Outcomes of Neoadjuvant Transarterial Chemoembolization to Downstage Hepatocellular Carcinoma Before Liver Transplantation

Chapman, William C.; Doyle, Maria B. Majella; Stuart, Jourdan E.; Vachharajani, Neeta; Crippin, Jeffrey S.; Anderson, Christopher; Lowell, Jeffrey A.; Shenoy, Surendra; Darcy, Michael; Brown, Daniel B.

doi:10.1097/sla.0b013e31818a07d4

Cited by 292 publications

(243 citation statements)

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“…Only 1 study has reported safety data in any detail, and it described a 2.2% mortality rate for patients undergoing TACE. 9 This is higher than the rate expected in a nontransplant setting. Another report described a mortality rate of 3.3% after resection or laparoscopic RFA for down-staging.…”

Section: By What Technique Should Down-staging Be Achieved?mentioning

confidence: 79%

“…[3][4][5][6][7][8][9][10][11][12] This outcome measure starts from the time at which a patient with HCC is subjected to down-staging treatments before LT listing and takes into consideration tumor progression beyond acceptable limits (ie, changes in the tumor size or number, vascular invasion, or extrahepatic tumor dissemination) that leads to delisting or dropout from the LT waiting list. Dropout from the waiting list depends not only on the tumor biology but also on the time on the wait-list for deceased donor LT in a particular transplant center or region.…”

Section: What Are the Goals And Expected Outcomes Of Down-staging?mentioning

confidence: 99%

“…Most of the published reports have used the Milan criteria as the endpoint of down-staging. [3][4][5][6][7][8] The Response Evaluation Criteria in Solid Tumors (RECIST) [9][10][11] and other criteria 12,13 have also been used to define the response to tumor down-staging, especially when eligibility for LT is not restricted to patients meeting the Milan criteria. Because we are defining the response to down-staging according to measurements of only the viable tumor after locoregional therapy, the RECIST approach does not fit well into this scheme: it defines treatment responses according to the measurement of the entire tumor (including both the ablated or necrotic portion and the viable tumor).…”

Section: What Should Be the Endpoint Or Endpoints Of Down-staging?mentioning

confidence: 99%

“…[6][7][8][9][10][11][12][13] Only a few reports have clearly stated the upper limits of the tumor burden before down-staging. [3][4][5] In the UCSF experience, 3,4 the upper limits for down-staging were a single tumor with a diameter up to 8 cm, 2 to 3 tumors with individual diameters up to 5 cm and with a total diameter up to 8 cm, or 4 to 5 tumors with individual diameters up to 3 cm and with a total diameter up to 8 cm.…”

Section: What Are the Eligibility Criteria For Down-staging?mentioning

confidence: 99%

“…Efficacy was defined as the ability to achieve HCC down-staging according to the authors' criteria and by the rate of recurrence after LT. The techniques described in the literature include radio frequency ablation (RFA), [3][4][5]8 TACE, [3][4][5][6][7][8][9][10][11][12][13] arterial chemoinfusion, 6 alcohol injection, [3][4][5] resection, [3][4][5] and radioembolization. 7,8 With the exception of alcohol injection, it is clear that all these techniques are able to reduce the tumor burden to achieve the authordefined endpoints.…”

Section: By What Technique Should Down-staging Be Achieved?mentioning

confidence: 99%

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Does a patient qualify for liver transplantation after the down-staging of hepatocellular carcinoma?

et al. 2011

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We searched the MEDLINE database (PubMed) and the Cochrane Library to identify studies evaluating down-staging and locoregional therapy for hepatocellular carcinoma (HCC) before liver transplantation (LT). The search was restricted to studies written in English and published from 1995 to 2010. The key words for the search included down-staging, liver transplantation, hepatocellular carcinoma, locoregional therapy, staging, treatment outcomes, radio frequency ablation, and transarterial chemoembolization. All published articles and abstracts were reviewed and screened by 2 members of the working group independently (F.Y.Y. and S.B.), and relevant articles and abstracts were selected for further review by the group. The group agreed on 5 key questions for addressing this topic, and each of the 5 members of the working group led the review and summary of an assigned question. The summary was reviewed and approved by all members of the working group. The level of evidence was graded according to the standards of the Oxford Centre for Evidence-Based Medicine and was approved by all group members.

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Section: By What Technique Should Down-staging Be Achieved?mentioning

confidence: 79%

Section: What Are the Goals And Expected Outcomes Of Down-staging?mentioning

confidence: 99%

Section: What Should Be the Endpoint Or Endpoints Of Down-staging?mentioning

confidence: 99%

Section: What Are the Eligibility Criteria For Down-staging?mentioning

confidence: 99%

Section: By What Technique Should Down-staging Be Achieved?mentioning

confidence: 99%

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Does a patient qualify for liver transplantation after the down-staging of hepatocellular carcinoma?

et al. 2011

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Evaluation of Patients With Hepatocellular Carcinomas That Do Not Produce α-Fetoprotein

et al. 2017

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IMPORTANCE Serum α-fetoprotein (AFP) is a biomarker for hepatocellular carcinomas (HCCs) associated with a more aggressive tumor phenotype and inferior outcomes after a liver transplant (LT). Data on the outcomes for patients with HCCs that do not produce AFP are limited.OBJECTIVE To compare characteristics and outcomes among LT recipients with radiographically apparent HCC lesions with AFP-producing tumors or with tumors that do not produce AFP (hereafter referred to as non-AFP-producing tumors), and to identify factors influencing recurrence in LT recipients with non-AFP-producing tumors. DESIGN, SETTING, AND PARTICIPANTSRetrospective analysis at a university transplant center of 665 adults with HCC who underwent an LT during the period from 1989 to 2013. Of the 665 LT recipients, 457 (68.7%) had AFP-producing tumors, and 208 (31.3%) had non-AFP-producing tumors (the maximum AFP level before an LT was Յ10 ng/mL). Dates of study analysis were from August 2015 to June 2016. INTERVENTION Liver transplant. MAIN OUTCOMES AND MEASURESRecurrence-free survival and recurrence rates. RESULTSPatients with non-AFP-producing tumors had radiographic tumor characteristics similar to those of patients with AFP-producing tumors, but, pathologically, they had fewer lesions (25% vs 35% with >2 lesions; P = .03), smaller cumulative tumor diameters (4.2 vs 5.0 cm; P = .02), fewer microvascular (17% vs 22%) and macrovascular (2% vs 9%) invasions (P < .001), and fewer poorly differentiated tumors (15% vs 28%; P < .001). Patients with non-AFP-producing tumors also had significantly superior recurrence-free survival at 1, 3, and 5 years (88%, 74%, and 67% vs 76%, 59%, and 51%, respectively; P = .002) and lower 5-year recurrence rates (8.8% vs 22%; P < .001) than patients with AFP-producing tumors. When stratified by radiologic Milan criteria, 5-year survival was better, and recurrence lowest, among patients with non-AFP-producing tumors within the Milan criteria (71% survival and 6% recurrence), and survival was worse, and recurrence highest, for patients with AFP-producing tumors outside the Milan criteria (40% survival and 42% recurrence; P < .001). Significant predictors of recurrence among patients with non-AFP-producing tumors include radiologic (>2 tumors [HR, 4.98; 95% CI, 1.72-14.4; P = .003]; cumulative diameter [1.70 per log SD; 1.12-2.59; P < .001]; outside the Milan criteria [10.0; 3.7-33.3; P < .001) and pathologic factors (>2 tumors [4.39; 1.32-14.6; P = .02]; cumulative diameter [2.32 per log SD; 1.43-3.77; P = .001]; microvascular [3.07; 1.02-9.24; P = .05] and macrovascular invasion [8.75; 2.15-35.6; P = .002]).CONCLUSIONS AND RELEVANCE Nearly one-third of patients with radiographically apparent HCC have non-AFP-producing tumors that have more favorable pathologic characteristics, lower posttransplant recurrence, and superior survival compared with patients with AFP-producing tumors. Posttransplant HCC recurrence for patients with non-AFP-producing tumors is predicted by important radiologic and pathologic factors, an...

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Transplant Considerations

Schwartz

2011

Clinical Dilemmas in Primary Liver Cancer

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Outcomes of Neoadjuvant Transarterial Chemoembolization to Downstage Hepatocellular Carcinoma Before Liver Transplantation

Abstract: Selected patients with stage III/IV HCC can be downstaged to Milan criteria with TACE. Importantly, patients who are successfully downstaged and transplanted have excellent midterm disease-free and overall survival, similar to stage II HCC.

Cited by 292 publications

References 23 publications

Does a patient qualify for liver transplantation after the down-staging of hepatocellular carcinoma?

Does a patient qualify for liver transplantation after the down-staging of hepatocellular carcinoma?

Evaluation of Patients With Hepatocellular Carcinomas That Do Not Produce α-Fetoprotein

Transplant Considerations

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