Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jan 27, 2020; 12(1): 17-27
Published online Jan 27, 2020. doi: 10.4240/wjgs.v12.i1.17
Outcomes associated with the intention of loco-regional therapy prior to living donor liver transplantation for hepatocellular carcinoma
Tsung-Han Wu, Yu-Chao Wang, Chih-Hsien Cheng, Chen-Fang Lee, Ting-Jung Wu, Hong-Shiue Chou, Kun-Ming Chan, Wei-Chen Lee
Tsung-Han Wu, Yu-Chao Wang, Chih-Hsien Cheng, Chen-Fang Lee, Ting-Jung Wu, Hong-Shiue Chou, Kun-Ming Chan, Wei-Chen Lee, Department of General Surgery and Chang Gung Transplantation Institute, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
Kun-Ming Chan, Department of Organs Transplantation Institute, Chang Gung University College of Medicine, Taoyun 33305, Taiwan
Author contributions: Wu TH drafted the manuscript; Chan KM, Wu TH, Cheng CH, Wu TJ, Chou HS, and Lee WC contributed to the acquisition of data; Chan KM and Lee WC contributed to the critical revision of the manuscript for important intellectual content; all authors contributed to the work.
Institutional review board statement: This study was fully approved by the internal review board of Chang Gung Memorial Hospital at Linkou (Approval No.: 99-3089B), and informed consent from patient was waived due to its retrospective nature.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: The authors have no conflicts of interest.
Data sharing statement: No additional data are available. All data generated or analyzed during this study are included in this published article.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Kun-Ming Chan, MD, Associate Professor, Chief Doctor, Surgeon, Department of General Surgery and Chang Gung Transplantation Institute, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, 5 Fu-Hsing Street, Gui-Shan District, Taoyuan 33305, Taiwan.
Received: October 3, 2019
Peer-review started: October 3, 2019
First decision: October 24, 2019
Revised: November 6, 2019
Accepted: November 28, 2019
Article in press: November 28, 2019
Published online: January 27, 2020
Research background

Liver transplantation (LT) has become an ideal curative treatment for liver cirrhosis associated with hepatocellular carcinoma (HCC) as it simultaneously removes the tumors and cures the underlying liver cirrhosis. Although the overall outcome of LT for HCC is favorable, tumor recurrence is still a great concern. Hence, there remain several unmet needs for improving the long-term outcome of LT for HCC.

Research motivation

Living donor LT (LDLT) account for the majority of LT in most of Asian region because of the scarcity of organ from deceased donors. LDLT offers a flexible timing for transplantation providing timeframe for well preparation of transplantation. Theoretically, a pre-operative treatment might mitigate the tumor burden and improve the overall outcome of HCC patients. Therefore, further investigation of LDLT in terms of pre-transplantation loco-regional therapy remains important to optimize therapeutic strategies for patients with HCC.

Research objectives

The main objectives of this study were to analyze patients who underwent LDLT for HCC to investigate the outcome in relation to the intention of pre-transplantation loco-regional therapy.

Research methods

All patients who had undergone LDLT for HCC between August 2004 and December 2018 were retrospectively analyzed. Subsequently, patients were grouped according to the intention of loco-regional therapy prior to LDLT, and outcomes of patients were analyzed and compared between groups. Group I comprised patients who had not received any loco-regional therapy before LDLT. Group II comprised patients who had HCC within the University of California at San Francisco (UCSF) radiological criteria (rUCSF), but had loco-regional before LDLT. Group III comprised patients who had an HCC beyond rUCSF criteria, and loco-regional therapy was performed for the purpose of down-staging.

Research results

Of 308 patients who underwent LDLT for HCC during the study period were divided into Group I (n = 52), Group II (n = 228) and Group III (n = 28) based on aforementioned definition. Overall, 38 patients (12.3%) were detected with HCC recurrence during the follow-up period after LDLT. Group III patients had significant inferior outcomes to other two groups for both recurrence-free survival (RFS, P < 0.0005) and overall survival (OS, P = 0.046). However, RFS and OS outcomes between group I and II were statistically similar. Moreover, patients with defined profound tumor necrosis by loco-regional therapy had a superior RFS as compared with others.

Research conclusions

The outcome of LDLT for patient with HCC was satisfactory with a favorable RFS rate in this study. Nonetheless, loco-regional therapy prior to LDLT seems to not provide beneficial outcome unless a certain effect of loco-regional therapy prior to transplantation is achieved. Loco-regional therapy prior to LDLT might be insufficient for achieving a better outcome but still encouraged as long as the patient is suitable for such treatment.

Research perspectives

The study is still unable to establish a definitive therapeutic protocol to achieve a beneficial outcome of HCC patients after LDLT. Nonetheless, loco-regional therapy for HCC patient awaiting LT remains an international consensus for the management of HCC patients during the waiting time. The low incidence of HCC recurrence might be unable to reflect significance difference in this study. Therefore, additional loco-regional therapy studies in terms of high quality or larger prospective cohort studies could be undertaken in HCC patients listed for LDLT.