Living donor liver transplantation for Barcelona clinic liver cancer (BCLC) intermediate-stage hepatocellular carcinoma

Abstract

Background: Barcelona clinic liver cancer (BCLC) stage B (intermediate stage) hepatocellular carcinoma (HCC) is highly heterogeneous; thus, identifying the most effective treatment for individual patients represents a significant clinical challenge. However, transarterial chemoembolization (TACE) is the only recommended treatment option. Therefore, we aimed to investigate the patient characteristics and outcomes of living donor liver transplantation (LDLT) for BCLC stage B HCC.Methods: A total of 516 patients with BCLC stage B HCC who underwent LDLT (n=104) or did not undergo LDLT (non-LDLT; n=412) between 2004 to 2018 were analyzed by propensity score matching (PSM; 1:4) analysis. Factors influencing overall survival (OS) and recurrence were analyzed using Cox's proportional hazards models.Results: Patients treated with LDLT achieved better OS than the non-LDLT group, including liver-and non-liver related survival (all P<0.001). Multivariate Cox regression analysis showed age >60 years (P=0.006), a neutrophil-lymphocyte ratio (NLR) >4 (P=0.016) and >3 locoregional therapies (LRT) before LDLT (P<0.001) were independent risk factors for HCC recurrence. In addition, age >60 years (P<0.001) and >3 LRT before LDLT (P=0.001) were independent risk factors for OS. Using a combination of age, NLR, and LRT before liver transplantation (LT), the patients can be divided into low-risk (none of risk), intermediaterisk (one of risk), and high risk (more than two of risk) groups. There were significant differences in the cumulative HCC recurrence (P<0.001) and mortality (P<0.001) rates among the three groups.Conclusions: LDLT may represent a valuable therapeutic option for selected patients with BCLC stage B HCC.

Intermediate-stage hepatocellular carcinoma: refining substaging or shifting paradigm?

“…Additionally, LT represents a valuable surgical option for selected patients with intermediate-stage HCC, as shown in several studies reporting favorable outcomes in terms of survival and recurrency rates. 46 Tsai et al 47 observed a longer OS in BCLC-B patients treated with living donor LT compared with BCLC-B patients not allocated to LT. They delineated how a combination of age, neutrophil to lymphocyte ratio and locoregional treatments before LT were able to stratify the risk of HCC recurrence and mortality in LT patients.…”

“…However, their data resulted from a retrospective analysis, and LT patients were compared with a population subjected to heterogeneous treatments, including both curative treatments, like radiofrequency ablation (RFA), and palliative treatments, like TACE and systemic therapies. 47 …”

“…However, their data resulted from a retrospective analysis, and LT patients were compared with a population subjected to heterogeneous treatments, including both curative treatments, like radiofrequency ablation (RFA), and palliative treatments, like TACE and systemic therapies. 47 In contrast to surgical options, the evidence supporting curative ablative techniques is far less clear. The majority of available evidence supporting ablation is primarily extrapolated from studies that encompass different treatments, such as those by Pecorelli et al 38 and other similar studies.…”