1. In patients with hepatocellular carcinoma who underwent liver transplantation, response to transarterial chemoembolization and radiologic size of tumor were both shown to independently predict rates of recurrence.
2. Patients with no response to chemoembolization and a radiologic tumor size greater than 3 cm had a recurrence rate of 35.8% compared with 1.9% for patients responding to chemoembolization and a tumor size less than 3 cm.
Evidence Rating Level: 2 (Good)
Study Rundown: Liver transplantation has played an increasing role in the treatment of hepatocellular carcinoma (HCC). Recurrence following transplantation remains an issue, however, and pre-operative identification of patients at a higher risk for recurrence is limited. This study aimed to identify pre-operative factors to predict rates of HCC recurrence in patients after liver transplantation. Through multivariate analysis, the authors found that a lack of tumor responsiveness to transarterial chemoembolization (TACE) and radiologic tumor size greater than 3 cm were both independent predictors of HCC recurrence. Vascular invasion of the tumor had the strongest association with recurrence but such information is not known pre-operatively, limiting its predictive value. This study provides a means by which to identify patients who are at higher risk of HCC recurrence following liver transplantation. The true utility of such pre-transplant identification is limited by the ethical dilemma in preferentially selecting patients for transplants who lie in the theoretical “lower-risk” group. That said, there is certainly value in identifying patients with a high risk of recurrence as it would allow for more extensive pre-transplant therapy. This study is limited by selection bias imposed by its retrospective nature as only patients who were treated with TACE and had sufficient time for pre-transplantation radiologic follow-up were included in the analysis.
In-Depth [retrospective cohort]: 173 patients with HCC who received a liver transplant were selected for inclusion into the study if they underwent pre-transplant TACE along with radiologic follow-up. Patient’s response to TACE was assessed using modified response evaluation criteria in solid tumors (mRECIST) and patients were accordingly grouped as “responders” or “non-responders.” mRECIST response categories are organized by the extent of arterial invasion of the tumor. Response to TACE was shown to be predictive of HCC recurrence. 5-year recurrence was 5.3% in the “responder” group compared to 17.6% in the in the non-responders. Tumor size greater than 3 cm was also independently predictive of HCC recurrence. The rate of recurrence in patients who were non-responders to TACE and had a tumor size grater than 3 cm was 35.8%, 10.8% for patients who were non-responders but who had a tumor size less than 3 cm, 11.9% for patients who were responders with a tumor size greater than 3 cm, and 1.9% for patients who responded to TACE and had a tumor size less than 3 cm (log-rank, p=.0007).
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