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Downstaging of HCC leads to low recurrence, high post-transplant survival

Patients who underwent successful downstaging for hepatocellular carcinoma had a lower chance of recurrence and higher chance of survival post-liver transplant vs. patients without downstaging, according to study data.

“In this ongoing prospective study, we evaluated the long-term [intention-to-treat] outcome of a larger cohort of consecutive patients with HCC undergoing downstaging of HCC to within T2 [Milan] criteria,” the researchers wrote. “We also compared the outcomes after downstaging with a group of consecutive patients with T2 HCC at initial presentation who were listed for [liver transplant] over the same time period.”

The researchers analyzed data of 118 patients with HCC who underwent downstaging before liver transplant (LT) between 2002 and 2012 and compared results with 488 patients with HCC that met T2 Milan criteria and were on the LT waitlist. All patients undergoing downstaging underwent computed tomography or MRI of the abdomen 1 month after each local regional therapy (LRT) and at a minimum of every 3 months, according to the research.

Downstaging was successful in 65.3% of patients (n = 77) and at follow-up, 54.2% underwent LT (n = 64) and nine were still waitlisted. Sixty-eight percent of patients in the T2 group underwent LT (n = 332), eight were still waitlisted and 24.5% had dropped out (n = 121)

Among the downstaging patients who underwent LT, 7.5% developed HCC recurrence (n = 5) during a median follow-up of 3.8 years. Of these five patients, two had four to five tumors.

The 1-year drop-out probability rate was 24.1% and 34.2% at 2 years in the patients who underwent downstaging compared with 20.3% at 1 year and 25.6% at 2 years for patients in the T2 group (P = .04).

The probability of 5-year post-transplant survival was 77.8% in the downstaging group vs. 81% in the T2 group (P = .69). However, recurrence-free probability was greater in the downstaging group vs. the T2 group (90.8% vs. 88%, respectively; P = .66).

The 5-year intention-to-treat survival rate was 56.1% in the downstaging group and 63.3% in the T2 group (P = .29).

Using competing risk analysis, predictors for dropout in the downstaging group were Child’s B vs. Child’s A cirrhosis (P = .04) and a baseline pre-treatment alpha-fetoprotein level of at least 1,000 ng/mL (P = .02).

“Owing to the small number of patients with 4 to 5 tumors, further investigations are needed to confirm the efficacy of downstaging in this subgroup,” the researchers concluded. “In spite of this and other limitations of the present study, the overall low rate of HCC recurrence after LT and the very low incidence of either poorly differentiated grade or microvascular invasion in the liver explant support the role of downstaging in the selection of patients with tumors of more favorable biology that respond to LRT and also do well after LT.” – by Melinda Stevens

Disclosures: Yao reports no relevant financial disclosures. Please see the study for a full list of all other authors’ relevant financial disclosures.