Survival advantage of primary liver transplantation for hepatocellular carcinoma within the up-to-7 criteria with microvascular invasion

Abstract

PurposeMicrovascular invasion of hepatocellular carcinoma (HCC) is considered a poor prognostic factor of liver resection (LR) and liver transplantation (LT), but its significance for lesions within the up-to-7 criteria is unclear. This study investigated the survival benefit of primary LT against LR for HCC with microvascular invasion and within the up-to-7 criteria.MethodsAdult patients who underwent LR or LT as the primary treatment for HCC were included for study. Patients with prior local ablation, neoadjuvant systemic chemotherapy, targeted therapy, positive resection margin, or metastatic spread were excluded.ResultsThere were 471 LR patients and 95 LT recipients (70 with living donor, 25 with deceased donor). Seventy-seven (81.1%) LT recipients had HCC within the up-to-7 criteria. Twenty-five (26.3%) LT recipients had HCC with either macrovascular (n = 4) or microvascular (n = 21) invasion. The 5-year survival rate was 85.7% for LT recipients with HCC within the up-to-7 criteria, unaffected by the presence or absence of vascular invasion (88.2 vs. 85.1%). The rate was comparable with that of LR patients with HCC without vascular invasion (81.2%, p 0.227), but far superior to that of LR patients with lesions with vascular invasion (50.0%, p < 0.0001). Overall survivals were compromised by multiple tumors [odds ratio (OR) 1.902, confidence interval (CI) 1.374–2.633, p = 0.0001], vascular invasion (OR 2.678, CI 1.952–3.674, p < 0.0001), blood transfusion (OR 2.046, CI 1.337–3.131, p = 0.001), and being beyond the up-to-7 criteria (OR 1.457, CI 1.041–2.037, p = 0.028). LT was a favorable factor for survival (OR 0.243, CI 0.130–0.454, p < 0.0001).ConclusionPrimary LT for HCC with microvascular invasion and within the up-to-7 criteria doubled the chance of cure as compared with LR.

Rescue Living-donor Liver Transplantation for Liver Failure Following Hepatectomy for Hepatocellular Carcinoma

“…HCC patients within the standard criteria or the “up-to-7” criteria who undergo LT despite the presence of microvascular invasion have a 5-year survival rate of 85% [19], which is comparable to the survival rate for LT recipients with no HCC. However, the survival outcome of salvage LT for HCC recurrence is poor [20].…”

Selection of patients with hepatocellular carcinoma for liver transplantation: Past and future

“…In 2009, Mazzaferro et al [42] found that a total tumor diameter greater than 7 cm resulted in an increase in the percentage of recurrence and proposed a new MC (the so-called up-to-seven), using seven as the sum of the size of the largest tumor (in centimeter) and the number of tumors, which yielded 5-year overall survival of 71.2%. Many groups have validated these criteria [43,44] , but after 5 years, they have not been accepted as widely as the MC. Other authors have made similar suggestions [45] ; however, others have placed this limit at 10 cm, which results in a decrease in DFS [46] .…”

The Indian National Association for Study of the Liver (INASL) Consensus on Prevention, Diagnosis and Management of Hepatocellular Carcinoma in India: The Puri Recommendations

“…119 The use of primary liver transplantation for small tumors has survival advantage and thus may be more cost-effective. 120(p7), 121 In a Markov-based decision analytic model simulated outcomes, expressed in costs and quality-adjusted life years, for the three treatment strategies (resection, loco-regional therapy followed by salvage liver transplantation, and primary liver transplantation), it was found that in patients with HCC within the Milan Criteria, primary liver transplantation increases survival and quality of life at decreased costs compared with resection or loco-regional therapy followed by salvage liver transplantation. 121 Some authors have suggested that the Milan criteria may be too restrictive, and that a slight expansion may benefit some patients who are usually excluded.…”