Using Hepatocellular Carcinoma Tumor Burden Score to Stratify Prognosis after Liver Transplantation

Abstract

Liver transplantation (LT) remains a mainstay of treatment for hepatocellular carcinoma (HCC). Tumor factors such as size and number of tumors define eligibility for LT using the Milan criteria. The tumor burden score (TBS) incorporates both tumor number and size into a single continuous variable and has been used to differentiate prognosis among patients undergoing resection for HCC. The objective of the present study was to evaluate the ability of the TBS to predict overall and recurrence-free survival in patients undergoing LT for HCC. The Scientific Registry of Transplant Recipients (SRTR) was used to analyze all liver transplants for HCC, with initial tumor size data from 2004 to 2018. There were 12,486 patients in the study period. In the unadjusted analyses, patients with a high TBS had worse overall (p < 0.0001) and recurrence-free (p < 0.0001) survival. In the adjusted analyses, a high TBS was associated with a greater hazard ratio (HR) of death (HR = 1.21; 95%CI, [1.13–1.30]; p < 0.001) and recurrence (HR = 1.49; 95%CI [1.3–1.7]; p < 0.001). When we superimposed the TBS on the Milan criteria, we saw that a higher TBS was associated with a higher hazard of recurrence at values that were either all within (HR = 1.20; 95%CI, [1.04–1.37]; p = 0.011) or variably within (HR = 1.53; 95%CI, [1.16–2.01]; p = 0.002) the Milan criteria. In conclusion, the TBS is a promising tool in predicting outcomes in patients with HCC after LT.

Tumor burden score as a new prognostic marker for patients with hepatocellular carcinoma undergoing transarterial chemoembolization

“…In multivariate Cox analysis, patients with higher TBS had increased risk of mortality compared with medium TBS and low TBS. These results are consistent with previous studies 14–16 . Our results further support the idea that TBS can be used as an independent prognostic predictor to assess tumor burden and outcome in these patients.…”

“…advocated using tumor burden score (TBS) in liver to determine tumor burden in colorectal cancer with liver metastasis undergoing surgical resection 13 . The discriminatory ability of TBS in HCC patients undergoing surgical resection and liver transplantation was reported by independent study groups 14–16 . However, the feasibility and prognostic accuracy of TBS in patients undergoing TACE have not been well evaluated.…”

Risk factors and management of post-liver transplant recurrence of hepatocellular carcinoma

“…There is no firm consensus on the protocol, frequency or duration of monitoring TR after LT [50,69,70] . Most centres follow a similar protocol of thoraco-abdominal CT and AFP levels at 3-to 6-months intervals during the first 2 or 3 years.…”

“…PET-CT are very sensitive in picking up bone metastases [75,76] . When PET-CT is unavailable, a contrast CT should be combined with Tc-bone scan to complete a skeletal survey [2,4,70] .…”

“…A series from Korea showed a significantly higher 5-year survival rate (44.7% vs. 12.8%) when pulmonary OR (defined in the study as up to 3 tumours) were resected [79] . Residual pulmonary reserve and function remained an important consideration in such resections [2,70,79,80] . Stereotactic body radiotherapy (SBRT) is an option for patients where inadequate lung function precludes resection.…”