The Survival Benefit of Liver Transplantation for Hepatocellular Carcinoma Patients with Hepatitis B Virus Infection and Cirrhosis

Abstract

BackgroundA precise predictive survival model of liver transplantation (LT) with antiviral prophylaxis for hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) and cirrhosis has not been established. The aim of our study was to identify predictors of outcome after LT in these patients based on tumor staging systems, antitumor therapy pre-LT, and antiviral prophylaxis in patients considered to be unfit by Milan or UCSF criteria.MethodsFrom 2002 to 2008, 917 LTs with antiviral prophylaxis were performed on patients with HBV-cirrhosis, and 313 had concurrent HCC.ResultsStratified univariate and multivariate analyses demonstrated that independent predictors for poor survival were tumor size >7.5 cm (P = 0.001), tumor number >1 (P = 0.005), vascular invasion (P = 0.001), pre-LT serum alpha-fetoprotein (AFP) level ≥1000 ng/ml (P = 0.009), and pre-LT aspartate aminotransferase (AST) level ≥120 IU/L (P = 0.044). Pre-LT therapy for HCC was an independent predictor of better survival (P = 0.028). Based on CLIP and TNM tumor staging systems, HCC patients with HBV-cirrhosis who met the following criteria: solitary tumor ≤7.5 cm, or ≤4 multifocal nodules, the largest lesion ≤5 cm and total tumor diameter ≤10 cm, or more nodules with the largest lesion ≤3 cm, and pre-LT serum AFP level <1000 µg/L and AST level <120 IU/L without vascular invasion and lymph node metastasis who were unfit for UCSF, had survival rates of 89% at 5 years. There was a 47% 5-year survival rate for patients with HCC exceeding the revised criteria.ConclusionsThe current criteria for LT based on tumor size, number and levels of AFP and AST may be modestly expanded while still preserving excellent survival after LT. The expanded criteria combined with antiviral prophylaxis and pre-LT adjuvant therapy for HCC may be a rational strategy to prolong survival after LT for HCC patients with HBV-associated cirrhosis.

Alpha-Fetoprotein Detection of Hepatocellular Carcinoma Leads to a Standardized Analysis of Dynamic AFP to Improve Screening Based Detection

“…Elevated AFP has been associated with poorer outcome following HCC diagnosis, particularly around the level of >20kU/L, often used as a decision limit [ 35 – 37 ]. We therefore examined the effect of AFP at diagnosis on patient survival.…”

Diabetes mellitus may affect the long-term survival of hepatitis B virus-related hepatocellular carcinoma patients after liver transplantation

“…However, it is unknown whether HBV infection acts directly or additively with steatohepatitis on the incidence of HCC in DM patients. Liver transplantation (LT) has been established as the only curative method for simultaneous treatment of HCC and cirrhosis[18,19], and is generally accepted as superior for early HCC with cirrhosis compared to hepatic resection[20,21]. …”

Analysis of prognostic factors of more/equal to10 years of survival for liver cancer patients after liver transplantation

“…There may be synergistic effects of the AFP level and other risk factors, and the Cox proportional hazards model was used to correct for other factors; thus, an increase in the AFP level was no longer an independent risk factor for long-term survival. Some studies have used a cutoff value for AFP before liver transplantation of 1000 µg/L (Pawlik et al 2005 ) and an AFP level ≥ 5000 µg/L (Zhang et al 2015 ) as an independent predictive factor of poorer survival after liver transplantation. Therefore, defining the AFP cutoff as ≥ 400 µg/L may not be sufficient to predict risk.…”