Influence of Preoperative Transarterial Lipiodol Chemoembolization on Resection and Transplantation for Hepatocellular Carcinoma in Patients With Cirrhosis

Abstract

ObjectiveTo investigate the impact of preoperative transarterial lipiodol chemoembolization (TACE) in the management of patients undergoing liver resection or liver transplantation for hepatocellular carcinoma. Patients and MethodsTACE was performed before surgery in 49 of 76 patients undergoing resection and in 54 of 111 patients undergoing liver transplantation. Results were retrospectively analyzed with regard to the response to treatment, the type of procedure performed, the incidence of complications, the incidence and pattern of recurrence, and survival. ResultsIn liver resection, downstaging of the tumor by TACE (21 of ConclusionsDownstaging or total necrosis of the tumor induced by TACE occurred in 62% of the cases and was associated with improved disease-free survival both after liver resection and 688

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

“…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).…”

“…14 Published data on the outcomes of tumor downstaging for LT are summarized in Tables 1 and 2; the data are classified according to the endpoint of downstaging. The concept of applying locoregional therapy to reduce the size of HCC tumors and thus facilitate resection or LT was first tested by Majno et al 13 (Hôpital Paul-Brousse, Villejuif, France). Two subsequent studies have suggested that a response to locoregional therapy with transarterial chemoembolization (TACE) for HCC meeting or exceeding the Milan criteria could serve as a prognostic marker for improved posttransplant outcomes and for the selection of LT candidates.…”

“…[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.…”

“…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.…”

Reply: Selection criteria for liver transplantation in patients with hepatocellular carcinoma: Beyond tumor size and number?

“…It has been performed by several transplantation centers. [3][4][5][6] The new aspect in our approach is that patients exceeding the Milan criteria 7 were downstaged, 8 and, in contrast to any other study, the patients listed for LT were continuously treated by TACE during the waiting period according to a strict protocol. Risk of tumor recurrence was low in the patients without measurable tumor progress compared with patients with minimal tumor progress during the waiting time, even if this "progress" remained within the official definition of stable disease.…”