Background
Several important changes were made to the 8th edition of the American Joint Committee on Cancer (AJCC) tumor staging system for intrahepatic cholangiocarcinoma (ICC). We assessed the ...prognostic impact of this new tumor staging system compared to the 7th edition.
Methods
A retrospective single‐institution study was performed with 626 patients who underwent R0 resection for ICC over 20‐year period.
Results
Anatomical resection and concurrent bile duct resection were performed in 571 (91.2%) and 62 (9.9%) patients, respectively. Cumulative tumor recurrence and patient survival rates were 40.6% and 73.3% at 1 year; 66.7% and 43.8% at 3 years; 73.6% and 30.4% at 5 years; and 74.4% and 20.3% at 10 years, respectively. Independent prognostic factors for tumor recurrence and patient survival were multiple tumors, carbohydrate antigen 19‐9 >200 U/ml, tumor size >5 cm, direct invasion to extrahepatic structure, and lymph node metastasis. For tumor‐node‐metastasis stages in the 7th versus the 8th editions, concordance index was 0.615 and 0.625 for tumor recurrence and 0.626 and 0.628 for patient survival, respectively.
Conclusions
The 8th edition of the AJCC staging system appears to provide high prognostic contrast for T stage categories, except for T3. However, overall prognostic performance of the 8th edition was not markedly improved over the 7th edition.
Highlight
In this high‐volume single‐center study, Kang and colleagues compared the prognostic impact of the 7th and 8th editions of the AJCC tumor staging system for intrahepatic cholangiocarcinoma. The 8th edition appears to provide high prognostic contrast for most tumor stage categories, but no marked improvement in overall prognostic performance.
Background
Salvage liver transplantation is a definite treatment for recurrent hepatocellular carcinoma (HCC) after hepatectomy. ADV score is calculated by multiplying α‐fetoprotein and ...des‐γ‐carboxyprothrombin concentrations and tumor volume. Prognostic accuracy of ADV score was assessed in patients undergoing salvage living donor liver transplantation (LDLT) and their outcomes were compared with patients undergoing primary LDLT.
Methods
This study was a retrospective, single‐center, case‐controlled study. Outcomes were compared in 125 patients undergoing salvage LDLT from 2007 to 2018 and in 500 propensity score‐matched patients undergoing primary LDLT.
Results
In patients undergoing salvage LDLT, median intervals between hepatectomy and tumor recurrence, between first HCC diagnosis and salvage LDLT, and between hepatectomy and salvage LDLT were 12.0, 37.2, and 29.3 months, respectively. Disease‐free survival (DFS, P = .98) and overall survival (OS, P = .44) rates did not differ significantly in patients undergoing salvage and primary LDLT. Pretransplant and explant ADV scores were significantly predictive of DFS and OS in patients undergoing salvage and primary LDLT (P < .001). DFS after prior hepatectomy (P = .52) and interval between hepatectomy and LDLT (P = .82) did not affect DFS after salvage LDLT. Milan criteria and ADV score were independently prognostic of DFS and OS following salvage LDLT, and prognosis of patients within and beyond Milan criteria could be further stratified by ADV score.
Conclusions
Risk factors and posttransplant outcomes were similar in patients undergoing salvage and primary LDLT. ADV score is surrogate biomarker for posttransplant prognosis in salvage and primary LDLT recipients. Prognostic model incorporating ADV scores can help determine whether to perform salvage LDLT.
Highlight
Hwang and colleagues developed a prognostic model for hepatocellular carcinoma based on α‐fetoprotein and des‐γ‐carboxyprothrombin concentrations and tumor volume (ADV). The ADV score is a surrogate biomarker for post‐transplant prognosis in salvage and primary liver transplant recipients. Prognostic models incorporating ADV scores can help determine whether to perform salvage liver transplantation.
When timely access to deceased‐donor livers is not feasible, living‐donor liver transplantation (LDLT) is an attractive option for patients with hepatorenal syndrome (HRS). This study's primary ...objective was to describe outcomes after LDLT among HRS recipients, and the secondary objective was to determine predictors of poor renal recovery after LDLT. This single‐center, retrospective study included 2185 LDLT recipients divided into HRS (n = 126, 5.8%) and non‐HRS (n = 2059, 94.2%) groups. The study outcomes were survival and post‐LT renal recovery. The HRS group had a higher death rate than the non‐HRS group (17.5% vs. 8.6%, p < 0.001). In the HRS group, post‐LT renal recovery occurred in 69.0%, and the death rate was significantly lower in association with HRS recovery compared with non‐recovery (5.7% vs. 43.6%, p < 0.001). Multivariable analysis indicated that post‐LT sepsis (p < 0.001) and non‐recovery of HRS (p < 0.001) were independent negative prognostic factors for survival. Diabetes mellitus (p = 0.01), pre‐LT peak serum creatinine ≥3.2 mg/dl (p = 0.002), time interval from HRS diagnosis to LDLT ≥38 days (p = 0.01), and post‐LT sepsis (p = 0.03) were important negative prognostic factors for renal recovery after LDLT. In conclusion, post‐LT renal recovery was important for survival, and the interval from HRS to LDLT was significantly associated with post‐LT renal recovery.
When timely access to deceased‐donor livers is not available for candidates with hepatorenal syndrome, expeditious living‐donor liver transplantation can reduce the risk of death or permanent renal failure. Selzner and Wong comment on page 2291
Combined hepatocellular carcinoma–cholangiocarcinoma (cHCC‐CC) is a rare disease. We investigated the clinicopathological features of cHCC‐CC and compared the longterm outcomes following liver ...transplantation (LT) and hepatic resection (HR). We identified 32 LT patients with cHCC‐CC through an institutional database search. The HR control group (n = 100) was selected through propensity score‐matching. The incidence of cHCC‐CC among all adult LT patients was 1.0%. Mean patient age was 53.4 ± 6.7 years, and 26 patients were male. Thirty patients had hepatitis B virus infection. All patients of cHCC‐CC were diagnosed incidentally in the explanted livers. Mean tumor diameter was 2.5 ± 1.3 cm, and 28 patients had single tumors. Tumor stage was stage I in 23 and II in 9. Concurrent hepatocellular carcinoma (HCC) was detected in 12 patients with stage I in 5 and II in 7. Mean tumor diameter was 1.9 ± 1.2 cm, and 5 had single tumors. Tumor recurrence and survival rates were 15.6% and 84.4% at 1 year and 32.2% and 65.8% at 5 years, respectively. Patients with very early stage cHCC‐CC (1 or 2 tumors ≤ 2.0 cm) showed 13.3% tumor recurrence and 93.3% patient survival rates at 5 years, which were significantly improved than those with advanced tumors (P = 0.002). Tumor recurrence and survival rates did not differ significantly between the LT and HR control groups (P = 0.22 and P = 0.91, respectively); however, postrecurrence patient survival did (P = 0.016). In conclusion, cHCC‐CC is rarely diagnosed following LT, and one‐third of such patients have concurrent HCC. The longterm posttransplant prognosis was similar following LT and HR. Very early cHCC‐CC resulted in favorable posttransplant prognosis, thus this selection condition can be prudently considered for LT indication. Liver Transplantation 23 330–341 2017 AASLD.
Background
The resection of liver tumors that involve the hepatic veins adjacent to the vena cava or hepatic hilum is technically challenging. We present our surgical techniques and the long‐term ...outcome of five patients with conventionally unresectable tumors.
Methods
Five patients with conventionally unresectable tumors were successfully treated by “ex‐situ liver resection” and “in‐situ and ante‐situm hypothermic liver perfusion” under total vascular exclusion and venovenous bypass.
Results
These approaches allowed complete tumor removal with vascular reconstruction under a bloodless surgical field, while minimizing hepatic ischemic injury and preserving liver function. No perioperative mortalities occurred, and postoperative complications were minimal. The postoperative survival periods were limited due to the advanced malignancies in our patients, but the survival benefit was encouraging. The median postoperative survival time was 29.1 months, with the longest survival period being nearly 10 years. These approaches improved the quality of life and provided an opportunity for additional treatment.
Conclusions
Hypothermic perfusion hepatectomy is a realistic option for achieving surgical cure or significantly improved survival and quality of life in patients with tumors deemed unresectable using conventional normothermic hepatectomy. These approaches can overcome the limitations of the liver's restricted normothermic ischemia tolerance or inaccessible tumor locations.
Highlight
Some liver tumors are conventionally unresectable because of the liver’s limited tolerance to long normothermic ischemia or inaccessible tumor location. Yoon and colleagues present their surgical technique and long‐term outcomes of five cases treated by in‐situ or ante‐situm hypothermic liver perfusion or ex‐situ liver resection under total vascular exclusion and venovenous bypass.
Background
Surgical and oncological outcomes in ruptured hepatocellular carcinoma (HCC) are not well known. The objective of this study was to review and compare survival outcomes and recurrence ...rates between ruptured and unruptured HCC.
Methods
Data of patients with ruptured HCC who underwent curative surgical resection between January 2000 and December 2016 were retrospectively reviewed. To compare survival outcomes between ruptured and unruptured HCC, 1:2 individual matching was conducted.
Results
The 1-, 3-, and 5-year overall survival (OS) rates were 88.8%, 67.0%, and 51.9%, respectively. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 51.7%, 32.8%, and 25.0%, respectively. OS and DFS rates were significantly lower in the ruptured HCC group than the matched unruptured HCC group. HCC recurred in 63 patients (70.8%), 33 (52.4%) of whom presented with both intrahepatic and extrahepatic recurrences. Mean recurrence interval was 12.6 ± 13.8 months. The 1-, 3-, and 5-year survival rates after recurrence were 61.6%, 40.2%, and 33.6%, respectively. Mean survival time after recurrence was 26.4 ± 29.5 months. Incidence of peritoneal seeding (PS) was 18.0%, and eight of them demonstrated solitary lesion. Mean recurrence interval was 5.9 ± 8.2 months. The 1-, 3-, and 5-year OS rates after recurrence were significantly lower in patients with PS (49.7%, 18.7%, and 9.3%, respectively) than in patients without PS.
Conclusions
Hepatectomy in ruptured HCC did show worse survival outcome compared with unruptured HCC and bear a high risk of PS. However, surgical resection combined with transcatheter arterial chemoembolization could help in achieving acceptable oncological outcomes.
Background & Aims With the introduction of rituximab prophylaxis, the survival of ABO-incompatible (ABOi) adult living donor liver transplant (ALDLT) has been strikingly improved due to the decreased ...incidence of antibody-mediated rejection. However, biliary stricture (BS) related to ABO incompatibility remains an unresolved concern. Methods Excluding 105 dual graft ALDLTs, 1102 ALDLT cases including 142 ABOi recipients were included in this study. The desensitization protocol for overcoming the ABO blood group barrier comprised pretransplant plasma exchange, and rituximab (300–375 mg/m2 BSA). Results The mean follow-up period was 34.2 ± 15.4 months. The cumulative graft and patient survival rates were comparable in the two groups. The 1- and 3-year BS-free survival rates of ABOi ALDLT were 81.5 and 79.0%, respectively, lower than those of ABOc ALDLT (87.6 and 85.7%, respectively, p = 0.022). In the risk factor analysis, diameter of graft bile duct opening <5 mm, antecedent acute cellular rejection, and ABO incompatibility were independent risk factors for BS. Diffuse intrahepatic biliary stricture (DIHBS) exclusively occurred in 12 patients (8.5%) receiving ABOi ALDLT. The deaths of 3 patients and 4 cases of re-transplantation were related to DIHBS. Graft and patient survival rates were significantly reduced in ABOi ALDLT recipients with DIHBS. However, we failed to identify any significant risk factors for DIHBS. Conclusions The incidence of BS in ABOi ALDLT is higher than in ABOc, mainly due to the fact of DIHBS which significantly affected survival outcomes. To predict and prevent DIHBS, we need further studies to identify significant risk factors.
Background
We assessed the prognostic impact of the ADV score (α-fetoprotein AFP–des-γ-carboxyprothrombin DCP–tumor volume TV score) for predicting hepatocellular carcinoma (HCC) recurrence and ...patient survival after living donor liver transplantation (LDLT).
Methods
This study included 843 HCC patients who underwent LDLT between January 2006 and December 2015 at Asan Medical Center. These cases were divided into treatment-naïve (TN,
n
= 256) and pretransplant-treated (PT,
n
= 587 69.6%) groups.
Results
There were weak or nearly no correlations among AFP, DCP, and TV. There existed high correlations between the pretransplant and explant findings regarding tumor number, size, and ADV score. Right lobe grafts were implanted in 760 (90.2%) patients. HCC recurrence and all-cause patient death occurred in 182 (15.9%) and 126 (15.0%) respectively during the follow-up period for 75.6 ± 35.5 months. The 5-year tumor recurrence (TR) and overall patient survival (OS) rates were 21.5% and 86.2%, respectively. The PT group showed higher TR (
p
< 0.001) and lower OS rates (
p
< 0.001). TR and OS were closely correlated with both pretransplant and explant ADV scores in the TN and PT groups. The ADV score enabled further prognostic stratification of the patients within and beyond the Milan, UCSF, and Asan Medical Center criteria. Compared with the 7 pre-existing selection criteria, ADV score with a cutoff of 5log showed the highest prognostic contrast regarding TR and OS.
Conclusions
Our prognostic prediction model using ADV scores is an integrated quantitative surrogate biomarker for posttransplant prognosis in HCC patients and can provide reliable information that assists the decision-making for LDLT.
Backgrounds
The anatomy of the left hepatic vein (LHV) is variable; thus, it should be considered for graft hepatic vein (GHV) venoplasty for left lateral section (LLS) and left liver grafts. This ...study assessed the incidence of superficial LHV (sLHV) branches according to LHV anatomy and its usability for GHV venoplasty in pediatric liver transplantation (LT).
Methods
This study consisted of three parts: (1) anatomical classification of LHV variations and the incidence of sLHV branches; (2) morphometric simulative analysis of GHV reconstruction and (3) clinical application based on LHV anatomy.
Results
The LHV anatomy of 248 potential LLS graft donors was classified into four types according to the number and location of GHV openings: one single opening (type 1; n = 186 75.0%), two large openings (type 2; n = 35 14.1%), one large and one small adjacent opening (type 3; n = 14 5.6%), and two large widely‐separated openings (type 4; n = 13 5.2%). An sLHV branch was identified in 87 of 248 (35.1%) donor livers. Morphometric analysis of simulative GHV venoplasty with an sLHV branch increased GHV diameters by 30% in type 1 LLS grafts and 20% in type 2/3 LLS grafts. An analysis of 50 consecutive patients who underwent pediatric LT showed that the 2‐year rates of GHV obstruction were 2.0% with LLS grafts and 0% with left liver grafts.
Conclusions
The GHV orifice can be enlarged through LHV anatomy‐based unification venoplasty. Unification venoplasty with an sLHV branch provided sufficient enlargement of the GHV orifice.
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