Extended postinterventional tumor necrosis-implication for outcome in liver transplant patients with advanced HCC.
BACKGROUND
Locoregional interventional bridging therapy (IBT) is an accepted neoadjuvant approach in liver transplant candidates with hepatocellular carcinoma (HCC). However, the prognostic value of IBT in patients with advanced HCC is still undefined.


OBJECTIVE
The aim of this trial was to evaluate the impact of postinterventional tumor necrosis on recurrence-free long-term survival after liver transplantation (LT) in patients with HCC, especially focusing on those exceeding the Milan criteria on pretransplant radiographic imaging.


METHODS
A total of 93 consecutive liver transplant candidates with HCC were included in this trial. In 36 patients, tumors were clinically staged beyond Milan criteria prior LT. Fifty-nine patients underwent IBT by transarterial chemoembolization or radiofrequency ablation pretransplantation. Postinterventional tumor necrosis rate as assessed at liver explant pathology was correlated with outcome post-LT.


RESULTS
There was no significant difference in 5-year tumor-free survival rate between the IBT- and the non-IBT subpopulation (78% versus 68%, P=0.25). However, tumor response following IBT (≥ 50% tumor necrosis rate at explant pathology) resulted in a significantly better outcome 5 years post-LT (96%) than tumor non-response to IBT (<50% tumor necrosis rate at explant pathology; 21%; P<0.001). Five-year recurrence-free survival rate was 80% in Milan Out patients with extended post-IBT tumor necrosis versus 0% in Milan Out patients without tumor response to IBT (P<0.001). None of macromorphological HCC features, but only the absence of increased (18)F-fluoro-deoxy-glucose ((18)FDG) uptake on pretransplant positron emission tomography (PET) was identified as independent predictor of postinterventional tumor response (P<0.001).


CONCLUSIONS
Our results implicate that extended postinterventional tumor necrosis promotes recurrence-free long-term survival in patients with HCC beyond standard criteria. Pretransplant PET assessment may identify those patients with advanced HCC that will benefit from post-IBT tumor response and may, thereby, achieve excellent posttransplant outcome.
Department of Surgery, Klinikum rechts der Isar, Technical University, Munich, Germany. ArnoKornberg@aol.com
Arno
A
Kornberg
Ulrike
U
Witt
Edouard
E
Matevossian
Bernadett
B
Küpper
Volker
V
Assfalg
Alexander
A
Drzezga
Norbert
N
Hüser
Moritz
M
Wildgruber
Helmut
H
Friess
D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D017115:Catheter Ablation; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging / Q000601:surgery*; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D016031:Liver Transplantation; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging; D015999:Multivariate Analysis; D009336:Necrosis; D009364:Neoplasm Recurrence, Local; D049268:Positron-Emission Tomography; D011379:Prognosis; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome