Living donor liver transplantation for hepatocellular carcinoma: Increased recurrence but improved survival

Abstract

In regions with a limited deceased donor pool, living donor adult liver transplantation (LDALT) has become an important treatment modality for patients with hepatocellular carcinoma (HCC) and cirrhosis. Studies have shown higher recurrence rates of HCC after LDALT in comparison with deceased donor liver transplantation (DDLT). The aim of our study was to examine the outcome results and recurrence rates for patients with HCC who underwent LDALT at our center. During an 8-year period, 139 patients underwent LDALT, of whom 28 (20.1%) had HCC in their explanted livers. The median follow-up was 40.8 months.The mean explant tumor size was 3.3 Ϯ 1.2, and the mean number of tumors was 1.5 Ϯ 0.8. Twenty-one patients (75%) had tumors within the Milan criteria, 5 patients had tumors outside the Milan criteria but within the University of California San Francisco (UCSF) criteria, and 2 patients were beyond the UCSF criteria. The overall 1-and 5-year patient and graft survival rates were 96% and 81%, respectively. Survival following LDALT was significantly better than survival following DDLT for HCC during the same time period (P ϭ 0.02). Eight patients (28.6%) developed tumor recurrence. Poor differentiation of tumor cells was the most significant determinant of recurrence. Despite high recurrence rates of HCC following LDALT, overall 5-year survival appears to be excellent.

Should we perform deceased donor liver transplantation after living donor liver transplantation has failed?

“…25 After LDLT, HCC recurrence rates at 3 years vary substantially (from 13% 24 to 55% 26 ). Similar outcomes have been reported at 5 years (a recurrence rate of 29% 27 ).…”

Milan criteria in liver transplantation for hepatocellular carcinoma: An evidence-based analysis of 15 years of experience

“…The meta-analysis included 19 studies 2,15,16,19,26,33,35,39,40,42,46,48,[53][54][55]57,63,67,84 that used different methodologies to compare the overall survival of patients meeting the MC and patients exceeding the criteria at the time of the explant pathology examination; 3949 patients were also stratified by the graft origin (deceased or living donors).…”

Inappropriate inferences from registry data: Pitfalls of inaccurate data handling?

“…There is no data available or analyzed pertaining to duration from detection to transplant, presence or absence of chronic liver disease, etiology of liver disease or details of bridging procedures performed in the waiting period. The type of transplant performed (whole liver vs. partial graft), donor (living vs. deceased), underlying liver quality (cirrhosis vs. fibrosis vs. normal liver) that have been shown to influence CSS in other studies [23,24] are conspicuous by their absence in this analysis.…”

“…Swiss researchers outlined a five-pronged strategy to optimize outcome of LT for HCC [22]: select patients with low baseline circulating tumor cells, decrease peri-transplant release of cells, prevent engraftment of circulating tumor cells, use anti-cancer drugs after LT and tune immunity to clear tumor cells after LT. Type of liver graft used [23,24], recurrence of disease (hepatitis B or C, alcohol recidivism) [24][25][26], episodes of acute cellular rejection as well as type of maintenance immunosuppression [27] employed have been reported to impact HCC recurrence rates. Therefore, capturing these data for analysis seems important to ensure that the groups are comparable for accurate statistical applications to be applied and correct inferences drawn.…”