Living donor liver transplantation for hepatocellular carcinoma in Seoul National University

Abstract

Background: Liver transplantation is an effective treatment modality for hepatocellular carcinoma (HCC).Due to deceased organ shortage, living donor liver transplantation (LDLT) accounts for the majority of liver transplants in Korea. The aim of this study is to evaluate the recent trend of LDLT for HCC, and to suggest guidelines and criteria for selecting the appropriate candidates for LDLT.Methods: Between January 2000 and December 2015, 532 patients underwent LDLT for HCC.Clinicopathologic data were analyzed as well as overall survival rate (SR) and disease-free survival rate (DFSR) according to the Milan criteria based on explant pathology, positron emission tomography (PET) positivity, and serum alpha-fetoprotein (AFP) level. Results:The 5-year overall SR and DFSR were 81.5% and 75.5% respectively. According to our previously reported combination of AFP and PET [Seoul National University Hospital (SNUH) criteria]; low risk group [AFP <200 ng/mL, PET (−)], intermediate risk group [AFP >200 ng/mL, PET (−) or AFP <200 ng/mL, PET (+)], and high risk group [AFP >200 ng/mL, PET (+)], the 5-year DFSR of low risk group was 86.1%, intermediate risk group was 79.0%, and high risk group was 18.5% (P<0.001). Within the Milan criteria, the 5-year DFSR of low risk group was 88.4%, intermediate risk group was 79.9%, and high risk group was 60.0% (P=0.016). Beyond the Milan criteria, the 5-year DFSR of low, intermediate, and high risk group was 80.3%, 77.7%, and 9.1%, respectively (P<0.001). Conclusions:In conclusion, our data and experience suggest that a continued paradigm shift from a conventional size based criteria to a biological marker based criteria is indicated when evaluating LDLT candidates with HCC.

Different prognostic factors and strategies for early and late recurrence after adult living donor liver transplantation for hepatocellular carcinoma

“…Patient selection and post‐LT immunosuppressive details have been previously described . Usage of mammalian target of rapamycin inhibitor (mTORi) was considered for patients with far advanced HCC, defined as HCC larger than 10 cm or more than 10 in number, or with macrovascular invasion, 1 month after LT . All LT recipients underwent follow‐up examinations once a week during the first month after discharge, twice a month during the second and third months, monthly during the first year, and every 3 or 4 months thereafter.…”

“…Recurrent HCC lesions after LT were treated based on general principles . Surgical removal or radiofrequency ablation was initially attempted if indicated.…”

“…More than 2000 LTs were performed at Seoul National University Hospital since 1988. Recently, about 140 cases have been performed annually, of which about 60% are performed for HCC . We previously reported that the HCC recurrence rate after LT was about 20% and the progression of recurrent disease was rapid, resulting in very poor prognosis .…”

Pro (With Caution): Extended oncologic indications in liver transplantation

“…It is likely to become the leading cause of death after the decrease in HCV‐related cirrhosis, which makes the potential number of LT candidates overwhelming if we consider that only 4%‐6% of newly diagnosed HCC cases are offered transplantation in Western countries. In the East, 30%‐40% of LTs for HCC are performed in patients outside of the conventional Milan criteria . Although these statistics arise from different contexts, these appear to be unwarrantable differences that should be corrected with concerted action to bring the practices of different regions within the boundaries of reproducible outcomes.…”

“…In the East, 30%-40% of LTs for HCC are performed in patients outside of the conventional Milan criteria. (15) Although these statistics arise from FIG. 1.…”