Abstract
Simple SummaryThe XXL trial has recently shown that biological downstaging is an effective strategy to also allow liver transplantation into patients with more advanced hepatocellular carcinoma without alternative curative options. Some potential limits of the XXL downstaging protocol are (a) the rather high downstaging failure rate (i.e., 32%), and (b) the additional prioritization of transplantation for patients with a potential good prognosis without transplant, i.e., those obtaining a complete response to downstaging. In this study, we showed that, using aggressive surgical downstaging, it is possible to considerably decrease the downstaging failure rate. Moreover, we showed that it is possible to avoid an immediate prioritization of transplantation for patients with a sustained complete response to downstaging by applying a “wait and see” policy. This policy seems to spare a relevant number of organs without worsening patient outcome.The XXL trial represents the first prospective validation of “biological downstaging” in liver transplantation (LT) for hepatocellular carcinoma. The aim of this study was to compare the Padua downstaging protocol to the XXL protocol in terms of downstaging failure rates and patient outcome. A total of 191 patients undergoing aggressive surgical downstaging and potentially eligible for LT from 2012 to 2018 at our center were retrospectively selected according to XXL trial criteria. Unlike the XXL trial, patients with a complete response to downstaging did not receive any prioritization for LT. Downstaging failure was defined as stable progressive disease or post-treatment mortality. The statistical method of “matching-adjusted indirect comparison” was used to match the study group to the XXL population. Downstaging failure rate was considerably lower in the study group than in the XXL trial (12% vs. 32%, d value = |0.683|). The survival curves of our LT group (n = 68) overlapped with those of the LT-XXL group (p = 0.846). Survival curves of non-LT candidates with a sustained complete response (n = 64) were similar to those of transplanted patients (p = 0.281). Our study represents a validation of the current Padua and Italian policies of denying rapid prioritization to patients with complete response to downstaging. Such a policy seems to spare organs without worsening patient outcome.
Highlights
Liver transplantation (LT) represents the best therapy for patients with hepatocellular carcinoma (HCC) regardless of tumor stage [1,2]
Intermediate-stage HCC patients have an optimal post-LT outcome when they fulfill validated extended criteria [6,7,8,9] or when they have a good response to a downstaging protocol [10,11,12]
Downstaging based on biological criteria leads to excellent post-transplant survival results, similar to those of patients transplanted at earlier stages of the disease
Summary
Liver transplantation (LT) represents the best therapy for patients with hepatocellular carcinoma (HCC) regardless of tumor stage [1,2]. Patients with early-stage HCC and wellcompensated cirrhosis usually represent a low transplant benefit category, since they show great potential for non-transplant curative therapies, such as liver resection or ablation, as alternatives to LT [5]. Intermediate-stage HCC patients have an optimal post-LT outcome when they fulfill validated extended criteria [6,7,8,9] or when they have a good response to a downstaging protocol [10,11,12]. The first strategy aims to bring a patient whose tumor burden is outside accepted criteria for LT to within acceptable criteria (i.e., morphological downstaging). The second strategy aims to select tumors with a good biology and, good outcomes with low risks, irrespective of morphological criteria (i.e., biological downstaging) [10]
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