Downstaging HCC to Milan criteria prior to liver transplant yield ‘excellent outcomes’
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Researchers reported excellent 10-year outcomes among patients with hepatocellular carcinoma that was downstaged to within Milan criteria prior to liver transplant, according to a multicenter analysis published in JAMA Surgery.
“The outcomes provided in the current study ... increase the level of recommendation for the downstaging policy on a global basis,” co-lead author of the study Parissa Tabrizian, MD, assistant professor of surgery at the Icahn School of Medicine at Mount Sinai, told Healio. “In addition, these results are aligned with the first randomized, controlled phase 2b/3 trial published supporting downstaging in Italian centers. We hope that these results provide the rational to adopt this policy on a global basis.”
In a review of prospectively collected data, Tabrizian and colleagues analyzed the results of 2,645 adults (median age, 59.9 years; 76.7% men) with HCC who underwent LT at five U.S. academic centers. Of those, 2,122 patients had disease that was always within Milan criteria (defined as having one lesion of no more than 5 cm or two to three lesions of no more than 3 cm), 341 patients had their disease downstaged to within criteria at the time of LT and 182 patients did not have their disease downstaged.
Investigators defined successful downstaging as reduced viable tumor burden following locoregional therapy to within Milan criteria. The median follow-up was 55.3 months.
Among the downstaged cohort, 10-year survival after transplant was 52.1% and recurrence rate was 20.6%. These rates were 61.5% and 13.3%, respectively, for patients whose disease was always within Milan criteria and 43.3% and 41.1%, respectively, among patients whose disease was not downstaged.
“We demonstrated excellent 10-year outcome on post-transplant patients and those successfully downstaged within Milan criteria at the time of surgery,” Tabrizian said. “In addition, we assessed the effect of the different treatment modalities when patients’ cancer recurred post-transplantation. The outcomes of patients were improved if the patients were eligible for curative treatments once their cancer recurred.”
According to results, downstaging failure correlated with tumor size greater than 7 cm at the time of diagnosis, alpha-fetoprotein response of 20 ng/mL or more with less than 50% improvement from maximum alpha-fetoprotein prior to transplant, and more than three tumors at diagnosis.
“It was overall motivating to confirm on a larger scale what has been demonstrated in several studies over the past few years,” Tabrizian said. “We validated national downstaging policy, and we identified predictors of poor outcome. When expanding the criteria and adopting downstaging, excellent 10-year outcomes can be achieved in a subgroup of patients who have favorable tumor biology.”
She added: “We will conduct future clinical trials on the use of immunotherapy in liver cancer. A subset of patients with liver cancer have tremendous response to immunotherapy; which subset responds and whether immunotherapy is associated with long-term outcomes post-transplantation will need to be further investigated.”
Reference:
- Shrinking liver cancer tumors before transplant yields excellent outcomes, researchers report. https://www.mountsinai.org/about/newsroom/2022/shrinking-liver-cancer-tumors-before-transplant-yields-excellent-outcomes-mount-sinai-researchers-report. Published July 21, 2022. Accessed Aug. 4, 2022.
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