Macrovascular invasion is not an absolute contraindication for living donor liver transplantation

Abstract

The indication of liver transplantation (LT) for the treatment of advanced hepatocellular carcinoma (HCC) is expanding. However, portal vein tumor thrombus (PVTT) has been still accepted as an absolute contraindication. We experienced an unexpectedly good prognosis in selected patients. Therefore, we tried to identify the prognostic factors after LT for HCC with major PVTT. Among 282 patients who underwent living donor liver transplantation (LDLT) for HCC from January 2009 to December 2013, 11 (3.9%) patients with major PVTT that was preoperatively diagnosed were investigated. The 1-, 3-, and 5-year recurrence-free survival rates were 63.6%, 45.5%, and 45.5%, respectively, and all recurrent cases showed intrahepatic and extrahepatic recurrence. The 1-, 3-, and 5-year overall survival rates were 72.7%, 63.6%, and 63.6%, respectively, and 2 patients with delayed recurrence survived approximately 5 years after LT. Main portal vein (PV) invasion (P < 0.01), high alpha-fetoprotein 3 protein induced by vitamin K absence/antagonist-II (AP) score (20,000; P < 0.01), high standardized uptake value (SUV) ratio (tumor/background liver) in positron emission tomography (2.1; P < 0.01), and a large original tumor (7 cm; P 5 0.03) were significant risk factors for recurrence. In conclusion, if the PVTT has not expanded to the main PV and the AP score is not high, we can consider LDLT as a curative treatment option.

Hepatocellular carcinoma: when is liver transplantation oncologically futile?

“…Although absolute numbers were small, none of the patients with complete response to neoadjuvant treatment had HCC recurrence. This "oncologically favourable" outcome has been recently confirmed by several case series (19)(20)(21)(22). Of a total of 21 patients who underwent LT with macrovascular invasion, 8 patients developed HCC recurrence.…”

“…Of a total of 21 patients who underwent LT with macrovascular invasion, 8 patients developed HCC recurrence. Overall survival after 5 years was 64% in the largest series of patients with angioinvasive HCC (20). Main portal vein invasion was identified as the single most important risk factor for HCC recurrence, whereas a score including alpha-fetoprotein (AFP) and protein induced by vitamin K absence/antagonist-II (PIVKA-II) was predictive for recurrence free survival.…”

The clinical outcomes of patients with portal vein tumor thrombi after living donor liver transplantation

“…Furthermore, a PVTT below the second‐order branch is difficult to identify accurately on preoperative images, and there were few reports on the posttransplant prognoses of patients with PVTT below the second‐order branch. Lee et al reported that the level of PVTT affects tumor recurrence after LT . However, the result of this study is based on a small number of patients (n = 11).…”

“…However, in recent years, many transplant communities have sought to expand these conventional selection criteria to include patients with HCC for whom LT can prolong survival. However, there are few reports of post‐LT results according to the PVTT level . So, we sought to define the branch levels in which PVTT presence was acceptable in LT.…”

Expanded living‐donor liver transplantation criteria for patients with hepatocellular carcinoma based on the Japanese nationwide survey: the 5‐5‐500 rule ‐ a retrospective study

“…The differences in the number of listed patients and available grafts among regions, societies, and nations make it difficult to reach a worldwide consensus regarding the indications for liver transplantation for HCC, especially in the LDLT setting. Some centers strictly follow the Milan criteria, even for LDLT , while others have aggressively expanded the indications, even for those with macrovascular invasion .…”