Author Affiliations: Department of Hepato-Pancreato-Biliary Surgery (Irtan S, Barbier L, Dondéro F and Belghiti J) and Department of Hepatology (Francoz C and Durand F), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, University Denis Diderot-Paris VII, Clichy, France

Corresponding Author: Louise Barbier, MD, Department of Hepato-Pancreato-Biliary Surgery, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy Cedex, France (Tel: +33-1-4087-5895; Fax: +33-1- 4087-1724; Email: louise.barbier@bjn.aphp.fr)

 

© 2016, Hepatobiliary Pancreat Dis Int. All rights reserved.

doi: 10.1016/S1499-3872(16)60069-3

Published online February 2, 2016.

 

 

Contributors: Durand F and BJ proposed the study and revised manuscript. IS collected and analyzed data and wrote the first draft. BL revised the manuscript and submission. FC participated in the analysis and first draft. Dondéro F collected data and revised manuscript. BL is the guarantor.

Funding: None.

Ethical approval: This study was approved by the Ethics Committee of Beaujon Hospital.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

 

 

BACKGROUND: Hepatocellular carcinoma (HCC) recurrence remains a key issue after liver transplantation. This study aimed to determine a subgroup of HCC patients within the Milan criteria who could achieve a theoretical goal of zero recurrence rates after liver transplantation.

 

METHODS: Between 1999 and 2009, 179 patients who received liver transplantation for HCC within the Milan criteria were retrospectively included. Analysis of the factors associated with HCC recurrence was performed to determine the subgroup of patients at the lowest risk of recurrence.

 

RESULTS: Seventy-two percent of the patients received a bridging therapy, including 54 liver resections. Eleven (6.1%) patients recurred within a delay of 19±22 months and ultimately died. Factors associated with recurrence were serum alpha-fetoprotein level >400 ng/mL, satellite nodules, poor differentiation, microvascular invasion and cholangiocarcinoma component. Recurrence rates decreased from 6.1% to 3.1% in patients without any of these factors.

 

CONCLUSIONS: Among HCC patients within the Milan criteria, selecting patients with factors based on histology would allow tending towards zero recurrence, and prior histological assessment by liver biopsy or resection may be essential to rule out poorly differentiated tumors, microvascular invasion, and cholangiocarcinoma component.

 

(Hepatobiliary Pancreat Dis Int 2016;15:147-151)

KEY WORDS: hepatocellular carcinoma; liver transplantation; neoplasm recurrence; survival rate

Liver transplantation (LT) remains the best treatment of early hepatocellular carcinoma (HCC) developed on chronic liver disease. However, results are hampered by the long-lasting imbalance between an increasing number of candidates and graft shortage.^[1] The unsatisfactory initial results of LT for clinically advanced HCC, together with the observation that small HCCs incidentally detected during surgery have an extremely low risk of post-LT recurrence, led to propose strict selection criteria.^{[2, 3]} In this setting, the Milan criteria (single tumor ≤5 cm or 2-3 tumors ≤3 cm, in the absence of macroscopic vascular invasion) were adopted as guidelines for LT with the aim to achieve a 5-year overall survival rate of 70% and a recurrence rate of below 15%.^[3] Increasing experience showed that some HCC patients beyond the Milan criteria, without vascular invasion or poorly differentiated HCC, demonstrated acceptable rates of survival and recurrence.^[4] Several studies^{[5, 6]} showed that high or rapidly increasing alpha-fetoprotein (AFP) levels were associated with increased recurrence. A study from a Toronto team showed that patients beyond the Milan criteria with AFP level >400 ng/mL and well differentiated HCC could achieve excellent results after LT.^[7] On the other hand, even restricting LT for patients within the Milan criteria fails in completely ruling out post-LT for HCC recurrence^[8] since some small HCCs have aggressive features such as poorly differentiated grade or vascular invasion.^[9] In a context of graft shortage, a policy to select HCC candidates with post-LT outcomes similar to non-HCC recipients, while eliminating recurrence risk factors, should theoretically be considered. The aim of this study was therefore to determine a subgroup of patients within the Milan criteria, which could theoretically achieve a zero recurrence rate after LT.

 

 

All patients who underwent LT at Beaujon Hospital for HCC within the Milan criteria From 1999 to 2009 and survived at least 3 months after LT were included in the study. Data of the patients were retrospectively collected from their clinical files. The endpoint was HCC recurrence after LT and all factors were associated with recurrence.

 

HCC diagnosis was based on two imaging studies including triple-phase computed tomography scan and/or magnetic resonance imaging showing both early hyper-enhancement and delayed hypo-enhancement, in accordance with the American Association for the Study of Liver Diseases (AASLD) Practice Guidelines of Management of Hepatocellular Carcinoma.^[10] Patients with lesions within the Milan criteria had a solitary liver nodule not exceeding 5 cm in diameter, or 2 or 3 tumors not exceeding 3 cm in diameter, without detectable vascular invasion.^[3] Patients underwent regular ultrasound scan every 3-month to check that they remained within the Milan criteria.

 

Tumor size, number, differentiation grade, vascular invasion, and satellite nodules were analyzed systematically. Vascular invasion was identified either as macroscopic, when vessel invasion was visible on gross examination, or as microscopic, when it was visible only under microscopy. Satellite nodules were defined as tumors ≤2 cm in size and located at ≤2 cm from the main tumor. Cholangiocarcinoma differentiation (CC component) was reported when present. Combined HCC-CC was diagnosed according to histological findings of both tumor types.

 

A triple immunosuppressive regimen consisting of mycophenolate mofetil, tacrolimus and steroids has been routinely used since 1999. In the present study, patients were free of steroids at 4-month post-LT, and no patients were subjected to systematic mammalian target of rapamycin inhibitors.

 

Follow-up included liver function tests, serum AFP and ultrasound examination every 3 months. Elevation of AFP and/or presence of nodule at ultrasound led to perform triple-phase computed tomography or magnetic resonance imaging. HCC recurrence was defined as appearance of a new lesion with radiological features of HCC. Additional imaging techniques (bone scan, magnetic resonance imaging) were used if necessary.

 

Qualitative variables were expressed as number (percentage), and quantitative data as mean±standard deviation (SD). Overall survival was defined as time from surgery to death (excluding 90-day postoperative mortality). Disease-free survival was defined as time from surgery to the first recorded evidence of recurrence. Cumulative overall survival and disease-free survival rates were determined using the Kaplan-Meier method, and bivariate analysis of survival was performed using the log-rank test. Significance was considered at the P value of 0.05. All analyses were performed with the GraphPad Prism® 5.0c for Mac OS X (GraphPad Software, Inc., USA).

 

 

Among the 851 patients who underwent LT in our unit between 1999 and 2009, 258 (30.3%) had HCC on chronic liver disease and 218 (84.5%) had lesions within the Milan criteria before LT. Of these patients, 179 survived more than 3 months and comprised the study population.

 

Morphological evaluation before LT revealed that 96 (53.6%) patients had a single nodule with a mean diameter of 23.2±9.3 mm (range 30-50) and 72 had 2 or 3 nodules with a mean of 1.5±0.7 nodules each patient. Demographic data, etiology of underlying liver disease and MELD score are shown in Table 1. In this series, 129 (72.1%) patients received bridging therapy including transarterial chemoembolization (45 patients), percutaneous ethanol injection (14), radiofrequency ablation (55), and liver resection (54). Thirty-nine patients received two or more of these treatments in combination before LT. The mean duration on the waiting list was 5.7±5.3 months with no significant difference between the groups with and without bridging therapy (6.1±5.2 vs 4.7±5.5 months, respectively).

 

LT was performed using full grafts in 139 (77.7%) patients and partial grafts in 40 (22.3%), including grafts from living donors (23 patients) and from split procedures (17). Pathological examination of the explanted liver showed that 132 (73.7%) patients remained within the Milan criteria. Among the 47 patients beyond the Milan criteria histologically, 15 had a tumor size >50 mm and 23 had 4 nodules or more, and 9 patients had 2 or 3 nodules, with one nodule >30 mm. Ten patients (5.6%) showed an additional CC component.

 

The patients were followed up for 65.0±34.8 months. The overall 1-, 3- and 5-year survival rates were 86%, 75% and 71%, respectively. HCC recurrence was observed within a delay of 19±22 months in 11 (6.1%) patients. No patients had HCC recurrence within 3 months post-LT. HCC recurrence led to death in all patients with a mean delay between recurrence diagnosis and death of 6.7±5.0 months. All recurrences were multifocal either with pulmonary, lymph nodes or bone involvement. HCC recurrence was observed in 5 (10.6%) of the 47 patients beyond the Milan criteria histologically as compared with 6 (4.5%) of the 132 patients within the Milan criteria histologically (P=0.160). The results of bivariate analysis of factors associated with HCC recurrence are shown in Table 2. Serum AFP level >400 ng/mL, satellite nodules, poor differentiation, microvascular invasion and CC component were associated with HCC recurrence after LT. The recurrence rate of HCC decreased from 6.1% to 3.1% when all prognostic factors identified either by liver biopsy or liver resection were ruled out (Fig.).

 

In patients with adverse prognostic factors, those who underwent liver resection as a bridge to LT seemed to have better outcomes: two patients with a CC component had neither residual tumor in the explanted liver nor recurrence, and in eight patients with AFP >400 ng/mL, one experienced HCC recurrence.

 

 

This very restrictive approach we used could be theoretically interpreted as the most reasonable one in restricting organ waste and improving the accurate use.^[10] In this study, we focused on selection of patients within the pre-LT Milan criteria which represent the most consensual guidelines.^[11] HCC patients can be “favored” by allocation scores,^[12] and the identification of a population subgroup that would benefit the most from LT without recurrence remains a cornerstone.

 

In this setting, Hwang et al^[13] proposed a “super-selection category” of HCC patients with a recurrence rate of 1.3% at 10 years. The selection was based on four criteria: one or two tumor(s), size <2 cm, and AFP <200 ng/mL. In the present study, we chose a cut-off value of 400 ng/mL for AFP levels, as it was reported by Merani et al^[14] that the last pre-LT AFP level <400 ng/mL independently predicted the survival. In another study, Hameed et al^[15] focused on selection of HCC patients for LT. They found that, by choosing a threshold of AFP >400 ng/mL, 9% of the patients would not be considered for LT, with a reduction of HCC recurrence by 26% in the transplanted patients. In patients with AFP >400 ng/mL and a reduction of HCC recurrence by 50%, 28% could be excluded from the LT program.

 

This study has several limitations. First, the low number of patients with HCC recurrence for each variable did not allow us to perform a Cox multiple regression analysis.^[16] Second, complete histology was not obtained in the pre-LT period. Adverse histological factors can be assessed by pre-LT biopsy or bridging liver resection. Bridging liver resection has several advantages: decreasing the risk of dropout on the waiting list,^{[17, 18]} down-staging the tumor, and providing an accurate histological assessment. Our previous studies^{[19, 20]} showed the safety and feasibility of partial liver resection before LT, which allowed selection of patients and could reduce the effect of adverse histological factors such as high AFP levels and the presence of CC component as demonstrated in the present study. Resected specimens provide information on tumor grade and vascular invasion.^[21] If an HCC patient is assigned to have radiofrequency ablation while on the waiting list or as a down-staging treatment, a biopsy can be easily performed at the same time. Hence pre-LT biopsy could be useful in the selection of HCC patients for LT, even outside of the context of liver resection or radiofrequency ablation. Until now, HCC biopsy is mostly useful for the assessment of tumor differentiation,^[21] even if it is not always representative of overall tumor burden.^[22] However, other markers can be used to assess microvascular invasion or biological aggressiveness, such as keratin 19,^[23] PIVKA-II,^[24] and histone H4.^[25] Recently we found that pre-LT tumor biopsy did not negatively influence the oncologic course of HCC patients eligible for LT.^[26]

 

Combined HCC-CC, also known as mixed HCC-CC, is a rare (incidence of primary liver cancer ranges from 0.87% to 4.7%) but increasingly recognized primary malignant neoplasm in the liver.^[27-29] No significant differences have been found in etiologic risk factors between HCC-CC and HCC patients.^[30] Imaging studies of combined HCC-CC depend on whether HCC or CC is a predominant component. Classic computed tomography image of combined HCC-CC has been characterized by early hypo-enhancement in the periphery and delayed enhancement in the center of the mass.^[31] Determination of CC component could be improved by the evaluation of a delayed phase at magnetic resonance imaging showing the absence of contrast washout after a progressive arterial uptake.^[32] Nevertheless, preoperative characterization remains challenging, enlightening both better accuracy of imaging findings and the key role of preoperative tumor biopsy or resection. As it was recently published, once the diagnosis of HCC-CC is obtained by biopsy or resection, these poor prognosis patients should be excluded from the transplant program.^[33]

 

This proposed strategy of selecting HCC patients based more on histological criteria than on radiological findings can allow us to eliminate candidates within the Milan criteria, who are at the highest risk of recurrence, underlining the very important role of pre-LT biopsy and/or resection of both tumor and parenchyma. However, this strategy would certainly exclude some patients who have benefited from LT. Strategies aiming at transplant benefit, i.e. selection of patients whose difference in survival with LT with respect to other treatment is maximal, should actually be pursued for a major equity. Another benefit in grafts attribution strategies would be to adapt the timing of LT to the histological results of a prior liver resection for HCC. Patients with all good histological prognostic factors could be enlisted at the time of recurrence, whereas those with limited poor histological prognostic factors should be considered de principe for LT.^[34] When too many factors associated with recurrence are present at the time of resection (AFP >400 ng/mL, CC component, poor differentiation, microvascular invasion, satellite nodules), these patients should definitely be excluded from the transplant program.

 

In conclusion, decreasing post-LT recurrence rate towards zero is a hope in HCC patients within the Milan criteria. In order to achieve this theoretical goal, (i) patients with high AFP levels above 400 ng/mL should not be considered for LT, and (ii) pre-histological assessment by liver biopsy or liver resection would allow us to rule out poorly differentiated tumors, microvascular invasion, and CC component. Liver resection before LT could down-stage the tumor, provide important data about histological factors associated with post-transplant HCC recurrence, and thus help to select a subgroup population with a very-low potential recurrence rate.

 

 

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