Downstaging prior to liver transplantation for hepatocellular carcinoma: advisable but at the price of an increased risk of cancer recurrence - a retrospective study

Abstract

The use of downstaging prior to liver transplantation for hepatocellular carcinoma (HCC) still needs refinement. This study included patients with HCC listed for transplantation according to the Total Tumour Volume (TTV) ≤115 cm and alpha fetoprotein (AFP) ≤400 ng/ml criteria, with and without previous downstaging. Overall, 455 patients were listed, and 286 transplanted. Post-transplant follow-up was 38.5 ± 1.7 months. Patients downstaged to TTV115/AFP400 (n = 29) demonstrated similar disease-free survivals (DFS, 74% vs. 80% at 5 years, P = 0.949), but a trend to more recurrences (14% vs. 5.8%, P = 0.10) than those always within TTV115/AFP400 (n = 257). Similarly, patients downstaged to Milan criteria (n = 80) demonstrated similar DFS (76% vs. 86% at 5 years, P = 0.258), but more recurrences (11% vs. 1.7%, P = 0.001) than those always within Milan (n = 177). Among patients downstaged to Milan, those originally beyond TTV115/AFP400 (n = 27) had similar outcomes as those originally beyond Milan, but within TTV115/AFP400 (n = 53). However, the likelihood of being within Milan at transplant was lower for patients with more advanced original HCCs (P < 0.0001). Overall, despite an expected increase in post-transplant HCC recurrence, similar survivals can be achieved with and without downstaging, using the TTV115/AFP400 transplantation criteria, and including patients with advanced original HCCs. Downstaging should continue to be performed.

Liver transplantation for hepatocellular carcinoma after successful treatment of macrovascular invasion – a multi‐center retrospective cohort study

“…Unlike the previously described data, our study specifically looked at patients with successfully treated macrovascular HCC invasion (and with a mean time between treatment and transplant of 9 months) and reached an encouraging overall 5‐year post‐transplant survival of 60%. Such a data further highlight the benefit of downstaging, allowing to select patients with the most favorable tumor biology .…”

“…Regardless of the HCC size and number, patients with AFP < 10 ng/ml at the time of transplantation demonstrate a very low risk of post‐transplant recurrence of 11%, and a 5‐year post‐transplant survival of 83%. Such a combination of morphological and biological factors follows the same spirit as most modern scores stratifying the risk of HCC patients for transplantation .…”

Milan-out Criteria and Worse Intention-to-Treat Outcome Postliver Transplantation

“…Although patients successfully downstaged have worse overall intention-to-treat outcomes compared with Milan-in patients, they achieve satisfactory post-LT survival rates, greater than the “minimum” of 50% at 5 years, and thus should not be denied this therapeutic option. Whether the LT criteria following successful downstaging should be the Milan criteria as opposed to an expanded one 27 requires further investigation.…”

Applicability of Augmented Reality in an Organ Transplantation

“…Of the options available (chemotherapy, radiotherapy, chemo(radio)embolization, ablation, resection), surgical resection gives the best results in terms of long-term patient survival, with thermal ablation the second best. All these methods are also used to downstage tumor burden, and to transplant initially untransplantable patients, with acceptable results [ 35 ]. Even in low-risk patients, the tumor will recur in 15% to 20% of the transplanted livers [ 36 ], requiring intensive treatment.…”