Surgical dilemma: liver resection or liver transplantation for hepatocellular carcinoma and cirrhosis. Intention-to-treat analysis in patients within and outwith Milan criteria

AbstractBackgroundThe optimal role of surgery in the management of hepatocellular carcinoma (HCC) is in continuous evolution.ObjectiveThe objective of this study was to analyse survival rates after liver resection (LR) and orthotopic liver transplantation (OLT) for HCC within and outwith Milan criteria in an intention-to-treat analysis.MethodsDuring 1997–2007, 179 patients with cirrhosis and HCC either underwent LR (n= 60) or were listed for OLT (n= 119). Patients with incidental HCC after OLT, preoperative macrovascular invasion before LR, non-cirrhosis and Child–Pugh class C cirrhosis prior to OLT were eliminated, leaving 51 patients primarily treated with LR and 106 patients listed for primary OLT (84 of whom were transplanted) to be included in this analysis. A total of 66 patients fell outwith Milan criteria (26 LR, 40 OLT) and 91 continued to meet Milan criteria (25 LR, 66 OLT).ResultsThe median length of follow-up was 26 months. The mean waiting time for OLT was 7 months. During that time, 21 patients were removed from the waiting list as a result of tumour progression. Probabilities of dropout were 2% and 13% at 6 and 12 months, respectively, for patients within Milan criteria, and 34% and 57% at 6 and 12 months, respectively, for patients outwith Milan criteria (P < 0.01). Tumour size >3cm was found to be the independent factor associated with dropout (hazard ratio [HR] 6.0). Postoperative survival was slightly higher after OLT, but this was not statistically significant (64% for OLT vs. 57% for LR). Overall survival from time of listing for OLT or LR did not differ between the two groups (P= 0.9); for patients within Milan criteria, 1- and 4-year survival rates after LR were 88% and 61%, respectively, compared with 92% and 62%, respectively, after OLT (P= 0.54). For patients outwith Milan criteria, 1- and 4-year survival rates after LR were 69% and 54%, respectively, compared with 65% and 40%, respectively, after OLT (P= 0.42). Tumour size >3cm was again found to be an independent factor for poor outcome (HR 2.4) in the intention-to-treat analysis.ConclusionsSurvival rates for patients with HCC are similar in LR and OLT. Liver resection can potentially decrease the dropout rate and serve as a bridge for future salvage LT, particularly in patients with tumours >3cm

Yttrium-90 glass-based microsphere radioembolization in the treatment of hepatocellular carcinoma secondary to the hepatitis B virus: Safety, efficacy, and survival

Purpose: To evaluate outcomes of yttrium-90 radioembolization performed with glass-based microspheres in the treatment of hepatocellular carcinoma (HCC) secondary to the hepatitis B virus (HBV). Materials and Methods: A total of 675 patients treated between January 2006 and July 2014 were reviewed, of which 45 (age 62 y +/- 10; 91% male) received glass-based radioembolization for HCC secondary to HBV. All patients were stratified according to previous therapy (naive, n = 14; 31.1%), Child-Pugh class (class A, n = 41; 91%), Eastern Cooperative Oncology Group (ECOG) performance status (PS; 400 ng/mL (n = 17; 38%), and Barcelona Clinic Liver Cancer stage (A, n = 8; B, n = 9; C, n = 28). Results: A total of 50 radioembolization treatments were performed, with a 100% technical success rate (median target dose, 120 Gy). Clinical toxicities included pain (16%), fatigue (12%), and nausea (4%). Grade 3/4 laboratory toxicities included bilirubin (8%) and aspartate aminotransferase (4%) toxicities. Observed toxicities were independent of treatment dose. The objective response rates were 55% per modified Response Evaluation Criteria In Solid Tumors and 21% per World Health Organization criteria, and the disease control rate was 63%. Disease progression was secondary to new, nontarget HCC in 45% of cases. Median time to progression and overall survival were 6.0 mo (95% confidence interval [CI], 4.4-8.0 mo) and 19.3 mo (95% CI, 11.2-22.7 mo), respectively. Multivariate analysis demonstrated ECOG PS >= 1 and AFP level > 400 ng/mL to be independent predictors of inferior overall survival. Conclusions: Glass-based radioembolization for HCC secondary to HBV can be safely performed, with favorable target lesion response and overall survival

Outcomes of Radioembolization in the Treatment of Hepatocellular Carcinoma with Portal Vein Invasion: Resin versus Glass Microspheres

Purpose: To compare outcomes of yttrium-90 radioembolization performed with resin-based (Y-90-resin) and glass-based (Y-90-glass) microspheres in the treatment of hepatocellular carcinoma (HCC) with associated portal vein invasion. Materials and Methods: A single-center retrospeetive review (January 2005-September 2014) identified 90 patients (Y-90-resin, 21; Y-90-glass, 69) with HCC and ipsilateral portal vein thrombosis (PVT), Patients were stratified according to age, sex, ethnicity, Child-Pugh class, Eastern Cooperative Oncology Group status, alpha-fetoprotein > 400 ng/mL, extent of PVT, tumor burden, and sorafenib therapy. Outcome variables included clinical and laboratory toxicifies (Common Terminology Criteria Adverse Events, Version 4.03), imaging response (modified Response Evaluation Criteria in Solid Tumors), time to progression (TTP), and overall survival (OS). Results: Grade 3/4 bilirubin and aspartate aminotransferase toxicities developed at a 2.8-fold (95% confidence interval [CI], 1.3-6.1) and 2.6-fold (95% CI, 1.1-6.1) greater rate in the Y-90-resin group. The disease control rate was 37.5% in the Y-90-resin group and 54.5% in the Y-90-glass group (P = .39). The median (95% CI) TTP was 2.8 (1.9-4.3) months in the Y-90-resin group and 5.9 (4.2-19.1) months in the Y-90-glass group (P = .48). Median (95% CI) survival was 3,7 (2.3-6.0) months in the Y-90-resin group and 9.4 (7.6-45.0) months in the Y-90-glass group (hazard ratio, 2.6; 95% CI, 1.5-4.3, P < .001). Additional multivariate predictors of improved OS included age < 65 years, Eastern Cooperative Oncology Group status < 1, alpha-fetoproteiu <= 400 ng/mL, and unilobar tumor distribution. Conclusions: Imaging response of Y-90 treatment in patients with HCC and PVT was not significantly different between Y-90-glass and Y-90-resin groups. Lower toxicity and improved OS were observed in the Y-90-glass group

Right hepatectomy for living donation: Role of remnant liver volume in predicting hepatic dysfunction and complications

BACKGROUND: Extensive attention has been placed on remnant liver volume (RLV) above other factors to ensure donor safety. METHODS: We performed a retrospective review of 137 right hepatectomies in live donors between June 1999 and November 2010. RESULTS: Median right lobe volume was 1,029 cm(3), which correlated with its actual weight (r = 0.63, P 3 mg/dL or prothrombin time >18 s on postoperative day 4). RLV did not predict postoperative hepatic dysfunction (P = .9), but it was associated with peak international normalized ratio (INR) (P = .04). Donor age and male gender were predictors of increased bilirubin at postoperative day 4 (age, P = .03; gender, P = .02). Of the donors, 45 (33%) experienced complications, and 24 donors had RLVs <30%; 42% experienced complications compared to 31% of donors whose RLVs were greater than 30% (P = .3). Cell-saver utilization and aspartate-aminotransferase (AST) levels (OR = 3) were associated with complications. Volumetric assessment can predict RLV accurately. CONCLUSION: Although no demonstrable association between RLV <30% and complications was found, an RLV of 30% should remain the threshold for donor safety. Age and gender should be balanced in donors with a near threshold RLV of 30%. Surgical complexity, suggested by the need for intraoperative autoinfusion of blood and postoperative levels of AST, remained the independent predictor of complications.Fil: Facciuto, Marcelo. Mount Sinai Medical Center; Estados UnidosFil: Contreras Saldivar, Alan. Mount Sinai Medical Center; Estados UnidosFil: Singh, Manoj K.. Mount Sinai Medical Center; Estados UnidosFil: Rocca, Juan Pablo. Mount Sinai Medical Center; Estados UnidosFil: Taouli, Bachir. Mount Sinai Medical Center; Estados UnidosFil: Oyfe, Irina. Columbia University; Estados UnidosFil: LaPointe Rudow, Dianne. Mount Sinai Medical Center; Estados UnidosFil: Gondolesi, Gabriel Eduardo. Fundación Favaloro; Argentina. Universidad Favaloro; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Schiano, Thomas. Mount Sinai Medical Center; Estados UnidosFil: Kim Schluger, Leona. Mount Sinai Medical Center; Estados UnidosFil: Schwartz, Myron E.. Mount Sinai Medical Center; Estados UnidosFil: Miller, Charles M.. Cleveland Clinic. Digestive Disease Institute. Department of Hepato-Pancreato-Biliary and Transplant Surgery ; Estados UnidosFil: Florman, Sander. Mount Sinai Medical Center; Estados Unido