Benefit of downsizing hepatocellular carcinoma in a liver transplant population

Jang, Jeong Won; You, Chan Ran; Kim, C. W.; Bae, S. H.; Yoon, Sunkyung; Yoo, Young Sik; Kim, D. G.; Choi, Jong Young

doi:10.1111/j.1365-2036.2009.04167.x

Cited by 71 publications

(72 citation statements)

References 22 publications

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“…20,40,41,[55][56][57][58] Two studies treated the total tumor diameter as a continuous variable (the summation of the diameters of all nodules), and both assessed recurrence (HR ¼ 1.19, 95% CI ¼ 0.95-1.49; Table 1). 40,58 Three studies used a cutoff of 10 cm, and they all assessed overall survival.…”

Section: Total Tumor Diametermentioning

confidence: 99%

Which matters most: Number of tumors, size of the largest tumor, or total tumor volume?

et al. 2011

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Section: Total Tumor Diametermentioning

confidence: 99%

Which matters most: Number of tumors, size of the largest tumor, or total tumor volume?

et al. 2011

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“…Mostly, a predetermined disease stability for 3–6 months after TACE and before enlisting as a candidate is mandatory to select less aggressive tumors that have less chance of posttransplant recurrence. In a long-term follow-up study in patients with HCC initially exceeding the Milan criteria in Korea, it was suggested that patients with a maximum tumor size <7 cm in whom complete necrosis is reached together with AFP levels <100 ng/ml just before LT may be the best candidates for LT following downstaging using TACE [21]. This may contribute to optimizing the management of LT candidates with downsized HCC.…”

Section: Introductionmentioning

confidence: 99%

Treatment Algorithm for Intermediate and Advanced Stage Hepatocellular Carcinoma: Korea

Choi

2011

Oncology

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The practice guideline for hepatocellular carcinoma (HCC) in Korea was revised in 2009. It was based on clinical evidence. The treatment algorithm was divided into curative and noncurative treatments. According to Barcelona Clinic Liver Cancer (BCLC) staging, the curative treatment group included early stage HCC (BCLC-A), and the noncurative treatment group consisted of intermediate and advanced stages of HCC (BCLC-B, C). The intermediate stage of HCC stands for noncurative disease, and therefore surgical resection and radiofrequency ablation are not considered as primary treatment modalities. Transarterial chemoembolization (TACE) forms the backbone of the treatment for intermediate stage HCC with Child-Pugh A cirrhosis. Patients in whom complete necrosis is not achieved or early recurrence after TACE develops should receive individualized treatments such as systemic treatment or combined radiation therapy (RT). Liver transplantation (LT) can be carried out for intermediate stage HCCs. However, the long-term survival rate after LT for intermediate stage HCCs is inferior to that of early stage HCCs because intermediate stage HCCs exceed the Milan criteria. In patients with Child-Pugh C liver function, LT would be better than TACE in terms of survival gain if the tumor burden is acceptable by expert opinion standards. The treatment algorithm becomes very complicated when it comes to advanced stage HCC. Sorafenib, a multikinase inhibitor with antiangiogenic and antiproliferative properties, has been shown to prolong the median overall survival and the median time to radiological progression compared to placebo in randomized controlled trials (RCTs) and has become the current standard of care for patients with advanced-stage tumors not suitable for surgical or locoregional therapies. RT is in the process of becoming a modality with a high efficacy and minimum side effects for HCC treatment, with recent improvements in equipment as well as radiation methods. However, to discover whether RT is really beneficial in the treatment of large-sized intermediate and advanced stage HCC, prospective RCTs should be carried out.

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“…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] . This value should be universally accepted as the upper limit [26] .…”

Section: Importancementioning

confidence: 93%

“…Combined radiological and biological modifications permit documentation of the response to LRT in patients waiting for LT and are essential elements for further refining the selection criteria for potential liver recipients with HCC [94] . An AFP level ≥ 100 ng/mL, a maximum tumor size ≥ 7 cm and a lack of complete necrosis at LT after TACE were found to be independent predictors of HCC recurrence [46] . However, patients with maximum tumor size < 7 cm who achieve complete necrosis together with AFP levels < 100 ng/mL at LT may be the best candidates for LT following downstaging [46] .…”

Section: Response Criteria Following Downstaging With Lrtmentioning

confidence: 99%

“…An AFP level ≥ 100 ng/mL, a maximum tumor size ≥ 7 cm and a lack of complete necrosis at LT after TACE were found to be independent predictors of HCC recurrence [46] . However, patients with maximum tumor size < 7 cm who achieve complete necrosis together with AFP levels < 100 ng/mL at LT may be the best candidates for LT following downstaging [46] . In addition, an AFP slope > 15 ng/mL per month and mRECIST progression are unique independent risk factors for HCC recurrence and patient death regardless of whether the patient meets the MC [94] .…”

Section: Response Criteria Following Downstaging With Lrtmentioning

confidence: 99%

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

Soriano¹

2016

WJH

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The aim of liver transplantation (LT) for hepatocellular carcinoma (HCC) is to ensure a rate of disease-free survival similar to that of patients transplanted due to benign disease. Therefore, we are forced to adopt strict criteria when selecting candidates for LT and prioritizing patients on the waiting list (WL), to have clarified indications for bridging therapy for groups at risk for progression or recurrence, and to establish certain limits for downstaging therapies. Although the Milan criteria (MC) remain the standard and most employed criteria for indication of HCC patients for LT by far, in the coming years, criteria will be consolidated that take into account not only data regarding the size/ volume and number of tumors but also their biology. This criteria will mainly include the alpha fetoprotein (AFP) values and, in view of their wide variability, any of the published logarithmic models for the selection of candidates for LT. Bridging therapy is necessary for HCC patients on the WL who meet the MC and have the possibility of experiencing a delay for LT greater than 6 mo or any of the known risk factors for recurrence. It is difficult to define single AFP values that would indicate bridging therapy (200, 300 or 400 ng/mL); therefore, it is preferable to rely on the criteria of a French AFP model score > 2. Other single indications for bridging therapy include a tumor diameter greater than 3 cm, more than one tumor, and having an AFP slope greater than 15 ng/mL per month or > 50 ng/mL for three months during strict monitoring while on the WL. When considering the inclusion of patients on the WL who do not meet the MC, it is mandatory to determine their eligibility for downstaging therapy prior to inclusion. The upper limit for this therapy could be one lesion up to 8 cm, 2-3 lesions with a total tumor diameter up to 8 cm, or a total tumor volume of 115 cm 3 . Selection of patients with hepatocellular carcinoma for liver transplantation: Past and future the WL should take into account the recently described HCC model for end-stage liver disease, which considers hepatic function, HCC size and the number and the log of AFP values. This formula has been calibrated with the survival data of non-HCC patients and produces a dynamic and more accurate assessment model.

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Benefit of downsizing hepatocellular carcinoma in a liver transplant population

Abstract: SUMMARY BackgroundLong-term results after downstaging hepatocellular carcinoma (HCC) prior to liver transplantation (LT) remain unknown.

Cited by 71 publications

References 22 publications

Which matters most: Number of tumors, size of the largest tumor, or total tumor volume?

Which matters most: Number of tumors, size of the largest tumor, or total tumor volume?

Treatment Algorithm for Intermediate and Advanced Stage Hepatocellular Carcinoma: Korea

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

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