Selection criteria for liver transplantation in early-stage hepatocellular carcinoma with cirrhosis: Results of a multicenter study

Abstract

Orthotopic liver transplantation (OLT) offers the only chance to eliminate both tumor and liver disease in patients with hepatocellular carcinoma (HCC) and cirrhosis. However, tumor progression while on the waiting list and recurrence after OLT are frequent. We undertook a large multicenter study to assess survival and related factors of recurrence after OLT. This retrospective study analyses data from 307 consecutive patients with HCC and cirrhosis treated with OLT between 1990 and 1997 in eight centers in Spain. OLT was indicated only for small (<5 cm) localized tumors. Five-year rates after OLT were 63% for survival, 58% for disease-free survival, and 21% for recurrence. Tumor diameter larger than 5 cm was associated with other tumor characteristics that were significant indicators of poor outcome (absence of capsule, three or more nodules, bilobularity, satellite nodules, and vascular invasion). However, in multivariate analysis, alpha fetoprotein (AFP) levels greater than 300 ng/mL (P ‫؍‬ .04; P ‫؍‬ .02) and macroscopic vascular invasion (P ‫؍‬ .01; P ‫؍‬ .0001) were the only factors independently associated with mortality and recurrence, respectively. OLT is indicated in patients with small HCCs who have low AFP levels and no macroscopic vascular invasion or extrahepatic disease. By increasing our ability for preoperative tumor imaging, we will achieve better selection of patients with HCC before OLT. (Liver Transpl 2001;7: 877-883.) H epatocellular carcinoma (HCC) is the most common primary hepatic malignancy, 1 and in most cases, it develops in association with liver cirrhosis. Surgical removal, either by partial hepatic resection or orthotopic liver transplantation (OLT), offers the only chance for long-term cure. Results of HCC resection in cirrhotic patients have been disappointing, mainly because of postoperative liver decompensation and, subsequently, the high rate of intrahepatic recurrence. 2 OLT has the theoretical advantage of eliminating both the tumor and liver disease. In comparison to liver resection, recurrence after OLT in patients with selected HCC is low. 3,4 However, the waiting list for OLT is increasing because of the organ shortage, and tumor growth during this time may lead to exclusion criteria for OLT. Adult living donor transplantation is emerging as a new therapeutic option to overcome this problem. Consequently, the ability to determine the relative risk for recurrence of HCC after OLT would allow a more equitable allocation of a scarce resource. However, selection criteria before OLT are not agreed on and may vary among centers.Because data about risk factors of survival and recurrence from single-center studies are insufficient, we undertook a large multicenter study to assess selection criteria and related factors in patients with cirrhosis and HCC treated by OLT. Patients and MethodsThis retrospective study was performed between January 1990 and December 2000 in eight centers in Spain. Data from 388 consecutive patients with HCC and cirrhosis treated with OLT were collected...

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

“…With the improvement in surgical techniques and better immunosuppressants to reduce the risk of graft rejection, the hospital mortality rate is less than 5% in major centers and the 5-year survival rate is about 60-75% [269][270][271][272][273]. Tumor recurrence after transplantation is lower than after resection for small HCC, and the 5-year disease-free survival rate is about 60-70%.…”

Tools for monitoring patients with hepatocellular carcinoma on the waiting list and after liver transplantation

“…AFP has been studied in a series of mainly single-center retrospective reviews for its ability to predict posttransplant outcomes; predictive power has been reported at cutoff values ranging from >10 to > 1000 ng/mL. 17,[19][20][21][22][23][24][25][26][27][28][29][30] Despite an abundance of data, AFP has not yet been widely adopted as a selection criterion.…”

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“…This finding confirms that incidental HCC, despite the fact that the nodules are small, may have features of advanced malignancy and can recur after LT. 8,9 In our cohort, patients with a single tumor nodule with a maximum diameter of 5 cm; or up to 3 nodules, all less than 4.5 cm each with a cumulative diameter up to 8 cm; or more than 3 nodules is predictive of HCC recurrence. 10 Furthermore, a rapid increase in serum AFP before transplant might identify a tumor with highly malignant behavior, and might explain our observation that a rapid pre-LT increase was associated with post-LT recurrence. These data suggests the dynamic evaluation of AFP levels could be included in the pre-LT assessment.…”