Published online May 28, 2017. doi: 10.3748/wjg.v23.i20.3690
Peer-review started: January 19, 2017
First decision: February 9, 2017
Revised: March 7, 2017
Accepted: May 4, 2017
Article in press: May 4, 2017
Published online: May 28, 2017
Processing time: 128 Days and 23.2 Hours
To investigate the prognostic value of the radiological response after transarterial chemoembolization (TACE) and inflammatory markers in patients affected by hepatocellular carcinoma (HCC) awaiting liver transplantation (LT).
We retrospectively evaluated the preoperative predictors of HCC recurrence in 70 patients treated with conventional (n = 16) or doxorubicin-eluting bead TACE (n = 54) before LT. The patient and tumour characteristics, including the static and dynamic alpha-fetoprotein, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio (PLR) measurements, were recorded. Treatment response was classified according to the modified Response Evaluation Criteria in Solid Tumours (mRECIST) and the European Association for the Study of the Liver (EASL) criteria as complete response (CR), partial response (PR), stable disease or progressive disease. After examination of the explanted livers, histological necrosis was classified as complete (100% of the cumulative tumour area), partial (50%-99%) or minimal (< 50%) and was correlated with the preoperative radiological findings.
According to the pre-TACE radiological evaluation, 22/70 (31.4%) and 12/70 (17.1%) patients were beyond Milan and University of San Francisco (UCSF) criteria, respectively. After TACE procedures, the objective response (CR + PR) rates were 71.4% and 70.0% according to mRECIST and EASL criteria, respectively. The agreement between the two guidelines in defining the radiological response was rated as very good both for the overall and target lesion response (weighted k-value: 0.98 and 0.93, respectively). Complete and partial histological necrosis were achieved in 14/70 (20.0%) and 28/70 (40.0%) patients, respectively. Using histopathology as the reference standard, mRECIST criteria correctly classified necrosis in 72.9% (51/70) of patients and EASL criteria in 68.6% (48/70) of cases. The mRECIST non-response to TACE [Exp(b) = 9.2, p = 0.012], exceeding UCSF criteria before TACE [Exp(b) = 4.7, p = 0.033] and a preoperative PLR > 150 [Exp(b) = 5.9, p = 0.046] were independent predictors of tumour recurrence.
The radiological response and inflammatory markers are predictive of tumour recurrence and allow the proper selection of TACE-treated candidates for LT.
Core tip: The response to loco-regional therapy and biological markers appear to stratify the prognosis of hepatocellular carcinoma patients awaiting liver transplantation (LT) better than morphological criteria; however, their role in the selection scheme still needs validation. We analysed a homogeneous cohort of 70 patients treated exclusively by transarterial chemoembolization (TACE) prior to LT; the radiological response was assessed by two different enhancing methods (mRECIST and EASL criteria) that provided an accurate preoperative estimation of histological necrosis. We also demonstrated that a lack of response to TACE and a high platelet-to-lymphocyte ratio before surgery are strongly predictive of tumour recurrence, independently of the Milan criteria status at referral.