University Of California, San Francisco Criteria Research Articles

Impact of pathological features of primary hepatocellular carcinoma on the outcomes of intrahepatic recurrence management: single center experience from Southern Taiwan

BackgroundCurrently, there is no definitive management for hepatocellular carcinoma (HCC) intrahepatic recurrence (IHR) after primary resection (PR). The aim of this study was to analyze the outcomes of three modalities for patients who received curative PR and had IHR within the University of California San Francisco (UCSF) criteria. MethodsBetween 2003 and 2010, patients with IHR after PR were treated with salvage liver transplantation (SLT), re-resection (RR) or local ablation (LA). Clinico-pathological features of primary tumor and recurrent HCC were analyzed to determine the risk factors that adversely affected overall survival (OS) and disease free survival (DFS). ResultsThe study included 130 patients with subgroups of SLT (n = 25), RR (n = 31) and LA (n = 74). The 5-year DFS and OS were 75%, 31% and 17% and 80%, 60% and 58% respectively for each subgroup. SLT had a significantly better DFS than other modalities (p < 0.001). There was no difference in OS. In multivariate analysis, two variables adversely affected DFS: microvascular invasion in PR and not treating patients with SLT. ConclusionsSLT provides better DFS for patients with IHR within the UCSF criteria. However, SLT failed to show the same advantage in OS.

Accuracy of Imaging Study in Correlation to Pathology of Explanted Liver of Hepatocellular Carcinoma Cases

Aims: To determine the accuracy of different imaging modalities in assessment of HCC patients for LDLT, in correlation with the histopathological study of the explanted liver. Also, to study their accuracy to classify the potential recipients as regard the different selection criteria, and to assess their feasibility in evaluation of the effectiveness of pretransplant bridging procedures. Methods: From April 2003 to December 2013, 61 of 210 recipients underwent LDLT for HCC at National Liver Institute (NLI), Menoufiya University, Egypt. Imaging findings including tumor size, number, were correlated with histopathologic features of the explanted livers Results: Sixty one patients of 210 underwent LDLT for HCC, 54 patients of them proved to be HCC in pathology of explanted liver. Sensitivity & specificity of US & CT scan for detection of HCC were (100%) and (95.5%) respectively. Sensitivity & specificity of PET scan were (44.8%), (50%) respectively. US overestimated numbers and sizes of HCCs by 13/54 (24.1%) and 14/54 (25.9%) respectively. CT overestimated numbers & sizes of HCCs by 14/54 (25.9%), and 12/54 (22.2%) respectively. Thirty nine (63.9%) patients were within imaging Milan, and 51(83.6%) patients were within imaging University of California, San Francisco (UCSF) criteria, but 35(64.8%) patients were within pathological Milan, and 40(74.1%) patients were within pathological UCSF criteria. Nineteen (35.2%) patients underwent pretransplant bridging therapy for HCC, 6 of them had complete ablation of HCC in CT scan, and only 3 patients had complete ablation in pathology of explanted liver Conclusions: US & CT scan have high sensitivity for detection of HCC, and PET scan has less sensitivity, but PET scan might be of particular value in excluding extrahepatic HCC extension. Fallacies of the imaging study due to overestimation and underestimation should be considered during scheduling according to selection criteria. CT has doubtful value in addressing the efficacy of bridging therapy for HCC

321. Is AFP level a better prognostic of survival than tumour burden in patients with hepatocellular carcinoma undergoing living donor liver transplantation?

Background: Hepatocellular carcinoma (HCC) is one of the leading causes of death worldwide. The commonly used criteria for listing patients with HCC for treatment with living donor liver transplantation (LDTL) are: Milan criteria and University of California, San Francisco (UCSF) criteria. Both Milan and UCSF criteria focus on the tumour burden. We have analyzed our experience with LDTL in patients with HCC and Hepatitis C virus (HCV) associated liver disease in order to determine if alpha-fetoprotein (AFP) level is a better predictor of outcome than the tumour burden.

Accuracy of Imaging Study in Correlation to Pathology of Explanted Liver of Hepatocellular Carcinoma Cases.

Background: Living donor liver transplantation (LDLT) can provide life-saving therapy for many patients with hepatocellular carcinoma (HCC). Ultrasound (US), Multislice computed tomography (CT) and Positron emission tomography (PET) are used for pretransplant HCC evaluation. Objective: The objective of this study was to determine the accuracy of different imaging modalities in assessment of HCC patients for LDLT, in correlation with the histopathological study of the explanted liver. Also, to study the effectiveness of these imaging modalities to classify the potential recipients as regard the different selection criteria, and to assess their feasibility in evaluation of the effectiveness of pretransplant bridging procedures. Methods: From April 2003 to December 2013, 61 of 210 recipients underwent LDLT for HCC at National Liver Institute, Menofia University, Egypt. Imaging findings were correlated with histopathologic features of the explanted livers. Results: Sixty one patients of 210 underwent LDLT for HCC, 54 patients of them proved to be HCC in pathology of explanted liver. Sensitivity & specificity of US & CT scan for detection of HCC were (100%) and (95.5%) respectively. Sensitivity & specificity of PET scan were (44.8%), (50%) respectively. US overestimated numbers and sizes of HCCs by 13/54 (24.1%) and 14/54 (25.9%) respectively. CT overestimated numbers & sizes of HCCs by 14/54 (25.9%), and 12/54 (22.2%) respectively. Thirty nine (63.9%) patients were within imaging Milan, and 51(83.6%) patients were within imaging University of California, San Francisco (UCSF) criteria, but 35(64.8%) patients were within pathological Milan, and 40(74.1%) patients were within pathological UCSF criteria. Nineteen (35.2%) patients underwent pretransplant bridging therapy for HCC, and only 3 patients had complete ablation in pathology of explanted liver. Conclusion: US & CT scan have high sensitivity for detection of HCC, and PET scan has less sensitivity, but PET scan might be of particular value in excluding extrahepatic HCC extension. Fallacies of the imaging study due to overestimation and underestimation should be considered during scheduling according to selection criteria. CT has doubtful value in addressing the efficacy of bridging therapy for HCC.

Prostate-specific Antigen Density Toward a Better Cutoff to Identify Better Candidates for Active Surveillance

To investigate the impact of prostate-specific antigen density (PSAD) on existing prostate cancer (PCa) active surveillance (AS) protocols. Prospectively maintained database on men with PCa who underwent radical prostatectomy was reviewed retrospectively. Demographic data and pathologic characteristics of patients who fulfilled the AS inclusion criteria under the National Comprehensive Cancer Network (NCCN), Prostate Cancer Research International Active Surveillance (PRIAS), and University of California, San Francisco (UCSF) guidelines were examined. Of 930 patients, 231, 280, and 325 fulfilled the NCCN, PRIAS, and UCSF AS criteria, respectively. The frequencies of advanced disease on surgical pathology (upstaging and/or upgrading) were 31.6% (NCCN), 35.4% (PRIAS), and 34.2% (UCSF) of the study cohorts. PSAD was significantly higher in patients with advanced disease compared with that in patients with nonadvanced disease in all 3 AS schemas. Modifying the PRIAS and UCSF criteria using the NCCN's lower PSAD cutoff of 0.15ng/mL(2) decreased the rates of the advanced disease significantly to 33.5% and 31.4%, respectively. Using the receiver operating characteristic curve analysis, the optimal PSAD cutoff level for the prediction of advanced disease was 0.085ng/mL(2) (sensitivity/specificity of 76.7%/50.6% in NCCN and 75.6%/49.7% in PRIAS). Among patients with low-risk PCa who underwent radical prostatectomy, PSAD is a predictor of advanced disease at the time of surgery. Adopting a lower PSAD threshold of 0.085ng/mL(2) decreased the risk of the advanced disease to 17.5%-21.7%. Therefore, PSAD should be part of all AS guidelines.

Combination of morphologic criteria and α-fetoprotein in selection of patients with hepatocellular carcinoma for liver transplantation minimizes the problem of posttransplant tumor recurrence.

BackgroundSerum α-fetoprotein concentration (AFP) might be a useful addition to morphologic criteria for selecting patients with hepatocellular carcinoma (HCC) for liver transplantation (LT). The aim of this study was to evaluate the role of AFP in selecting HCC patients at minimal risk of posttransplant tumor recurrence in the setting of existing criteria.MethodsThis retrospective cohort study was based on 121 HCC patients after LT performed at a single institution. AFP was evaluated as a predictor of posttransplant tumor recurrence with respect to fulfillment of the Milan, University of California, San Francisco (UCSF), and Up-to-7 criteria.ResultsThere was a nearly linear association between AFP and the risk of HCC recurrence (p < 0.001 for linear effect; p = 0.434 for nonlinear effect). AFP predicted HCC recurrence in patients (1) beyond the Milan criteria (p < 0.001; optimal cutoff 200 ng/ml); (2) within the UCSF criteria (p = 0.001; optimal cutoff 100 ng/ml) and beyond them (p = 0.015; optimal cutoff 200 ng/ml); and (3) within the Up-to-7 criteria (p = 0.001; optimal cutoff 100 ng/ml) and beyond them (p = 0.023; optimal cutoff 100 ng/ml) but not in patients within the Milan criteria (p = 0.834). Patients within either UCSF and Up-to-7 criteria with AFP level <100 ng/ml exhibited superior (100 %) 5-year recurrence-free survival—significantly higher than those within UCSF (p = 0.005) or Up-to-7 (p = 0.001) criteria with AFP levels higher than the estimated cutoffs or beyond with AFP levels less than the estimated cutoffs.ConclusionsCombining the UCSF and Up-to-7 criteria with an AFP level <100 ng/ml is associated with minimal risk of tumor recurrence. Hence, this combination might be useful for selecting HCC patients for LT.

Section 5. Further expanding the criteria for HCC in living donor liver transplantation: when not to transplant: SNUH experience.

Living donor liver transplant (LDLT) is one of the important modalities to treat hepatocellular carcinoma (HCC) in Asian countries. LDLT for HCC consists of >50% of the total LDLT at Seoul National University Hospital (SNUH). Milan or University of California San Francisco (UCSF) criteria were not considered as absolute selection criteria for LDLT at SNUH. We experienced that some patients with beyond Milan criteria have long-term survival after LDLT. On the contrary, LDLT showed poorer outcome than deceased donor LT (DDLT) in patients with within UCSF criteria in our series. There are several reasons for higher recurrence rate in LDLT such as fast-track selection and rapid regeneration in LDLT. Therefore, the feasibility of conventional criteria based on tumor size and number to predict HCC recurrence after LDLT seemed somewhat different from that of DDLT. We identified significant pre-operative biological factors such as AFP, PIVKAII, and PET positivity. Combination of those biological factors predicted HCC recurrence better than conventional criteria based on size and number. All patients with three risk factors showed 100% recurrence. This group should be excluded regardless of Milan criteria.There have been debates in expanding the criteria in LDLT. Some centers still stick on the expanded criteria that are estimated to yield a 5-year survival of approximately 50%. However, there was no completely tailored criterion to predict HCC recurrence exactly. The survival after recurrence was also different from case by case. Furthermore, the introduction of m-TOR inhibitor and targeted agent improved survival after recurrence. Based on these ideas, we experimentally expanded our indication to the far advanced HCC (HCC larger than 10 cm or more than 10 numbers or with macrovascular invasion preoperatively). The patients with far advanced HCC have usually poor prognosis. However, the selected patients with low AFP (<200 ng/ml), 2-year recurrence free survival was 54.5%.In conclusion, we are now expanding the criteria selectively up to patients with macrovascular invasion if there are no other effective treatment options and the expected survival and risk after LT is acceptable in both recipient and donor. The current absolute contraindication for LDLT in SNUH is extrahepatic metastasis.

Living Donor Liver Transplantation Outcomes for Hepatocellular Carcinoma Beyond Milan or UCSF Criteria.

Liver transplantation (LT) is the most effective treatment for hepatocellular carcinoma (HCC) that arises from cirrhosis. The Milan and the University of California, San Francisco (UCSF) selection criteria have resulted in major improvements in patient survival. We assessed our outcomes for patients with HCC that were beyond the Milan and UCSF criteria after living donor liver transplantation. We reviewed the data for 109 patients with cirrhosis and HCC who underwent living donor right lobe liver transplantation (living donor liver transplantation; LDLT) during the period from July 2004 to July 2012. Sixteen (14.7%) patients had HCC recurrences during a mean follow-up of 35.4 ± 26.2months (range 4-100months). The mean time to recurrence was 11 ± 9.4months (range 4-26months). Survival rates were not significantly different between patients with HCC that met and were beyond the Milan and UCSF criteria (p = 0.761 and p = 0.861, respectively). The Milan and UCSF criteria were not independent risk factors for HCC recurrence or patient survival. Only poorly differentiated tumors were associated with a lower survival rate (OR = 8.656, 95% confidence interval (CI) 2.01-37.16; p = 0.004). Survival rates for patients with HCC that were beyond conventional selection criteria should encourage reconsidering the acceptable thresholds of these criteria so that more HCC patients may undergo LT without affecting outcomes.

Absence of Viable HCC in the Native Liver Is an Independent Protective Factor of Tumor Recurrence After Liver Transplantation

Prognostic factors for hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) are still a matter of debate. The absence of viable tumor in the native liver, due to effectiveness of pre-LT locoregional treatment or liver resection, is an intriguing prognostic factor that had never been evaluated. Between November 2000 and December 2011, 210 LTs were performed in patients with evidence of HCC and cirrhosis. Fifty-three (25.2%) patients did not show any evidence of active residual HCC in the native liver (Group NVH), whereas 157 (74.8%) patients showed viable HCC (Group VH). All patients in Group NVH were treated before LT with a multimodal approach combining transarterial chemoembolization, liver resection, radiofrequency ablation, percutaneous ethanol injection, or sorafenib, whereas, in Group VH, 110 of the 157 (70.1%) patients received bridging therapy (P<0.001). HCC recurrence occurred in none of the patients in Group NVH (0%) and in 25 (15.9%) patients in Group VH (P=0.003). Liver resection was the most effective treatment in obtaining absence of HCC on liver explantation. The results of multivariate analysis showed that existence of pathologic HCC findings outside of the University of California-San Francisco criteria (P=0.001; odds ratio, 4; confidence interval, 1.7-9.2) and the presence of viable HCC (P=0.003; odds ratio, 5.9; confidence interval, 1.5-17.6) were independently associated with HCC recurrence. The histologic absence of viable HCC in the native liver after LT and morphologic criteria, due to the high effectiveness of pre-LT bridging treatments, is a highly positive prognostic factor against HCC recurrence after LT.

Living-Donor Liver Transplantation Associated With Higher Incidence of Hepatocellular Carcinoma Recurrence Than Deceased-Donor Liver Transplantation

Living-donor liver transplantation (LDLT) is becoming an important tool in hepatocellular carcinoma (HCC) treatment. However, the oncologic outcome between LDLT and deceased-donor LT (DDLT) for HCC remains controversial. This study aims to compare the HCC recurrence rates after LDLT versus DDLT. Two hundred sixteen patients (166 LDLTs and 50 DDLTs) who underwent LT for HCC within University of California-San Francisco criteria were retrospectively reviewed. LDLT patients were divided into two groups: small living-donor graft (LDG; graft-to-recipient body weight ratio <1.0, n=59) and nonsmall LDG (graft-to-recipient body weight ratio ≥1.0, n=107). Patients were further stratified into low- and high-risk settings by the number of risk factors for recurrence. The recurrence-free survival was lower in LDLT compared with DDLT (88.6% and 80.7% vs. 96.0% and 94.0% at 1 and 5 years; P=0.045). There was no significant difference between two groups regarding the majority of clinical and tumor characteristics, with the exception of a higher proportion of microvascular invasion presence in LDLT. After the adjustment for microvascular invasion, LDLT was identified as an independent risk factor for recurrence. Moreover, recurrence-free survival between small and nonsmall LDG was not statistically significant. In low-risk setting (≤1 risk factor), LDLT showed comparable outcome with DDLT. However, the risk of recurrence was higher in LDLT than DDLT in high-risk patients. In conclusion, LDLT showed poorer outcome than DDLT. This should be considered to select optimal strategy for HCC.

Waitlist Priority for Hepatocellular Carcinoma Beyond Milan Criteria: A Potentially Appropriate Decision Without a Structured Approach

Due to the risk of waitlist dropout from tumor progression, liver transplant candidates with hepatocellular carcinoma (HCC) within Milan criteria (MC) receive standardized exception points. An expansion of this process to candidates with HCC beyond MC has been proposed, though it remains controversial. This study sought to better define the utilization of exception points in candidates with HCC beyond MC and the associated outcomes. We reviewed all nonstandardized HCC applications that underwent formal regional review board evaluation between January 1, 2005 and March 2, 2011; 2184 initial HCC exception point applications were submitted. Of these, 41.9% fulfilled MC, 26.6% fulfilled University of California-San Francisco (UCSF) criteria and 17.6% exceeded UCSF criteria. The majority of applications were accepted: 89.8% within UCSF and 71.2% beyond UCSF. There was a significantly (p < 0.001) higher risk of death on the waitlist or within 90 days of waitlist removal for candidates within UCSF (12.4%) or beyond UCSF (13.0%) criteria, compared to candidates with HCC within MC (6.0%). However, posttransplant outcomes were similar. While these results suggest increasing access to candidates with HCC beyond MC, comprehensive documentation of tumor characteristics and of successful downstaging is needed to ensure priority is restricted to those with the highest likelihood of favorable posttransplant outcome.

226 INCREASED INCIDENCE OF PATHOLOGICALLY NON-ORGAN CONFINED PROSTATE CANCER IN AFRICAN-AMERICAN MEN ELIGIBLE FOR ACTIVE SURVEILLANCE

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History (I)1 Apr 2013226 INCREASED INCIDENCE OF PATHOLOGICALLY NON-ORGAN CONFINED PROSTATE CANCER IN AFRICAN-AMERICAN MEN ELIGIBLE FOR ACTIVE SURVEILLANCE Yun-Sok Ha, Amirali Salmasi, Jeong Hyun Kim, Jae Young Joung, Dong Hyeon Lee, Wun-Jae Kim, and Isaac Yi Kim Yun-Sok HaYun-Sok Ha New Brunswick, NJ More articles by this author , Amirali SalmasiAmirali Salmasi New Brunswick, NJ More articles by this author , Jeong Hyun KimJeong Hyun Kim Chuncheon, Korea, Republic of More articles by this author , Jae Young JoungJae Young Joung Goyang, Korea, Republic of More articles by this author , Dong Hyeon LeeDong Hyeon Lee Seoul, Korea, Republic of More articles by this author , Wun-Jae KimWun-Jae Kim Cheongju, Korea, Republic of More articles by this author , and Isaac Yi KimIsaac Yi Kim New Brunswick, NJ More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1606AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES African-American (AA) men have a relatively higher risk of developing prostate cancer (PCa) and dying of PCa compared to White-American (WA) men. For this reason, it is unclear whether the same active surveillance (AS) criteria should be applied to AA men. The aim of the present study is to compare the clinicopathologic findings of AA and WA men with prostate cancer who were candidates for active surveillance (AS) and underwent radical prostatectomy (RP). METHODS Prospectively maintained database of men who underwent RP from two academic centers were analyzed retrospectively. Post-operative pathologic characteristics of patients who met the AS inclusion criteria of the University of California, San Francisco (UCSF) and National Comprehensive Cancer Network (NCCN) were evaluated. After RP, the rate of pathological upstaging and Gleason upgrading were compared between AA and WA. RESULTS In the AA cohort, 196 and 124 met the UCSF and NCCN criteria for AS, respectively. With respect to WA patients, 191 and 148 fulfilled the AS criteria for UCSF and NCCN. AA men had higher percentage of maximum biopsy core than WA (15.3- 20.4% vs. 11.5-15.0%, P< 0.05, respectively) in both cohorts. In addition, a greater proportion of AA men had multiple positive biopsy cores compared to WA (45.2% vs. 33.1%, P= 0.046) under NCCN criteria. A higher proportion of AA men were upstaged compared to WA (19.4% vs. 10.1%, P= 0.037). A multivariate regression test revealed that age, preoperative PSA, and number of positive cores were independent predictors of more advanced disease (upstaging and/or upgrading) in AA men. CONCLUSIONS AA men who were candidates for AS criteria had worse clinicopathological features on final surgical pathology than WA men. These results suggest that a more stringent AS criteria should be considered in AA men with prostate cancer. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e93 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yun-Sok Ha New Brunswick, NJ More articles by this author Amirali Salmasi New Brunswick, NJ More articles by this author Jeong Hyun Kim Chuncheon, Korea, Republic of More articles by this author Jae Young Joung Goyang, Korea, Republic of More articles by this author Dong Hyeon Lee Seoul, Korea, Republic of More articles by this author Wun-Jae Kim Cheongju, Korea, Republic of More articles by this author Isaac Yi Kim New Brunswick, NJ More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Increased Incidence of Pathologically Nonorgan Confined Prostate Cancer in African-American Men Eligible for Active Surveillance

To compare the clinicopathologic findings of African-American (AA) and White-American (WA) men with prostate cancer (PCa) who were candidates for active surveillance (AS) and underwent radical prostatectomy (RP). Prospectively maintained database of men who underwent RP from 2 academic centers were analyzed retrospectively. Postoperative pathologic characteristics of patients who met the AS inclusion criteria of the University of California, San Francisco (UCSF) and National Comprehensive Cancer Network (NCCN) were evaluated. After RP, the rate of pathological upstaging and Gleason upgrading were compared between AA and WA men. In the AA cohort, 196 and 124 men met the UCSF and NCCN criteria for AS, respectively. With respect to WA patients, 191 and 148 fulfilled the AS criteria for UCSF and NCCN, respectively. AA men had a higher percentage of maximum biopsy core than WA men (15.3%-20.4% vs 11.5%-15.0%, P<.05, respectively) in both cohorts. In addition, a greater proportion of AA men had multiple positive biopsy cores compared to WA men (45.2% vs 33.1%, P= .046) under the NCCN criteria. A higher proportion of AA men were upstaged (≥pT3) compared to WA men (19.4% vs 10.1%, P= .037). A multivariate regression test revealed that age, preoperative PSA, and number of positive cores were independent predictors of more advanced disease (upstaging and/or upgrading) in AA men. AA men who were candidates for AS criteria had worse clinicopathological features on final surgical pathology than WA men. These results suggest that a more stringent AS criteria should be considered in AA men with prostate cancer.

Outcome Comparisons Among the Hangzhou, Chengdu, and UCSF Criteria for Hepatocellular Carcinoma Liver Transplantation after Successful Downstaging Therapies

BackgroundIn Mainland China, many selection criteria for hepatocellular carcinoma (HCC) liver transplantation, such as the Hangzhou, the Chengdu, and the Fudan criteria, have been established. No comparisons have been made among the outcomes using the Hangzhou, Chengdu, and University of California, San Francisco (UCSF) criteria in patients who underwent successful downstaging therapies. MethodsAfter successful downstaging therapies, 72 patients met the UCSF criteria, 86 met the Chengdu criteria, and 102 met the Hangzhou criteria. The data on these HCC patients were retrospectively analyzed, and various outcomes, such as survival and the tumor-free survival rate, were compared among the three groups. ResultsNo significant differences were observed among the three groups with regard to the downstaging protocols, baseline characteristics, or liver function. However, the patients who met the Hangzhou criteria had significantly larger tumor targets than those who met the Chengdu or UCSF criteria (P < 0.05). The three groups showed similar 1-, 3-, and 5-year survival rates (90.9, 80.0, and 78.6 %, respectively, for the UCSF criteria; 91.6, 81.9, and 75.6 %, respectively, for the Hangzhou criteria; and 91.1, 83.3, and 79.4 %, respectively, for the Chengdu criteria); 1-, 3-, and 5-year tumor-free survival rates (83.3, 77.5, and 75 %, respectively, for the UCSF criteria; 86.3, 78.8, and 75.6 %, respectively, for the Hangzhou criteria; and 87.3, 79.2, and 76.4 %, respectively, for the Chengdu criteria); and 1-, 3-, and 5-year tumor recurrence rates (9.2, 17.5, and 21.4 %, respectively, for the UCSF criteria; 8.4, 16.4, and 20 % for the Hangzhou criteria; and 8.9, 14.6, and 17.6 % for the Chengdu criteria). ConclusionBecause they have contributed to similar outcomes but to larger HCC patient pools, the Hangzhou criteria for HCC transplantation should be comprehensively accepted in China for HCC patients after successful downstaging therapies.

Clinical outcome in patients with hepatocellular carcinoma after living-donor liver transplantation

To investigate risk factors for hepatocellular carcinoma (HCC) recurrence after living donor liver transplantation (LDLT) and efficacy of various criteria. From October 2000 to November 2011, 233 adult patients underwent LDLT for HCC at our institution. After excluding nine postoperative mortality cases, we analyzed retrospectively 224 patients. To identify risk factors for recurrence, we evaluated recurrence, disease-free survival (DFS) rate, survival rate, and various other factors which are based on the characteristics of both the patient and tumor. Additionally, we developed our own criteria based on our data. Next, we compared our selection criteria with various tumor-grading scales, such as the Milan criteria, University of California, San Francisco (UCSF) criteria, TNM stage, Barcelona Clinic Liver Cancer (BCLC) stage and Cancer of the Liver Italian Program (CLIP) scoring system. The median follow up was 68 (6-139) mo. In 224 patients who received LDLT for HCC, 37 (16.5%) experienced tumor recurrence during the follow-up period. The 5-year DFS and overall survival rates after LDLT in all patients with HCC were 80.9% and 76.4%, respectively. On multivariate analysis, the tumor diameter {5 cm; P < 0.001; exponentiation of the B coefficient [Exp(B)], 11.89; 95%CI: 3.784-37.368} and alpha fetoprotein level [AFP, 100 ng/mL; P = 0.021; Exp(B), 2.892; 95%CI: 1.172-7.132] had significant influences on HCC recurrence after LDLT. Therefore, these two factors were included in our criteria. Based on these data, we set our selection criteria as a tumor diameter ≤ 5 cm and AFP ≤ 100 ng/mL. Within our new criteria (140/214, 65.4%), the 5-year DFS and overall survival rates were 88.6% and 81.8%, respectively. Our criteria (P = 0.001), Milan criteria (P = 0.009), and UCSF criteria (P = 0.001) showed a significant difference in DFS rate. And our criteria (P = 0.006) and UCSF criteria (P = 0.009) showed a significant difference in overall survival rate. But Milan criteria did not show significant difference in overall survival rate (P = 0.137). Among stages 0, A, B and C of BCLC, stage C had a significantly higher recurrence rate (P = 0.001), lower DFS (P = 0.001), and overall survival rate (P = 0.005) compared with the other stages. Using the CLIP scoring system, the group with a score of 4 to 5 showed a high recurrence rate (P = 0.023) and lower DFS (P = 0.011); however, the overall survival rate did not differ from that of the lower scoring group. The TNM system showed a trend of increased recurrence rate, decreased DFS, or survival rate according to T stage, albeit without statistical significance. LDLT is considered the preferred therapeutic option in patients with an AFP level less than 100 ng/mL and a tumor diameter of less than 5 cm.

Salvage Liver Transplantation for Recurrent Hepatocellular Carcinoma within UCSF Criteria after Liver Resection

BackgroundSalvage liver transplantation (SLT) is restricted to patients who develop hepatocellular carcinoma (HCC) recurrence within Milan criteria (MC). Little is known about outcomes for SLT in patients with recurrent HCC within University of California San Francisco (UCSF) criteria after liver resection (LR).MethodsBetween January 2001 and December 2011, 380 patients with HCC meeting UCSF criteria, 200 of which were resected (LR group) from a perspective of SLT in case of recurrence, and 180 directly underwent LT (PLT). We compared patient characteristics, perioperative and long-term outcomes between SLT and PLT groups. We also assessed the outcome of LR and PLT groups.ResultsAmong the 200 patients in LR group, 86 (43%) developed HCC recurrence and 15/86 (17%) of these patients presented HCC recurrence outside UCSF criteria. Only 39 of the 86 patients underwent SLT, a transplantation rate of 45% of patients with HCC recurrence. Compared with PLT group, LR group showed lower overall survival rate (P = 0.005) and higher recurrence rate (P = 0.006). Although intraoperative blood loss and required blood transfusion were more frequent in SLT group, the perioperative mortality and posttransplant complications were similar in SLT and PLT groups. The overall survival and recurrence rates did not significantly differ between the two groups. When stratifying by graft type in the SLT group, overall survival and recurrence rates did not significantly differ between deceased donor LT (DDLT) and living donor LT (LDLT) groups. In the subgroup analysis by MC, similar results were observed between patients with recurrent HCC meeting MC and patients with recurrent HCC beyond MC but within UCSF criteria.ConclusionOur single institution experience demonstrated that prior hepatectomy and SLT for recurrent HCC within UCSF criteria was feasible and SLT could achieve the same outcome as PLT.

Comparison Between Living Donor Liver Transplantation Recipients Who Met the Milan and UCSF Criteria After Successful Downstaging Therapies

Background and AimsVarious downstaging therapies were introduced to liver recipients who could not meet the relative criteria for liver transplantation, and many endpoints were reported. The most common criteria used were the Milan criteria and the University of California, San Francisco (UCSF) criteria. However, no comparison was made between them, and we attempted to find possible differences between the living donor liver transplantation (LDLT) patients who met the Milan criteria and those who met the UCSF criteria after accepting preoperative downstaging therapies. Materials and MethodsWe performed a retrospective study of all 72 patients at our center from January 2003 to March 2009 who were diagnosed with advanced hepatocellular carcinoma but accepted various downstaging therapies. Some patients met the Milan criteria (group 1), and some met the UCSF criteria (group 2) but not the Milan criteria. We collected the data from the two groups and then compared the preoperative demographic data, downstaging therapies, intraoperative data from LDLT, and the recovery and complications after LDLT. Survival rates were compared using Kaplan–Meier analysis. ResultsOnly 44 patients (61.1 %) met the criteria for liver transplantation, 21 cases met the Milan criteria (group 1), and 23 cases met the UCSF criteria (group 2) but not the Milan criteria. All of the 44 patients accepted right lobe living liver donor liver transplantation in our center. The difference in the baseline characteristics between the two groups did not reach statistical significance. The mean number of downstaging treatments per patient was 1.81±0.35 in group 1 and 1.83±0.41 in group 2 (P = 0.928). Most of the patients received only one downstaging treatment, and transcatheter arterial chemoembolization (TACE) was the most common downstaging therapy. Four patients suffered complications after downstaging therapies: intra-abdominal hemorrhage after right hepatectomy, upper gastrointestinal hemorrhage after TACE, biliary fistula after resection, and hand–foot syndrome after taking sorafenib. All complications after LDLT, classified according to the Clavien–Dindo system, were compared within the two groups, and the calculated score of the complications in group 1 was 1.48 ± 1.63, which was greater than that of group 2 (1.39 ± 1.64), but this difference did not reach statistical significance (P = 0.865). The 1-, 3-, and 5-year survival rates were 90.4, 76.2, and 71.4 % in group 1 and 91.3, 73.9, and 69.6 % in group 2, respectively (P > 0.05). Seven patients (three in group 1 and four in group 2) had tumor recurrence after a median follow-up period of 72 months. The pathology findings were not different between the two groups. ConclusionRecipients who meet the Milan or UCSF criteria after accepting successful preoperative downstaging therapy in LDLT can achieve the same result.

Liver transplantation for hepatocellular cancer: UCL experience in 137 adult cirrhotic patients. Alpha-foetoprotein level and locoregional treatment as refined selection criteria

Liver transplantation (LT) is a validated treatment for selected cirrhotics with hepatocellular cancer (HCC). A retrospective single center study including 137 recipients having proven HCC was done to refine inclusion criteria for LT as well as to look at impact of locoregional treatment (LRT) on outcome. At pre-LT imaging, 42 (30.6%) patients were Milan criteria (MC)-OUT; 28 (20.4%) were University of California San Francisco criteria (UCSFC)-OUT. Pre-LT LRT was performed in 109 (79.6%) patients. Multivariate analysis identified four factors to be independently predictive of recurrence: tumour number >3, AFP level ≥400 ng/ml, microvascular invasion and rejection needing anti-lymphocytic antibodies. When considering pre-transplant variables only, AFP level ≥400 ng/ml (HR = 5.13; P < 0.0001) was the unique risk factor for recurrence; conversely, application of LRT was protective (HR = 0.42; P = 0.04). MC-IN patients having LRT (n = 79) had the best 5-year tumour-free survival (TFS) (91.6%). MC-IN patients without LRT (n = 16) and MC-OUT patients with LRT (n = 30) had similar good TFS (72.7% vs.77.5%); finally MC-OUT patients without LRT (n = 12) had the worst results (45.0%; vs. 1st group: P < 0.0001). Immediate pre-LT AFP and aggressive pre-transplant LRT strategy, especially in MC-OUT patients, are both important elements to further expand inclusion criteria without compromising long-term results of HCC liver recipients.

Patients with Multiple Hepatocellular Carcinomas Within the UCSF Criteria Have Outcomes After Curative Resection Similar to Patients Within the BCLC Early‐Stage Criteria

Surgical strategies for the treatment of multiple hepatocellular carcinomas (HCC) remain controversial. This study compared the prognostic power of the University of California, San Francisco (UCSF) criteria with the Barcelona Clinic Liver Cancer (BCLC) early-stage criteria. Clinical and survival data of 162 multiple-HCC patients in Child-Pugh class A who underwent curative resection were retrospectively reviewed. Prognostic risk factors were analyzed using univariate and multivariate analyses. UCSF criteria were shown to independently predict overall and disease-free survival. In patients within the UCSF criteria, 3-year overall and disease-free survivals were significantly better than in those exceeding the UCSF criteria (68 vs. 34 % and 54 vs. 26 %, respectively; both p < 0.001). There were no significant differences in 3-year overall and disease-free survival between patients within the UCSF criteria but exceeding the BCLC early stage and patients with BCLC early-stage disease (71 vs. 66 %, p = 0.506 and 57 vs. 50 %, p = 0.666, respectively). Tumors within the UCSF criteria were associated with a lower incidence of high-grade tumor (p = 0.009), microvascular invasion (p = 0.005), 3-month death (p = 0.046), prolonged Pringle's maneuver (p = 0.005), and surgical margin <0.5 cm (p < 0.001) than those exceeding the UCSF criteria. Tumors within the UCSF criteria but exceeding the BCLC early stage had invasiveness and surgical difficulty similar to those within the BCLC early-stage criteria. Multiple HCC patients within the UCSF criteria benefit from curative resection. Expansion of curative treatment is justified.

Younger Age and Presence of Macrovascular Invasion Were Independent Significant Factors Associated With Poor Disease-Free Survival in Hepatocellular Carcinoma Patients Undergoing Living Donor Liver Transplantation

ObjectivePatients with hepatocellular carcinoma (HCC) exceeding the University of California, San Francisco (UCSF) criteria are normally rejected for cadaveric liver transplants. However, whether they should be allowed to undergo living donor liver transplantation (LDLT) has been controversial. We reviewed the outcome of patients with advanced HCC who underwent LDLT at our center. MethodsFrom April 2002 to May 2011, 176 patients underwent LDLT at our center; of these, 77 (44%) had HCC at the explant liver. Patient overall survival and recurrence-free survival (RFS) was analyzed using Kaplan-Meier method. Multivariate analysis was performed by Cox analysis. ResultsAge was 56 ± 1 (56, 29–71) years; 62 (80.5%) were male; Model for End-stage Liver Disease Score was 11 ± 1 (9, 6–36), alpha fetoprotein (AFP) was 3683 ± 2019 (69, 3–139,591) ng/L; maximum tumor size was 4.5 (0.5–15) cm. Number or tumor nodules was 5 (1–10), and 32 (42%) had macrovascular invasion diagnosed pretransplant. Eleven (14%) were within UCSF criteria. After follow-up of 953 ± 90 (744, 2–2989) days, 53 (69%) were alive and 48 (62%) were recurrence-free. One-, 3- and 5-year overall survival (OS) and recurrence-free survival (RFS) were 80%, 70%, and 57% and 80%, 65%, and 48%, respectively. Five-year OS and RFS for those within UCSF criteria were both 78% versus 55% and 46% outside UCSF criteria (P = not significant). At multivariate analysis, high AFP, younger age, and macrovascular invasion were associated with both poor RFS. ConclusionIn HCC patients exceeding UCSF criteria, a reasonable 5-year overall survival of 55% post-LDLT can be obtained. Patients with HCC exceeding the UCSF criteria, especially in the older age group with no portal vein invasion and lower AFP level, should be actively considered for LDLT.