Living donor liver transplantation for hepatocellular carcinoma achieves better outcomes

Abstract

Liver transplantation (LT) for hepatocellular carcinoma (HCC) at Kaohsiung Chang GungMemorial Hospital mainly relies on live donor LT (LDLT). Owing to taking the risk of LD, we are obligated to adopt strict selection criteria for HCC patients and optimize the pre-transplant conditions to ensure a high disease-free survival similar to those without HCC, even better than deceased donor LT (DDLT).Better outcomes are attributed to excellent surgical results and optimal patient selection. The hospital mortality of primary and salvage LDLT are lower than 2% in our center. Although Taiwan Health Insurance Policy extended the Milan to University of California, San Francisco (UCSF) criteria in 2006, selection criteria will not be consolidated to take into account only by the morphologic size/number of tumors but also by their biology. The criteria are divided into modifiable image morphology, alpha fetoprotein (AFP), and positron emission tomography (PET) scan with standard uptake value (SUV) and unmodifiable unfavorable pathology such as HCC combined with cholangiocarcinoma (CC), sarcomatoid type, and poor differentiation. Downstaging therapy is necessary for HCC patients beyond criteria to fit all modifiable standards. The upper limit of downstaging treatment seems to be extended by more effective drug eluting transarterial chemoembolization in cases without absolute contraindications. In contrast, the pitfall of unmodifiable tumor pathology should be excluded by the findings of pretransplant core biopsy/resection if possible. More recently, achieving complete tumor necrosis in explanted liver could almost predict no recurrence after transplant. Necrotizing therapy is advised if possible before transplant even the tumor status within criteria to minimize the possibility of tumor recurrence. LDLT with low surgical mortality in experienced centers provides the opportunities of optimizing the pre-transplant tumor conditions and timing of transplant to achieve better outcomes.

Clinical Outcomes of Tuberculosis in Recipients After Living Donor Liver Transplantation

“…Especially for the latter reason wherein patients urgently need LT, further delay may further increase the risk of more complications and mortality [ 14 , 15 ]. As our results have shown, with our current standard of care described earlier [ 17 – 20 , 24 – 26 , 34 ] and a relatively readily available living donor [ 32 , 35 , 36 ], performing LDLT in patients with active TB is not significantly associated with unfavorable outcome and may be the best option for such patients who developed accelerated liver failure or aggressive, recurrent HCC to achieve favorable outcome. In terms of completing TB treatment before transplant, studies have shown that once diagnosed with active TB prior to transplant, treatment should start as soon as possible, but it is not necessary to complete TB treatment before transplant as long as the patient is already receiving treatment and stains for the detection of acid-fast bacilli in sputum are negative when the transplant is to be performed [ 1 , 29 ].…”

“…All of those who were not able to complete TB treatment had only up to a maximum of 4 months of anti-TB medication, and all of these same patients subsequently died of non-TB-related causes ( Table 2 ). With our current standard of care [ 17 – 20 , 24 – 26 , 34 ], most patients (88.5%) completed TB treatment and it is significantly associated with 100% overall survival ( Figure 2 ).…”

Factor VII-Induced MicroRNA-135a Inhibits Autophagy and Is Associated with Poor Prognosis in Hepatocellular Carcinoma

“…We further performed an association analysis between miR-135a expression and clinicopathological parameters in these HCC cases, categorized into miR-135a T > N (tumor > normal) and miR-135a T < N (tumor < normal) groups. The results indicated that in addition to Atg14 mRNA expression, hepatitis virus status, hepatitis B surface antigen (HBs-Ag), primary tumor stage, microvascular invasion, and alpha-fetoprotein (AFP) levels (cut-off = 70 ng/mL) 24 were significantly associated with miR-135a expression ( Table 3 ), suggesting an involvement in HCC development and progression. Importantly, these cases were followed up for tumor recurrence and survival.…”

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“…For good results and for a better judgment of transplantation, they found that HCC must be staged with USCF criteria, with high AFP levels as an indication for downstaging therapy and high uptake of FDG PET/CT necessitating liver biopsy. 40 …”