Liver transplantation outcomes after transarterial chemotherapy for hepatocellular carcinoma

Abstract

Background Transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) awaiting liver transplantation is widespread, although evidence that it improves outcomes is lacking and there exist concerns about morbidity. The impact of TACE on outcomes after transplantation was evaluated in this study. Methods Patients with HCC who had liver transplantation in the UK were identified, and stratified according to whether they received TACE between 2006 and 2016. Cox regression methods were used to estimate hazard ratios (HRs) for death and graft failure after transplantation adjusted for donor and recipient characteristics. Results In total, 385 of 968 patients (39·8 per cent) received TACE. Five-year patient survival after transplantation was similar in those who had or had not received TACE: 75·2 (95 per cent c.i. 68·8 to 80·5) and 75·0 (70·5 to 78·8) per cent respectively. After adjustment for donor and recipient characteristics, there were no differences in mortality (HR 0·96, 95 per cent c.i. 0·67 to 1·38; P = 0·821) or graft failure (HR 1·01, 0·73 to 1·40; P = 0·964). The number of TACE treatments (2 or more versus 1: HR 0·97, 0·61 to 1·55; P = 0·903) or the time of death after transplantation (within or after 90 days; P = 0·291) did not alter the outcome. The incidence of hepatic artery thrombosis was low in those who had or had not received TACE (1·3 and 2·4 per cent respectively; P = 0·235). Conclusion TACE delivered to patients with HCC before liver transplant did not affect complications, patient death or graft failure after transplantation.

Locoregional Treatments for Bridging and Downstaging HCC to Liver Transplantation

“…Two recent retrospective studies conducted in large cohorts of transplanted patients who were previously submitted to intra-arterial therapies showed that the incidence of hepatic artery thrombosis was quite similar in those who had (1.3–2) or had not received TACE (2–2.4%, respectively). Furthermore, in contrast to the study of Sneiders et al, in these studies TACE did not affect arterial complications [ 62 , 63 ].…”

Downstaging Therapies for Patients with Hepatocellular Carcinoma Awaiting Liver Transplantation: A Systematic Review and Meta-Analysis on Intention-to-Treat Outcomes

“…Duvoux et al [ 9 ] demonstrated that patients moving from high to low risk of recurrence, according to the AFP model, after downstaging, had the same risk of recurrence as those initially included in the low-risk category. However, there are conflicting opinions on the optimal downstaging protocols, assessment of response to downstaging and criteria for downstaging eligibility, with no universally accepted downstaging protocol [ 39 , 40 , 41 ]. In 2017, the United Network for Organ Sharing (UNOS) adopted the University of California, San Francisco (UCSF)/Region 5 downstaging protocol (UNOS-DS), the outcomes of which have recently been assessed by Mehta et al [ 13 ].…”

Role of Pretransplant Treatments for Patients with Hepatocellular Carcinoma Waiting for Liver Transplantation

“…Regarding complications related to locoregional therapies, a recent systematic review showed that TACE increased the risk of hepatic artery-related complications after LT [ 79 , 90 , 91 ]. However, more recently, Wallace et al [ 92 ] reported that there was no difference in the incidence of hepatic artery thrombosis and other potentially TACE-related complications such as biliary stricture and leaks after LT between patients with and without TACE. On the other hand, there is concern that widespread adhesions after RFA may increase complications after LT.…”