these criteria in patients exceeding the Milan criteria and in patients exceeding the UCSF criteria and found 5-year overall survival rates of 69% and 66%, respectively, which was not significantly lower than in patients within the Milan criteria (39,40).…”

Living donor liver transplantation for patients with advanced hepatocellular carcinoma

“…The most commonly used locoregional techniques are stereotactic body radiation, transarterial chemoembolization, transarterial radio-embolization, and radiofrequency ablation. Aravinthan et al [46] reported their outcomes after liver transplantation in patients with advanced HCC within extended Toronto Criteria.…”