Response to transarterial chemoembolization may serve as selection criteria for hepatocellular carcinoma liver transplantation

Abstract

Aims: This study sought to extend the inclusion criteria for hepatocellular carcinoma (HCC) liver transplantation (LT), particularly addressing the safety and effectiveness of pre-LT transarterial chemoembolization (TACE).

Materials and methods: Our study included 115 patients with HCC who underwent LT after TACE. The response measured after each TACE session was based on the mRECIST criteria: complete response (CR), partial response (PR), stable disease (SD) or progressive disease (PD). We defined CR and PR patients as responders (64 cases) and SD and PD patients as non-responders (51 cases).

Results: The majority of responders could be identified after the first or second TACE sessions (57 cases, 89.1%). Overall survival rates at 1, 3 and 5 years were 95.3%, 89.1% and 75.0%, respectively, in the responder group, and these rates were much higher than those in the non-responder group (86.3%, 66.7% and 54.9%, P=0.016). In addition, the tumor-free survival rate in the responder group was also higher than in the non-responder group (P=0.009). In the responder group, a statistically improved long-term outcome was observed in patients whose HCC did not satisfy the Milan criteria (P<0.05). Univariate and multivariate Cox analyses showed that achieving CR or PR was the best predictor of survival and tumor-free survival following TACE.

Conclusion: The response to TACE, particularly following the first two sessions, primarily and robustly predicted overall and tumor-free survival in HCC patients, particularly those whose HCC did not satisfy the Milan criteria.

Keywords: hepatocellular carcinoma; liver transplantation; selection; transarterial chemoembolization.

Figure 1. The majority of patients received TACE twice (51 patients), although TACE was administered once in 30 patients, three times in 23 patients, and more than three times in 11 patients

A response was recorded in 19 patients after one session of TACE, in 38 patients after a second session, in 4 patients after a third session, and in only 3 patients when over four sessions were used.

Figure 2

(A) The overall survival rates at 1, 3 and 5 years were 95. 3%, 89.1% and 75.0% in the responder group and 86.3%, 66.7% and 54.9% in the non-responder group (P=0.016), respectively; (B) The 1-, 3- and 5-year tumor-free survival rates in the responder group were 86.3%, 66.7% and 54.9%, respectively, and 78.4%, 47.1% and 47.1%, respectively, in the non-responder group (P=0.009).

Figure 3

(A) In the subgroup of patients within the Milan criteria , the responders showed 1-, 3- and 5-year survival rates of 94. 1%, 91.2% and 76.5%, respectively, and non-responders showed cumulative 1-, 3- and 5-year overall survival rates of 91.3%, 70.0% 56.5% (P=0.146), respectively; (B) For those within the Milan criteria, the 1-, 3- and 5-year tumor-free survival rates were comparable between the responder and non-responder groups (P=0.205); (C) In the subgroup outside of the Milan criteria, the 1-, 3- and 5-year overall survival rates were 96.7%, 86.7% and 76.7%, respectively, in the responder group and 82.1%, 64.3% and 57.1%, respectively, in the non-responder group(P=0.043); (D) The 1-, 3- and 5-year tumor-free survival rates were 90.0%, 76.7% and 70.0%, respectively, in the responder group and 71.4%, 42.9% and 42.9%, respectively, in the non-responder group (P=0.017).

Figure 4

(A) In the responder subgroup, the patients who achieved a response after the first two TACE sessions showed much better 1-, 3- and 5-year overall survival rates than patients who achieved a response after 3 or more TACE sessions (P=0. 024); (B) The tumor-free survival rate was also better in responders to the first two TACE sessions compared with responders to 3 or more TACE sessions (P=0.080).