A PROSPECTIVE TRIAL OF PRE-TRANSPLANT CHEMOEMBOLIZATION FOR THE TREATMENT OF STAGE 3 AND 4a HEPATOMA

Abstract

174 Purpose: Survival following liver transplantation (OLT) for hepatocellular carcinoma (HCC) is relatively poor. Aggressive neoadjuvant therapy may be the best way to decrease tumor burden and occult spread thereby improving outcomes. Superselective trans-arterial chemoembolization (CE) was performed on patients with Stage 3 and 4a HCC while they awaited OLT. Methods: From 8/1/90 until 12/31/97 289 OLT were performed. Each recipient had an ultrasound and CT of the liver. Suspicious lesions were further evaluated by MRI and/or angiography. Biopsy confirmation of HCC was obtained for lesions >2 cm and a metastatic screen was performed. Patients were staged radiologically and listed (if appropriate) for OLT. All listed stage 3 and 4a patients received pre-transplant CE. Superselective catheterization was followed by injection of an adriamycin-lipiodol mixture and Gelfoam embolization. CE was done by a single radiologist approximately every 4 weeks until OLT. CE patients received adriamycin at surgery and then every 4 weeks for 6 months. MRI was performed every 3 months for the first year and every 6 months thereafter. All 289 explants were pathologically staged. Results: Seventeen patients received TACE; 16 Child's B or C cirrhotics and 1 non-cirrhotic. During the trial period 22 "incidental" HCC's (non-CE) were found. In the CE group there were 11 stage 4a, 5 stage 3, and 1 stage 2 patients. In the non-CE group there were 5 stage 4a, 2 stage 3, 5 stage 2, and 10 stage 1 patients. Stage 4a non-CE patients had either diffuse, infiltrating HCC not detected on imaging or were not eligible for the trial. Mean follow-up in CE patients was 14.2 mos (range 3-53) and in non-CE patients was 26.5 mos (range 2-70). CE patients received a median of 1 treatment (range 1-4). The median dose of adriamycin per CE was 100 mg. Complications included "CE syndrome" (fever, RUQ pain, elevated transaminases), hair loss, and groin hematoma. There was 1 case of worsening liver failure due to CE. CE treated explants had extensive tumor necrosis and fibrous capsule formation. There has been no tumor recurrence documented in the CE group. Fourteen of 17 patients are alive and free of disease. Three patients died disease-free (2 sepsis, 1 recurrent hepatitis B). Eighteen of 22 patients are alive in the non-CE group; 2 have recurrent HCC. Both recurrences occurred at 30 months. The 4 deaths were not HCC related. Four CE patients and 5 non-CE patients with stage 4a disease had 12 months follow-up. All CE patients were disease-free, but 2/5 non-CE patients had recurred. Overall group survival (n=39) was 82% (32/39) none of whom died of recurrent disease. There were no recurrences in patients with at least 3 years follow-up (n=8; 2 CE [both stage 4a] and 6 non-CE) Conclusions: 1) CE can be performed safely in Child's B and C cirrhotics. Careful attention to achieving superselectivity during catheterization is essential. 2) In this prospective trial with limited follow-up there have been no HCC recurrences in CE treated patients. CE may be especially useful in stage 4a disease 3) The overall outcome of patients with HCC undergoing OLT is better in this study than in other reported series. Longer follow-up is required.