Liver Transplantation is a Preferable Alternative to Palliative Therapy for Selected Patients with Advanced Hepatocellular Carcinoma.
BACKGROUND
Patients with hepatocellular carcinoma (HCC) beyond the traditional criteria (advanced HCC) are typically offered palliation, which is associated with a 3-year survival rate lower than 30%. This study aimed to describe the outcomes for a subset of patients with advanced HCC who satisfied the Extended Toronto Criteria (ETC) and were listed for liver transplantation (LT).


METHODS
All patients listed in the Toronto liver transplantation program with HCC beyond both the Milan and University of California, San Francisco criteria were included in this study. Data were extracted from the prospectively collected electronic database. All radiologic images were reviewed by two independent radiologists. The primary end point was patient survival.


RESULTS
Between January 1999 and August 2014, 96 patients with advanced HCC were listed for LT, and 62 (65%) of these patients received bridging therapy while on the waiting list. Bridging therapy led to a significant reduction in tumor progression (p = 0.02) and tumor burden (p < 0.001). The majority of those listed underwent LT (n = 69, 72%). Both tumor progression on waiting list (hazard ratio [HR] 4.973; range1.599-15.464; p = 0.006) and peak alpha-fetoprotein (AFP) at 400 ng/ml or higher (HR, 4.604; range 1.660-12.768; p = 0.003) were independently associated with waiting list dropout. Post-LT HCC recurrence occurred in 35% of the patients (n = 24). Among those with HCC recurrence, survival was significantly better for those who received curative treatment (p = 0.004). The overall actuarial survival rates from the listing were 76% at 1 year, 56% at 3 years, and 47% at 5 years, and the corresponding rates from LT were 93, 71, and 66%.


CONCLUSIONS
Liver transplantation provides significantly better survival rates than palliation for patients with selected advanced HCC.
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.|National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK.
Aloysious D
AD
Aravinthan
Department of Medical Imaging, University of Toronto, Toronto, Canada.
Silvio G
SG
Bruni
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Adam C
AC
Doyle
Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
Hla-Hla
HH
Thein
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Nicolas
N
Goldaracena
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Assaf
A
Issachar
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Leslie B
LB
Lilly
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Nazia
N
Selzner
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Mamatha
M
Bhat
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Boraiah
B
Sreeharsha
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Markus
M
Selzner
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Anand
A
Ghanekar
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Mark S
MS
Cattral
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Ian D
ID
McGilvray
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
Paul D
PD
Greig
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.|Department of Medicine, Max Rady College of Medicine/Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
Eberhard L
EL
Renner
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
David R
DR
Grant
Multiorgan Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada. gonzalo.sapisochin@uhn.ca.|Abdominal Transplant & HPB Surgical Oncology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. gonzalo.sapisochin@uhn.ca.
Gonzalo
G
Sapisochin
D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D018579:Patient Selection; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D047368:Tumor Burden