Source: DGNews  |  Posted 1 year ago

SAN FRANCISCO -- July 28, 2010 -- Treatments used on liver cancers beyond the established Milan criteria for liver transplantation may be appropriate for all patients with hepatocellular carcinoma (HCC) who are listed for transplantation, according to researchers at the University of California, San Francisco (UCSF), San Francisco, California. Watching tumour behaviour, meanwhile, may provide improved outcomes.

Full details appear in the August issue of Liver Transplantation, published on behalf of the American Association for the Study of Liver Diseases (AASLD).

The authors suggest that the Milan and other criteria have proved inadequate. Lead investigator John P. Roberts, MD, UCSF Transplant Service, explains, "It has not been shown there is any particular size of tumour that represents a 'no risk' of recurrence -- at least among those tumours that can be detected radiologically. Further, the degree of risk is not the same for all patients within the Milan criteria."

Dr. Roberts points out that tumour size and number are only surrogate markers for underlying tumor biology, and that using another marker -- tumour behavior over time --allows the biology of the tumour to become apparent, dictating the most appropriate treatment strategy.

The UCSF team has taken a "down staging" approach for patients with large tumours. This process involves radiofrequency ablation, chemoembolisation, or both to control the tumour, and then a requisite waiting period to determine tumour biology over time as the development of extra-hepatic or intra-hepatic spread is observed. This paradigm results in about 30% of the patients being ineligible for transplantation because of HCC progression, but those who make it to transplantation have an excellent outcome compared with patients transplanted with tumours beyond the Milan criteria who are not treated.

In this study, the median time between the first ablative procedure and transplantation was 8.2 months, with a range of 3 to 25 months. This approach suggests that the test of time may be the surest method to select patients with HCC who are destined to have good transplant outcomes. Dr. Roberts argues that this approach -- ablating the tumour and waiting -- should be expanded to all patients listed for transplantation with HCC, as the test of time can eliminate from transplantation those patients in whom disease is likely to recur after transplantation.

"Our experience with ablative treatment and then observation suggests that the ultimate outcomes of transplantation are not dependent on the primary tumour, but more on time spent waiting for transplantation," Dr. Roberts concluded. "It would seem logical that smaller and/or fewer tumours, though more unlikely to have spread, would also benefit from a period of time if the primary tumour can be controlled. The waiting period may be able to decrease the 10% recurrence rate seen in patients transplanted within Milan [criteria]."

SOURCE: Liver Transplantation