title: Morphological features of advanced hepatocellular carcinoma as a predictor of downstaging and liver transplantation: an intention-to-treat analysis.
abstract: In selected patients, locoregional therapy (LRT) has been successful in downstaging advanced hepatocellular carcinoma (HCC) so that the conventional criteria for liver transplantation (LT) can be met. However, the factors that predict successful treatment are largely unidentified. To determine these factors, we analyzed our experience with multimodal LRT in downstaging advanced HCC before LT in a retrospective cohort study. Thirty-two patients with advanced HCC exceeding conventional and expanded criteria for LT underwent therapy, but only those patients whose tumors were successfully downstaged were considered for LT. Eighteen patients (56%) had their tumors successfully downstaged; 14 patients (44%) did not. No intergroup differences existed with respect to patient characteristics or the types and number of treatments. However, mean alpha-fetoprotein levels were significantly higher in the non-downstaged group than in the downstaged group (P < 0.048), and significantly more patients in the non-downstaged group had infiltrative tumors (P = 0.0001). The median survival time was 42 and 7 months for the downstaged and non-downstaged groups, respectively (P = 0.0006). Fourteen patients (43.3%) underwent LT. After a median follow-up period of 35 months (range, 1.5-50 months) after LT, 2 patients (14.2%) developed tumor recurrence. The Kaplan-Meier survival rates after LT were 92% at 1 year and 75% at 2 years. The noninfiltrative expanding tumor type was the sole predictor of successful downstaging and improved outcome on univariate and multivariate analyses. Our study suggests that, in patients with advanced HCC, morphological characteristics of the tumor may predict a good response to downstaging and an improved outcome after LT.
authors.affiliation: Department of Hepatobiliary and Liver Transplant Surgery, St. Luke's Episcopal Hospital, 6624 Fannin, Houston, TX 77030, USA. omarbarakat@sbcglobal.net
authors.forename: Omar
authors.initials: O
authors.lastname: Barakat
authors.forename: R Patrick
authors.initials: RP
authors.lastname: Wood
authors.forename: Claire F
authors.initials: CF
authors.lastname: Ozaki
authors.forename: Victor
authors.initials: V
authors.lastname: Ankoma-Sey
authors.forename: Joseph
authors.initials: J
authors.lastname: Galati
authors.forename: Mark
authors.initials: M
authors.lastname: Skolkin
authors.forename: Barry
authors.initials: B
authors.lastname: Toombs
authors.forename: Mary
authors.initials: M
authors.lastname: Round
authors.forename: Warren
authors.initials: W
authors.lastname: Moore
authors.forename: Luis
authors.initials: L
authors.lastname: Mieles
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D009367:Neoplasm Staging; D018579:Patient Selection; D016016:Proportional Hazards Models; D040841:Resource Allocation; D012189:Retrospective Studies; D012307:Risk Factors; D009927:Tissue and Organ Procurement; D047368:Tumor Burden