Down-Staged Liver Cancer Associated With Good Post-Transplant Outcomes

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Title: Down-Staged Liver Cancer Associated With Good Post-Transplant Outcomes
URL: http://www.pslgroup.com/dg/22AF82.htm
Doctor's Guide
September 5, 2008

HOBOKEN, NJ -- September 5, 2008 -- Patients with liver cancer can become viable candidates for transplantation if their tumours respond to treatment, according to a new study published in the September issue of Hepatology.

Past studies have suggested that patients with larger lesions may do well with a transplant. But rather than expand the Milan criteria, researchers have suggested down-staging hepatocellular carcinoma to select for tumours with more favourable biology that will respond to treatment and do well following liver transplantation.

The impact of successful down-staging on post-transplant outcomes was heretofore unknown.

Francis Yao, MD, University of California at San Francisco, San Francisco, California, and colleagues conducted a prospective study of down-staging protocol and report intention-to-treat survival, dropout and post-transplant tumour recurrence, along with factors that may influence response to down-staging treatment.

Between June 2002 and January 2007, the researchers enrolled 61 patients with liver cancer whose tumour stage exceeded the Milan criteria. Of these patients, 55 received a combination of laparoscopic radiofrequency ablation (RFA) and transarterial chemoembolisation (TACE). The remaining 6 patients underwent resection as the down-staging procedure.

Down-staging was successful in 43 of the 61 patients (70.5%), and 35 of those received a liver transplant after a median of 8.2 months. While 2 of the transplant recipients died (1 from graft problems and 1 from recurrent hepatitis C infection), the remaining 33 were alive and free of liver cancer recurrence after a median follow-up of 25 months.

In the patients for whom down-staging was unsuccessful, 15 had tumour progression and 3 died (2 related to the down-staging, the other not).

Comparing the clinical characteristics of the 35 patients who received a liver transplant to the 18 patients with treatment failure, only median alpha fetoprotein (AFP) level was significantly different. Treatment failure was the eventual outcome in 7 of the 8 patients with pretreatment AFP >1000 ng/mL.

"High AFP may be a marker for vascular invasion or extra-hepatic disease that escapes detection by conventional imaging techniques," the authors wrote.

The authors note the heterogeneity of the locoregional therapy may be a weakness of their study and that the optimal treatment should be determined on a case-by-case basis.

They also point out that 25 months of post-transplant follow-up may be too short to fully determine the risk of liver cancer recurrence.

"Our results suggest that tumour down-staging to meet conventional criteria for orthotopic liver transplantation among carefully selected patients is associated with excellent post-transplant outcome," the authors conclude.

"Down-staging put selection pressure against aggressive tumours that are likely to progress despite treatment, whereas tumours with more favourable histology are more likely to respond to treatment and do well after OLT [orthotopic liver transplant]."

They call for further studies to refine down-staging treatment strategies to improve the intention-to-treat outcome.

SOURCE: Wiley-Blackwell

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