Published online Jan 27, 2020. doi: 10.4240/wjgs.v12.i1.17
Peer-review started: October 3, 2019
First decision: October 24, 2019
Revised: November 6, 2019
Accepted: November 28, 2019
Article in press: November 28, 2019
Published online: January 27, 2020
Liver transplantation (LT) has become an ideal curative treatment for liver cirrhosis associated with hepatocellular carcinoma (HCC) as it simultaneously removes the tumors and cures the underlying liver cirrhosis. Although the overall outcome of LT for HCC is favorable, tumor recurrence is still a great concern. Hence, there remain several unmet needs for improving the long-term outcome of LT for HCC.
Living donor LT (LDLT) account for the majority of LT in most of Asian region because of the scarcity of organ from deceased donors. LDLT offers a flexible timing for transplantation providing timeframe for well preparation of transplantation. Theoretically, a pre-operative treatment might mitigate the tumor burden and improve the overall outcome of HCC patients. Therefore, further investigation of LDLT in terms of pre-transplantation loco-regional therapy remains important to optimize therapeutic strategies for patients with HCC.
The main objectives of this study were to analyze patients who underwent LDLT for HCC to investigate the outcome in relation to the intention of pre-transplantation loco-regional therapy.
All patients who had undergone LDLT for HCC between August 2004 and December 2018 were retrospectively analyzed. Subsequently, patients were grouped according to the intention of loco-regional therapy prior to LDLT, and outcomes of patients were analyzed and compared between groups. Group I comprised patients who had not received any loco-regional therapy before LDLT. Group II comprised patients who had HCC within the University of California at San Francisco (UCSF) radiological criteria (rUCSF), but had loco-regional before LDLT. Group III comprised patients who had an HCC beyond rUCSF criteria, and loco-regional therapy was performed for the purpose of down-staging.
Of 308 patients who underwent LDLT for HCC during the study period were divided into Group I (n = 52), Group II (n = 228) and Group III (n = 28) based on aforementioned definition. Overall, 38 patients (12.3%) were detected with HCC recurrence during the follow-up period after LDLT. Group III patients had significant inferior outcomes to other two groups for both recurrence-free survival (RFS, P < 0.0005) and overall survival (OS, P = 0.046). However, RFS and OS outcomes between group I and II were statistically similar. Moreover, patients with defined profound tumor necrosis by loco-regional therapy had a superior RFS as compared with others.
The outcome of LDLT for patient with HCC was satisfactory with a favorable RFS rate in this study. Nonetheless, loco-regional therapy prior to LDLT seems to not provide beneficial outcome unless a certain effect of loco-regional therapy prior to transplantation is achieved. Loco-regional therapy prior to LDLT might be insufficient for achieving a better outcome but still encouraged as long as the patient is suitable for such treatment.
The study is still unable to establish a definitive therapeutic protocol to achieve a beneficial outcome of HCC patients after LDLT. Nonetheless, loco-regional therapy for HCC patient awaiting LT remains an international consensus for the management of HCC patients during the waiting time. The low incidence of HCC recurrence might be unable to reflect significance difference in this study. Therefore, additional loco-regional therapy studies in terms of high quality or larger prospective cohort studies could be undertaken in HCC patients listed for LDLT.