Treatment of HCC Japanese Consensus JSH meeting 2003

1
Living donor liver transplantation for patients
with hepatocellular carcinoma exceeding Milan
criteria
Yasutsugu TAKADA Department of Transplantation
and Immunology Kyoto University
2
DDLT vs. LDLT for HCC patients
DDLT

• Scarce donor organs should be effectively used
• Milan criteria for reducing the risk of recurrence

LDLT

• The donor only for the related recipient
• Possible to extend the
  selection criteria
• Donor risk and higher morbidity/mortality

3
Selection criteria of our LDLT program for HCC
patients

• HCC not suitable for resection or local ablation
  therapies
• - advanced tumor spreading
• - repeated, uncontrolled recurrence
• - poor liver function reserve
• 2. Excluding HCC with extrahepatic metastasis or
  macroscopic venous invasion on preoperative
  imaging
• no restrictions on the number or size of
  tumors

4
Aim

• To evaluate the results of LDLT for HCC patients
  using our own selection criteria
• To investigate the possibility to extend the
  Milan criteria

5
LDLT for HCC at Kyoto Univ. (1999.02
? 2005.03)

• - patient n114
• - malefemale 7935
• - age 2269 y.o. (median 54)
• - previous Tx 84 cases (74)
• TAE 69
• PEI, RFA 53
• Hx 15
• - follow-up 376 months (median 35)

6
Underlying disease
Others (3)
PBC (3)
Unknown (2)
Alcoholic (3)
HCV (66)
HBV (37)
(Total n114)
7
Preoperative Condition (n103)
Child-Pugh grade
MELD Score
gt30 (n6)
A (n21)
10 (n22)
2130 (n27)
C (n54)
B (n39)
1120 (n59)
median 15
8
Milan criteria (MC)
Incidental (11)
Within MC (55)
Over MC(48)
Total n114
9
Survival rates after LDLT
1
Overall 5-y 66
.8
.6
Survival rate
Recurrence-free 5-y 61
.4
(n114)
.2
0
0
1
2
3
4
5
6
Post-transplant year
10
Milan criteria and survival rates
(excluding 11 incidental cases)
1
Within-MC (n55) 5-y 70
.8
.6
Over-MC (n48) 5-y 60
Recurrence rate
.4
pN.S.
.2
0
0
1
2
3
4
5
6
Post-transplant year
11
Recurrence rate after LDLT
Site of recurrence lung bone liver
LN adrenal 1brain
diaphragm
1
5 3 3 2 1 1 1 16
.8
.6
Recurrence rate
.4
Overall 5-y 22
.2
0
0
1
2
3
4
5
6
Post-transplant year
12
Milan criteria (MC) and recurrence rates
(excluding 11 incidental cases)
1
.8
p0.0340
.6
Recurrence rate
Over-MC (n48) 5-y 32
.4
.2
Within-MC (n55) 5-y 16
0
0
1
2
3
4
5
6
Post-transplant year
13
Tumor size, number and recurrence rates
(excluding 11 incidental cases)
Tumor number
Tumor size
1
1
P0.082
P0.0002
.8
.8
5cmlt (n12)
Recurrence rate
.6
.6
10? (n17)
.4
.4
49 (n20)
?3cm (n63)
.2
.2
?3 (n66)
35cm (n28)
0
0
0
1
2
3
4
5
6
0
1
2
3
4
5
6
Post-transplant year
Post-transplant year
14
Subgroup analysis in over-MC group
Over-MC (n48) divided into 2 subgroups
A n?9 and all ?5 cm in diameter (n23)
B n?10 or gt5 cm in diameter (n25)
15
Subgroup analysis of recurrence rates in over-MC
group
(excluding 11 incidental cases)
1
.8
.6
Recurrence rate
.4
.2
0
0
1
2
3
4
5
6
Post-transplant year
16
Survival rates in over-MC group
(excluding 11 incidental cases)
1
.8
.6
Survival rate
.4
.2
0
0
1
2
3
4
5
6
Post-transplant year
17
Preope. criteria of n?9 and all ?5 cm and
pathological venous invasion and histological
grade
Pathological venous invasion
Histological grade
Plt0.01
P0.075
100
vi(-)
80
well or mod
70
60
40
vi()
36
31
20
poor
16
0
n?10 or gt5 cm (n25)
n?10 or gt5 cm (n25)
n?9 and ?5 cm (n78)
n?9 and ?5 cm (n78)
????
???1?2?
???3???
????
???1?2?
???3???
18
Pathological n?9 and ?5 cm in the explanted
liver and recurrence rate
()
1
p0.0002
.8
n?10 or gt5 cm (n29) 5-y 49
Recurrence rate
.6
.4
n?9 and ?5 cm (n85) 5-y 13
.2
0
0
1
2
3
4
5
6
Post-transplant year
19
Conclusion
Although the recurrence rate was significantly
higher for the over-MC group than for the
within-MC group, the results of subgroup analysis
suggest that selection criteria can be safely
extended up to n?9 and all ?5 cm in diameter with
acceptable outcomes.