Extending Indication: Role of Living Donor Liver Transplantation for Hepatocellular Carcinoma

LIVER TRANSPLANTATION 13:S48-S54, 27 SUPPLEMENT Extending Indication: Role of Living Donor Liver Transplantation for Hepatocellular Carcinoma Satoru Todo, 1 Hiroyuki Furukawa, 2 Mitsuhiro Tada, 3 and the Japanese Liver Transplantation Study Group 1 Department of General Surgery, Hokkaido University Graduate School of Medicine, 2 Department of Organ Transplantation and Regenerative Medicine, Hokkaido University Graduate School of Medicine, and 3 Research Section of Molecular Pathogenesis, Division of Cancer-Related Genes, Institute for Genetic Medicine, Hokkaido University, Sapporo, Japan KEY CONCEPTS Living donor liver transplantation. Indication of hepatocellular carcinoma. Milan criteria. United Network for Organ Sharing (UNOS) tumor staging. Alfa-fetoprotein (AFP). Protein induced by vitamin K absence or antagonism factor II (PIVKA II). Liver Transpl 13:S48-S54, 27. 27 AASLD. Hepatocellular carcinoma (HCC) is the fifth most common cause of malignant disease and the third cause of cancer-related mortality worldwide. Age-adjusted incidence is 14.9 per million in male and 5.5 per million in female subjects, and it is 5-6-fold higher in Asian countries than North America and Europe as a result of the endemic prevalence of hepatitis B virus (HBV) infection. In the United States, approximately 1, new cases occur annually, and it is estimated that the number will double over the next 2 decades because of increased hepatitis C virus (HCV) infection during 197s and 198s. Of the 5, individuals who die annually of end-stage liver disease in Japan, HCC accounts for 35, deaths, in spite of wide varieties of therapeutic modalities, including percutaneous ethanol injection, transarterial chemoembolization, microwave coagulation therapy, radiofrequency ablation, systemic chemotherapy, hepatic resection (Hx), and liver transplantation (LT). DISEASED DONOR LT LT theoretically offers cure for patients with HCC by achieving total removal of cancerous lesions and underlying HBV and HCV liver cirrhosis. Early experiences of deceased donor liver transplantation (DDLT) for HCC, however, were discouraging because of the higher recurrence rate and resulting decreased patient survival (Table 1). Thus, the detection of risk factors for recurrence and the selection criteria for HCC patients who would have less incidence of recurrence after DDLT were 2 important topics during early 199s. The Pittsburgh group determined that pathological risk factors consisted of lymph node metastasis, vascular invasion, and tumor number and size. On the basis of this and the other analysis, in 1996, the Milan criteria were proposed, which limit patients with HCC for DDLT. The criteria include solitary tumor up to 5 cm in diameter, or multiple nodules (fewer than 3), each 3 cm in diameter. Patients with extrahepatic spread and/or macroscopic vascular invasion of disease were not eligible for transplantation. Worldwide adoption of the Milan criteria as a standard improved 5-year patient survival by 3-7% (Table 1). Subsequently, slightly expanded criteria the University of California, San Francisco (UCSF), criteria were proposed. The UCSF criteria are as follows: solitary tumor 6.5 cm, or 3 nodules with the largest lesion 4.5 cm and total tumor diameter 8 cm. The UCSF criteria allowed 1- and 5-year patient survival of 9% and Abbreviations: HCC, hepatocellular carcinoma; HBV, hepatitis B virus; HCV, hepatitis C virus; LT, liver transplantation; Hx, hepatic resection; DDLT, deceased donor liver transplantation; UCSF, University of California, San Francisco; UNOS, United Network for Organ Sharing; MELD, Model for End-Stage Liver Disease; LDLT, living donor liver transplantation; DFS, disease-free survival; AFP, alfa-fetoprotein; PIVKA II, protein induced by vitamin K absence or antagonism factor II; A-P levels, AFP 2 ng/ml and PIVKA II 1 mau/ml. Address reprint requests to Satoru Todo, MD, Department of General Surgery, Hokkaido University Graduate School of Medicine, N-15, W-7, Kita-ku, Sapporo -8638, Japan. Telephone: 81-11-76-5923; FAX: 81-11-717-7515; E-mail: stodo@med.hokudai.ac.jp DOI 1.12/lt.21334 Published online in Wiley InterScience (www.interscience.wiley.com). S48 Liver Transplantation, Vol 13, No 11, Suppl 2 (November), 27: pp S48-S54

LDLT FOR HCC IN JAPAN S49 TABLE 1. Deceased Donor Liver Transplantation Before and After Implementation of Milan Criteria Transplantation n 5-yr survival rate (%) Recurrence (%) Deceased donor liver transplantation before Milan criteria Penn (1991) 365 18. 39. Ringe (1991) 61 15.2... Iwatsuki (1991) 15 35.6 42.9 Deceased donor liver transplantation after Milan criteria Mazzaferro (1996) (Milan criteria) 48 75.4* 8. Jonas (21) (Milan criteria) 12 71. 16. Figueras (21) ( 5 cm, localized) 37 63. 21. Yao (21) (UCSF criteria) 7 75.2 11.4 Abbreviation: UCSF, University of California, San Francisco. *Four-year survival rate. TABLE 2. Living Donor Liver Transplantation for Hepatocellular Carcinoma Survival rate (%) Recurrence Study n r r (%) Todo (Japan, 24) 316 Met Milan criteria 137 79.4... 1.4 Did not meet Milan criteria 172.... 22.2 Hwang (Korea, 25) 237 Met Milan criteria 173 88. 88.... Did not meet Milan criteria 64....... Jonas (Germany, 27) 21 Met Milan criteria 8 75. 75.... Did not meet Milan criteria 13 62. 62.... Lo (Hong Kong, 27) 43 Within Milan or UCSF criteria... 8.... 29. A2ALL (USA, 27) 58...... All... 67.... 29. Abbreviation: UCSF, University of California, San Francisco. 75.2%, respectively, compared with a 5% 1-year survival for those who exceeded the criteria limits. Although patient survival was improved by adoption of the Milan criteria and/or the UCSF criteria, the high number of candidate dropouts due to the organ shortage remained an important problem. Thus, the United Network for Organ Sharing (UNOS) staging classification has been introduced under the Model for End- Stage Liver Disease (MELD) organ allocation policy. The classification includes T (no tumors), T1 (single tumor 1.9 cm), T2 (single tumor 5 cm, or 2-3 tumors 3 cm), T3 (single tumor 5 cm, or 2-3 tumors 3 cm), T4A ( 4 nodules of any size), and T4B (any stage with macroscopic vascular invasion). Patients with T2 tumor receive 21 MELD points. The outcome of the recipients with UNOS tumor stage T2 or less is equivalent to that obtained with recipients within the Milan criteria. LIVING DONOR LT Alternative alleviation of organ shortage is the use of liver grafts from living donors for transplantation. Living donor liver transplantation (LDLT), initially invented for pediatric recipients, has recently been applied to adult patients with benign liver diseases. In addition, it has extensively been performed in patients with HCC, particularly in countries where there are many patients with HCC but few deceased donor organ donations, like in Korea, Hong Kong, and Japan (Table 2). Of these, some centers strictly adhere to the Milan criteria for patient selection, whereas others make a case-by-case decision. The rationales behind the latter lie in evidence that LDLT offers theoretical survival benefit over DDLT by shortening the waiting time and lowering the dropout rate; that even in patients who exceed the Milan criteria and who are not eligible for DDLT, LDLT definitely provides an acceptable patient survival; and that LDLT is a family matter that weighs the risks and benefits for the recipient and donor, without jeopardizing the public resource of donated deceased donor organs. Previously, we performed a national survey of 316 adult patients with HCC undergoing LDLT at 49 centers

S5 TODO ET AL. LDLTx for HCC in Japan LDLTx 653 337 Yes Milan Criteria? (Pathology) No 316 No Yes Recurrence? No Yes 328 9 233 83 Figure 1. Living donor liver transplantation for hepatocellular carcinoma in Japan. during 1989-23. The results showed that LDLT demonstrated similar patient survival with the same recurrent risk factors as DDLT. In addition, nearly half the recipients who exceeded the Milan criteria survived for 3 years after LDLT. In the present study, by analyzing data from the preceding 316 patients and new recipients, we tried to determine new selection criteria to salvage HCC patients who are not eligible for DDLT because they exceed the Milan criteria, but who may receive survival benefit from LDLT. 278 5 5 4 173 41 42 alive died alive died alive died alive died Figure 2. Outcome of living donor liver transplantation for hepatocellular carcinoma in Japan. LIVING DONOR LT IN JAPAN Patients From October 1989 to December 25, a total of 653 patients with HCC received LDLT at 49 centers in Japan (Fig. 1). They were followed until the end of June 26, with a median follow-up period of 21.5 months (range, 6-97.8 months). Median age was 56 years (range, 21-7 years). A total of 476 patients (72.9%) were male, and 177 (27.1%) were female. HCV infection was a leading cause of liver cirrhosis, occurring in 385 recipients (59%), vs. HBV for 199 (3%). Half the patients had advanced liver failure (Child-Pugh class C), whereas 3% were Child-Pugh class B and 1% were Child-Pugh class A. Patient Survival Of the 653 recipients, at time of last follow-up, 497 (76.1%) were alive without (n 451) or with (n 46) HCC recurrence; 156 (23.9%) had died of recurrent HCC (n 46) or for other reasons (n 11; Fig. 2). Actuarial patient survival was 82.6% at 1 year, 72.6% at 3 years, and 68.9% at 5 years; actuarial disease-free survival (DFS) was 77.4% at 1 year, 65.1% at 3 years, and 61.5% at 5 years (Fig. 3). By univariate analysis, pretransplantation serum levels of alfa-fetoprotein (AFP) and protein induced by vitamin K absence or antagonism factor II (PIVKA II), MELD score, and tumor characteristics of explanted livers (e.g., number and size of tumors, differentiation, and vascular invasion) were found to be important risk factors for patient survival. AFP and PIVKA II were found to be independent Figure 3. Patient survival, disease-free survival, and recurrence rate after living donor liver transplantation in Japan. risk factors for patient survival by multivariate analysis (Table 3). Patient survival of the patients who pathologically satisfied (n 337) and exceeded (n 316) the Milan criteria were 86.9% and 78.% at 1 year, 82.7% and 63.6% at 3 years, and 77.6% and 6% at 5 years, respectively (Fig. 4). HCC Recurrence Ninety-two recipients (14.1%) developed recurrence after LDLT. The cumulative recurrence rate was 9.2% at 1 year, 19.9% at 3 years, and 21.6% at 5 years. Tumor stage, age, AFP, PIVKA II, and pathological characteristics of tumors (e.g., number and size of tumors, distribution, vascular invasion, and differentiation) were closely associated with HCC recurrence by univariate analysis. By multivariate analysis, AFP, PIVKA II, vascular invasion, and number, distribution, and size of tumors were found to be independent risk factors for recurrence (Table 4). The recurrence rate of the patients who were within and beyond the Milan criteria were, respectively, 1.% and 17.7% at 1

LDLT FOR HCC IN JAPAN S51 TABLE 3. Mutivariate Analysis* of Risk Factors for Patient Survival Parameter P value Hazard ratio 95% confidence interval AFP (ng/ml) 1,.1 2.538 1.661 3.878 1, PIVKA II (mau/ml) 1,.8 1.844 1.172 2.9 1, Abbreviations: AFP, alfa-fetoprotein; PIVKA II, protein induced by vitamin K absence or antagonism factor II. *Cox proportional hazard model. LDLTx for HCC in Japan Milan Criteria (Pathology) Patient Survival Disease Free Survival 1 8 4 2 86.9 82.8 78. 63.1 77.8 6 Log Rank p<.1 year, 4.6% and 34.2% at 3 years, and 4.6% and 37.3% at 5 years. RISK FACTORS FOR HCC RECURRENCE AFP Levels Preoperative serum AFP levels were inversely correlated with patient survival: 83.8% at 1 year, 77.3% at 3 years, and 72.2% at 5 years when AFP was 2 ng/ml (n 473), and 64.9% at 1 year, 42.5% at 3 years, and 34.% at 5 years when AFP was 1, ng/ml (n 48). PIVKA II Levels Preoperative serum PIVKA II levels were also inversely correlated with patient survival; 96.2% at 1 year, 92.3% at 3 years, and 91.% at 5 years when PIVKA II was 1 mau/ml (n 386), and 71.9% at 1 year, 37.1% at 3 years, and 29.7% at 5 years when PIVKA II was 1, mau/ml (n 44). Vascular Invasion within (n=337) beyond (n=316) 1 LTx1 2 3 4 5 6 7 8 Survival of the patients with no vascular invasion, microscopic vascular invasion, or macroscopic vascular invasion (more than into the subsegmental portal 8 4 2 86.7 8.5 75.6 67.6 5.1 47.1 Log Rank p<.1 Figure 4. Patient survival and disease-free survival by the Milan criteria in Japan. branches) were 72.1%, 63.4%, and 33.3% at 5 years, respectively. Of the 44 patients with tumors of UNOS stage 4B, 24 (54.5%) developed HCC recurrence, and 5-year DFS was only 2% (Fig. 5). Tumor Number Five-year DFS of the patients who had no tumor, 1, 2, 3, and 4 tumors were 1%, 95.9%, 88.4%, 81.2%, and 62.6%, respectively. Tumor Size Five-year DFS of patients with maximum tumor diameter of 2 cm, 5 cm, and 5 cm was 91.5%, 76.1% and 39.5%, respectively. Tumor Distribution Five-year DFS of the patients whose tumor or tumors were located at either lobe of the liver or in both lobes was 84.7% and 73.%, respectively. INFLUENCE OF PRETRANSPLANTATION TREATMENTS Of the 653 recipients, 466 (71.4%) received various adjuvant treatments, alone or in combination, before LDLT: transarterial chemoembolization (n 374), percutaneous ethanol injection (n 187), radiofrequency ablation or microwave coagulation therapy (n 92), and Hx (n 69). Neither pretransplantation treatments nor the type of modalities showed any influence on patient survival and recurrence rate, compared with those of the recipients who received no treatment (Fig. 6). Tumor Staging by Preoperative Imaging Studies Vs. Pathological Analysis of Explants Almost all of the criteria for patient selection have been made by pathological analysis of explanted livers. However, the decision to proceed to transplant or not depends on the tumor extension diagnosed by preoperative imaging studies, including computed tomography and/or magnetic resonance imaging. In this study, Milan criteria established by imaging studies were identical to pathological classifications in 78.3%, underesti-

S52 TODO ET AL. TABLE 4. Mutivariate Analysis* of Risk Factor for Hepatocellular Carcinoma Recurrence Parameter P value Hazard ratio 95% CI AFP (ng/ml).1 3.441 2.93 5.656 1, 1,.1 2.8944 PIVKA II (mau/ml) 1.715 4.883 1, 1, Vascular invasion.1 2.592 1.638 4.99 Vp Vp1 Number.2 1.951 1.111 3.423 3 4 Distribution.32 1.815 1.54 3.125 Unilobar 5. Bilobar 5. Abbreviations: AFP, alfa-fetoprotein; PIVKA II, protein induced by vitamin K absence or antagonism factor II. *Cox proportional hazard model. 1 8 4 2 LDLTx for HCC in Japan UNOS Tumor Stage (Pathology) Patient Survival Disease Free Survival Log Rank p<.1 LTx1 2 3 4 5 6 7 8 1 8 4 2 mated in 15.8%, and overestimated in 5.8%. No differences in patient survival, DFS, and recurrence rate were found between the 2 methods of staging. Fiveyear DFS of the recipients who met and exceeded the criteria by imaging diagnosis and pathological study was 91.6% and.5%, and 95.4% and 62.7%, respectively. Proposal of New Criteria Log Rank p<.1 Stage (n=14) Stage1 (n=77) Stage2 (n=246) Stage3 (n=45) Stage4a (n=227) Stage4b (n=42) Figure 5. Patient survival and disease-free survival for hepatocellular carcinoma by United Network for Organ Sharing tumor stage. We suggest that high serum AFP and PIVKA II levels before LDLT are closely associated with biological aggressiveness of HCC as expressed by macroscopic vascular invasion, larger tumor size, and more nodules. These relate to worse patient survival and worse DFS. AFP 2 ng/ml and PIVKA II 1 mau/ml were set as cutoff values (Fig. 7). We refer to these 2 values taken together as the A-P level. 4 2 LDLT for HCC in Japan Pre-Transplant Treatment Patient Survival Log Rank p=111 Recurrence 1 Treatment 1 No Treatment 83.2 8 73.3 69.7 8 81.1 7.5 67.2 Criteria by Preoperative Imaging Study By preoperative imaging studies, 25 patients were found to have possible macroscopic vascular invasion, and 44 patients were diagnosed as not having HCC. Of the remaining 584 cases, 359 (61.5%) were within the Milan criteria, and 225 (38.5%) were beyond. Five-year DFS was 9% and 61.3%, respectively. When we exclude the 33 patients who lacked both AFP and PIVKA II levels, 343 satisfied the Milan criteria, and 28 were beyond them (Fig. 8). Five-year DFS of the patients who met the Milan criteria with lower (n 249) and higher (n 94) A-P level was 96.4% and 74.7%, respectively. In the patients who exceeded the criteria, 5-year DFS was 78.7% if A-P levels were below the Milan criteria (n 12); it was 39.9% when they were above the criteria (n 16). Thus, nearly half of the recipients who exceeded the Milan criteria but who had lower A-P levels 4 2 1.5 5.7 2.1 19.7 2.1 23.1 Log Rank p=.7284 Figure 6. Patient survival and recurrence rate with or without preoperative treatment for hepatocellular carcinoma in Japan.

LDLT FOR HCC IN JAPAN S53 AP levels Pathology 1. 1. 1. T Within 1. (325) Beyond (272) (28) Within, AP-Yes (96) Within, AP-No Beyond, AP-Yes (124).. <1 <2 <1 >1. T4b. Beyond, AP-No (131) 365 73 195 14 1825 219 2555 292 365 73 195 14 1825 219 2555 292 365 73 195 14 1825 219 2555 292 365 73 195 14 1825 219 2555 292 Figure 7. A-P (alfa-fetoprotein <2 ng/ml and protein induced by vitamin K absence or antagonism factor II <1 mau/ml) levels. Image Figure 9. Milan criteria and A-P (alfa-fetoprotein <2 ng/ml and protein induced by vitamin K absence or antagonism factor II <1 mau/ml) levels (pathological diagnosis). the A-P levels were found to survive as long as those who met the criteria. 1. T. T4b Within (343) Beyond (28) 365 73 195 14 1825 219 2555 292 365 73 195 14 1825 219 2555 292 were found to achieve similar DFS as those who satisfied the Milan criteria. Criteria by Postoperative Pathological Study Sixteen patients had HCC lesions that were totally necrotic as a result of preoperative treatment, and 44 patients had extensive vascular invasion. When we exclude these patients and the 38 patients without data for both these measurements, the 5-year DFS of those who met (n 325) and exceeded (n 272) the criteria were 95.3% and 66.4%, respectively (Fig. 9). When the A-P levels were below the criteria, the 5-year DFS of the patients who were within and exceeded the criteria were 99.5% (n 28) and 84.3% (n 124), although those with higher A-P levels had a 5-year DFS of 85.% (n 96) and 45.% (n 131), respectively. As with the imaging analysis, half the patients who exceeded the criteria but who satisfied 1.. (249) Within, AP-Yes (12) Beyond, AP-Yes Within, AP-No (94) Beyond, AP-No (16) Figure 8. Milan criteria and A-P (alfa-fetoprotein <2 ng/ml and protein induced by vitamin K absence or antagonism factor II <1 mau/ml) levels (imaging diagnoses). SUMMARY AND CONCLUSION The Milan criteria have been accepted as a standard for selection of HCC patients in DDLT worldwide. In the present study, the results of 653 Japanese recipients demonstrate that it is also applicable to LDLT. Although the criteria were originally created by pathological studies of explanted livers, criteria determined by preoperative imaging diagnosis showed the same prognostic power. The criteria were found to be able to predict the outcome of patients who underwent various attempts at pretransplantation tumor control, suggesting the usefulness of downstaging tumors to limit extension within the criteria. Thus, the reliability of the criteria for outcome estimation after LDLT was confirmed with a much larger patient population with a much longer follow-up than the previous study. However, the present study, as well as other DDLT studies, demonstrated that nearly half of the recipients who exceeded the criteria and would be removed from the waiting list survived free of disease for 5 years. Several efforts have been attempted to extend the indication to salvage these recipients, such as the UCSF criteria and the Barcelona Clinic Liver Cancer staging criteria, by using pathological tumor characteristics. In this study, we introduced A-P levels: AFP 2 ng/ml and PIVKA II 1 mau/ml. Both molecules have been used as serological markers of HCC, and they have been found to correlate with their biological behaviors. By using both the Milan criteria and the A-P levels, our study could differentiate the outcome of the recipients who were beyond the criteria into 2 groups: low A-P level patients (5%) with satisfactory survival without recurrence, and the other high A-P level patients (5%) with high recurrence rates. Although more detailed analyses are still in progress, our results indicate that molecular information reflecting HCC biology

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