Retrogradation of hepatocellular carcinoma before liver transplantation Results at 10 years

By ASCO Postal Staff

Posted: 07/26/2022 11:30:00 AM

Last update: 26/07/2022 14:37:49



In some patients with hepatocellular carcinoma, the downgrading of the disease within the criteria that qualifies the patient for a liver transplant leads to excellent post-transplant results at 10 years, according to new research published by Tabrizian et al in JAMA surgery. The results validate current national policies regarding transplant eligibility.

Milan Criteria

The selection of patients with hepatocellular carcinoma (HCC), the most common form of liver cancer, for transplantation has been guided for more than 2 decades by standards known as the Milan Criteria. The Milan criteria state that transplantation should be performed in people with a single tumor measuring 5 cm or less in diameter or three tumors each measuring 3 cm or less in diameter, without macrovascular invasion and without metastasis. Over time, increasing HCC incidence and mortality rates in the United States have led to improvements in screening policy, with an emphasis on guidelines that also incorporate tumor biology, response to bridging therapies and wait times for patients within and beyond the Milan Criteria.

Demotion

One aspect of the current criteria is known as downstaging: the process of applying liver-directed therapy to tumors too large for the Milan criteria in the hope of shrinking them to the suggested size. Downgrading is now an option in the selection of suitable liver transplant candidates with initial tumors that exceed the criteria. However, liver cancer can come back after a transplant, either in the liver or outside the liver. Treatment options for patients who have post-transplant recurrence are limited, and the prognosis in these patients tends to be poor.

  • Survival and recurrence rates at 10 years after transplantation were 52.1% and 20.6%, respectively, in people with reversed disease; 61.5% and 13.3% among those still meeting the criteria; and 43.3% and 41.1% in those whose disease was not reversed.
  • “Our study validates national policy on pre-transplant stage reduction and demonstrates the clear benefit of utility for transplant prioritization decision-making,” the authors commented.

Current study

In this cohort study, a retrospective multicenter analysis of prospectively collected data was conducted for 2645 adults who underwent liver transplantation for HCC at five US academic medical centers between January 2001 and December 2015; the analysis was performed from May 2019 to June 2021. The results of 341 patients whose disease was downgraded to meet the Milan criteria were compared with those of 2,122 patients whose disease still met the criteria and 182 patients whose disease has not been reversed.

Survival and recurrence rates at 10 years after transplantation were 52.1% and 20.6%, respectively, in people with reversed disease; 61.5% and 13.3% among those still meeting the criteria; and 43.3% and 41.1% in those whose disease was not reversed.

“Our study validates national policy on pre-transplant stage reduction and shows the clear benefit of utility for transplant prioritization decision-making,” said Parissa Tabrizian, MD, co-lead author of the study and associate professor of surgery at the Icahn School of Medicine at Mount Sinai. “These findings may increase the level of recommendations for downstaging policy globally. It also demonstrates that surgical management of HCC recurrences after transplantation is associated with improved survival in well-selected patients and should be continued. The study also supports the broadening of the downstaging policy applied to recommendations in Europe and Asia.

“Our study represents strong confirmation that [patients with] HCC effectively downgraded to Milan criteria has an exceptional median survival of 10 years, justifying the adoption of this policy globally,” said Josep Llovet, MD, PhDco-lead author of the study and founder and director of the Liver Cancer Program at Mount Sinai Health System.

Disclosure: For full disclosures from the study authors, visit jamnetwork.com.

The content of this article has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the views and opinions of ASCO®.


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