Effect of Bridging Local-Regional Therapy on Recurrence of Hepatocellular Carcinoma and Survival after Orthotopic Liver Transplantation

Abstract

Purpose To evaluate the influence of bridging local-regional therapy (LRT) on hepatocellular carcinoma (HCC) recurrence and overall survival after orthotopic liver transplantation and to identify factors that predict HCC recurrence after orthotopic liver transplantation. Materials and Methods The United Network for Organ Sharing database was used to identify patients with HCC who underwent liver transplantation between 2002 and 2013. Patients with complete explant data within the Milan criteria for whom a Model for End-Stage Liver Disease exception was approved were retrospectively analyzed. Kaplan-Meier estimation was used for survival analysis with log-rank test and Cox proportional hazard models to assess independent prognostic factors for overall survival. Propensity-matched analysis for treatment groups was performed to minimize selection bias. Results The rate of tumor recurrence after liver transplantation was 11.5% (321 of 2794), which significantly decreased overall survival (P < .001). The bridging LRT group exhibited lower recurrence (59 of 686 [8.6%]; P = .02) and longer median overall survival (75.9 months; P < .001). Recurrence was higher in patients older than 60 years, serum α-fetoprotein greater than 400 mg/L, bilobar distribution, multiple lesions, absent necrosis, microvascular invasion, and tumors beyond the Milan criteria (P < .05). Age, LRT status, serum α-fetoprotein, and microvascular invasion were independent risk factors (P < .05). In the matched cohort, similar factors that predicted recurrence were observed (P < .05), whereas bridging LRT (P = .03) and serum α-fetoprotein (P = .02) were independent risk factors for recurrence. Conclusion LRT significantly decreased tumor recurrence and lengthened overall survival. RSNA, 2016.

The Intention‐to‐Treat Effect of Bridging Treatments in the Setting of Milan Criteria–In Patients Waiting for Liver Transplantation

“…Very low 5‐year HCC‐dependent failure rates can be achieved in patients who initially received 1 LRT and did not exhibit disease progression after the treatment. Similar data were also observed in a large retrospective US analysis performed on 2794 LT patients, in which a lower posttransplant recurrence rate was reported in patients undergoing LRT, whereas AFP and tumor burden were independent risk factors for recurrence . In light of these results, we can postulate that tumor characteristics prevail over the treatment in influencing the ultimate therapeutic results.…”

“…Similar data were also observed in a large retrospective US analysis performed on 2794 LT patients, in which a lower posttransplant recurrence rate was reported in patients undergoing LRT, whereas AFP and tumor burden were independent risk factors for recurrence. (28) In light of these results, we can postulate that tumor characteristics prevail over the treatment in influencing the ultimate therapeutic results. Still, using LRT as a selection tool strongly discriminates between patients in terms of posttransplant clinical course.…”

Late recurrence of hepatocellular carcinoma after liver transplantation

“…[14–18] Other factors that have been reported to contribute include age, bilobar involvement, multiple lesions, absence of necrosis, tumor beyond Milan criteria, elevated neutrophil-to-lymphocyte ratio, microsatellitosis, and previous liver resection. [19–22] Two studies have found that the time between LT and HCC recurrence affects prognosis, with worse outcomes associated with early recurrence within 2 years. [23,24]…”

Patterns and challenges of treatment sequencing in patients with hepatocellular carcinoma: Experience from a German referral center

“…The Barcelona Clinic Liver Cancer (BCLC) classification is the most frequently used staging system for patients with HCC and is based on hepatic function, tumor number and size, vascular invasion, metastases, and performance status . Despite the attempts to allocate patients into specific treatment groups, decision‐making for the most appropriate treatment remains challenging in clinical practice as patients with HCC represent a very heterogeneous population …”

“…12 Despite the attempts to allocate patients into specific treatment groups, decision-making for the most appropriate treatment remains challenging in clinical practice as patients with HCC represent a very heterogeneous population. 8,[13][14][15] So far, there are no prospective studies on best treatment strategies and potential sequencing of different treatment options in HCC. According to the stage migration concept proposed by the BCLC classification, patients are supposed to shift upon progression to the next treatment option for a more advanced BCLC stage.…”