Tumor surveillance-what can and should be done? Screening for recurrence of hepatocellular carcinoma after liver transplantation

ArticleinLiver Transplantation 11(11 Suppl 2):S45-6 · November 2005with4 Reads
DOI: 10.1002/lt.20605 · Source: PubMed
Abstract
1. The overall rate of recurrence of hepatocellular carcinoma (HCC) after liver transplantation ranged from 11 to 18% in three of the largest series, with some differences in pre-transplant selection criteria. 2. Patients whose explant pathology is within the currently accepted criteria for transplantation have a low rate of recurrence (8%). Patients whose pathology is outside of the criteria have a 50% chance of recurrence, suggesting that post-operative pathology should be used to stratify screening. 3. About 10% of patients with recurrence appear to be long-term survivors after surgical therapy for the recurrence. 4. Screening all patients for HCC recurrence after transplantation is probably not cost effective and selecting patients with high risk explant pathology would be more cost effective. 5. Surprisingly, there is a dearth of information in the literature that would suggest rational screening protocols. I could not find a single article that examined protocols for screening for recurrence after transplantation. What follows is my interpretation of the effectiveness of screening after transplantation for HCC.
    • "Early discovery of post-LT tumor relapse may increase the options of curative treatment by surgical procedures [241, 242]. Close surveillance is nowadays standard of post-LT care in liver transplant patients with HCC meeting standard criteria [243]. Since LT for advanced stage HCC might be associated with an increased risk of HCC recurrence, post-LT surveillance program should be intensified in this special subset of patients. "
    [Show abstract] [Hide abstract] ABSTRACT: The implementation of the Milan criteria (MC) in 1996 has dramatically improved prognosis after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Liver transplantation has, thereby, become the standard therapy for patients with “early-stage” HCC on liver cirrhosis. The MC were consequently adopted by United Network of Organ Sharing (UNOS) and Eurotransplant for prioritization of patients with HCC. Recent advancements in the knowledge about tumor biology, radiographic imaging techniques, locoregional interventional treatments, and immunosuppressive medications have raised a critical discussion, if the MC might be too restrictive and unjustified keeping away many patients from potentially curative LT. Numerous transplant groups have, therefore, increasingly focussed on a stepwise expansion of selection criteria, mainly based on tumor macromorphology, such as size and number of HCC nodules. Against the background of a dramatic shortage of donor organs, however, simple expansion of tumor macromorphology may not be appropriate to create a safe extended criteria system. In contrast, rather the implementation of reliable prognostic parameters of tumor biology into selection process prior to LT is mandatory. Furthermore, a multidisciplinary approach of pre-, peri-, and posttransplant modulating of the tumor and/or the patient has to be established for improving prognosis in this special subset of patients.
    Article · Mar 2014
    • "Les critères de Milan (nodule unique >5c m, ou plus 3n odules >3c m) constituent le facteurd er isque de récidive majeur le plus classique dans les études. Lorsque la transplantation est réalisée selon les critères de Milan, le taux de récidive est de 8%,a lors qu'il est de 50 %l orsque les patients sont hors critères de Milan [16] . L'envahissement vasculaire et la différenciation cellulaire sont également des facteurs de risque de récidive retrouvés dans la majorité des études. "
    [Show abstract] [Hide abstract] ABSTRACT: La surveillance post-thérapeutique du carcinome hépatocellulaire ne fait l’objet d’aucune recommandation, ni d’aucun consensus à l’échelle internationale actuellement. Après traitement d’un CHC, le risque d’en développer un nouveau est probablement plus important que sur un foie « naïf » de tumeur. Par ailleurs, le risque de métastase hépatique ou extrahépatique vient se surajouter. Les modalités de surveillance (type d’examen d’imagerie, critères d’évaluation, rythme de surveillance) restent à déterminer par des études spécifiques. La présentation de la récidive est différente selon la thérapeutique appliquée (transplantation, résection, destruction percutanée, chimioembolisation ou thérapie ciblée). Ceci nécessite probablement une adaptation de cette surveillance pour optimiser la prise en charge de la récidive lorsqu’elle survient. Des recommandations ont été proposées dans la dernière version du Thésaurus National de Cancérologie Digestive (TNCD), et constituent un premier pas vers la standardisation de la surveillance. Des essais devraient rapidement voir le jour pour en démontrer le bénéfice en termes de survie. No consensus or guidelines are currently available for the posttherapeutic surveillance of hepatocellular carcinoma (HCC). After the treatment of HCC, the risk for developing a new HCC nodule is probably higher than that observed on a “simple” cirrhotic liver. Moreover, the risk for metastasis must be also taken into account. Surveillance modalities (type of imaging modality, evaluation criteria, rhythm for surveillance) have to be determined by specific studies. The presentation of recurrence is very different according the treatment applied (transplantation, resection, percutaneous ablation, chemoembolization or targeted therapy). This probably necessitates to adapt surveillance in order to optimize the treatment for recurrence when it happens. Recommendations have been proposed in the Thésaurus National de Cancérologie Digestive and represent a first step towards standardization of post-therapeutic surveillance. Trials are in preparation to definitively demonstrate the benefit in survival.
    Article · Dec 2010
    • "These results (high rates of recurrence in patients with high risk pathology, relatively early HCC recurrence post transplant, significantly longer survival for patients undergoing surgical therapy for recurrences) introduced a discussion about screening strategies for recurrence of HCC after LT [51]. Roberts in his editorial in the periodical " Liver Transplantation " proposed that screening for recurrence should be limited only to patients with tumors whose explant pathology is outside the Milan criteria in order to be cost effective [51]. With the increasing number of hepatitis C induced HCC [52] and the corresponding increase in LT for HCC on one side, and the efforts to " expand " the Milan criteria in several centers performing live donor LT on the other side [13, 17, 53], an increased number of patients with post-transplant HCC recurrence is expected . "
    [Show abstract] [Hide abstract] ABSTRACT: The purpose of this study was to systematically review tumor characteristics leading to recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT). A computer search of the Medline database was carried out. Tumor characteristics examined were: 1) no vascular versus vascular invasion, 2) solitary versus multifocal tumors, 3) well differentiated versus not well differentiated HCCs, 4) HCC meeting versus HCC exceeding the Milan criteria, 5) HCC < or =5 cm versus HCC>5 cm. Of 45 clinical studies screened, 9 fulfilled the study criteria. These studies included from 21 to 316 patients, for a total of 1198 patients. A fixed effects model was applied. A significant correlation between vascular invasion, not well differentiated HCC, tumor size >5 cm, HCC exceeding the Milan criteria, and HCC recurrence post transplant was shown (common odds ratio of 8.727, 2.89, 13.32 and 4.205, respectively). Heterogeneity for the parameter solitary versus multifocal tumor was shown. High risk pathology for HCC recurrence is characterized by not well differentiated tumors and by HCCs that exceed the Milan criteria. A clinical application of these data may be a scoring system which includes the tumor grading in the evaluation and listing of HCC patients to LT.
    Full-text · Article · Oct 2007
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