Risk factors for incisional hernia after liver transplantation in the era of mammalian target of rapamycin inhibitors use: a retrospective study of living donor liver transplantation dominant center in Korea

Purpose@#Incisional hernia (IH) is a common complication after liver transplantation (LT) with an incidence rate of 5% to 46%. This retrospective study aimed to evaluate the risk factors for IH development after LT in the era of mammalian target of rapamycin (mTOR) inhibitors use. @*Methods@#Data on patients who underwent LT between 2015 and 2021 were retrospectively reviewed. The patients were divided into 2 groups (IH group and non-IH group) according to the postoperative occurrence of IH. @*Results@#We analyzed data from 878 patients during the study period, with 28 patients (3.2%) developing IH. According to multivariate analysis, body mass index exceeding 25 kg/m² and the use of mTOR inhibitors within the first month after LT were the sole significant factors for both IH occurrence and the subsequent need for repair operations. Notably, a history of wound complications, a Model for End-stage Liver Disease score, and the timing of LT—whether conducted during regular hours or at night—did not emerge as significant risk factors for IH after LT. @*Conclusion@#Our study reveals a higher incidence of IH among obese patients following LT, often requiring surgical repair, particularly in cases involving mTOR inhibitor usage within the initial month after LT. Consequently, it is crucial to exercise increased vigilance, especially in obese patients, and exercise caution when considering early mTOR inhibitor administration after LT.

Long-term outcomes of liver transplantation using grafts from donors with active hepatitis B virus replication: a multicenter cohort study

Purpose@#Liver grafts from donors with HBV infection contributed to expanding the donor pool under the hepatitis B immunoglobulin and antiviral agents (nucleos(t)ide analogues) in the HBV-endemic area. We report long-term outcomes of liver transplantations (LTs) using grafts from donors with active or chronic HBV infection. @*Methods@#Overall, 2,260 LTs performed in 3 major hospitals in Seoul from January 2000 to April 2019 were assessed for inclusion. Twenty-six grafts (1.2%) were obtained from HBsAg (+), HBeAb (+), or HBcAb (+) donors, and recipient outcomes were retrospectively reviewed. Donor and recipient demographics and transplantation outcomes were analyzed. @*Results@#Sixteen deceased donor LTs were performed using active HBsAg (+) grafts. Ten other LTs were sourced from 10 living donors. There was no significant difference in survival in patients who received deceased donor LTs compared with that in those who underwent LT with non–hepatitis virus-infected grafts. Fourteen patients who were followed up for >5 years were stable, and no difference in hepatocellular carcinoma recurrence rate was observed 5 years after transplantation between transplants from donors with and those without HBV. @*Conclusion@#Considering long-term outcomes, liver grafts from donors with active HBV replication can be safely used for LT.

Recurrence in patients with totally necrotic nodules of hepatocellular carcinoma after liver transplantation: “totally” an inaccurate description

Purpose@#Total necrosis of hepatocellular carcinoma (HCC) achieved via locoregional treatment (LRT) is considered to indicate a lack of tumor viability. Nonetheless, there is insufficient evidence of recurrence after liver transplantation (LT) in patients with such a status. The aim of this study was to investigate the prognosis of patients diagnosed with totally necrotic nodules upon explant hepatectomy after LT. @*Methods@#We conducted a retrospective study of patients diagnosed with totally necrotic nodules after LT for HCC. A total of 165 patients with HCC who underwent living- or deceased-donor LT from 2000 to 2020 in our hospital were included. @*Results@#A total of 5 patients (3.0%) exhibited HCC recurrence during a median follow-up of 84 months (range, 4–243 months) after LT. The 5-year overall and recurrence-free survival rates of these patients were 92.8% and 92.2%, respectively. Four patients in the HCC-recurrence group (80.0%) died even after further treatment, including transarterial chemoembolization, surgery, and systemic treatment. Both univariate and multivariate analyses of clinicopathological factors identified a maximum diameter of the totally necrotic nodules of >5 cm as the only factor associated with tumor recurrence following LT (P = 0.005 and P = 0.009, respectively). @*Conclusion@#Total necrosis of HCC via LRT yielded excellent survival outcomes for patients undergoing LT. Nevertheless, patients with large tumors should be considered at high risk of recurrence after LT, suggesting the need for their active surveillance during the follow-up period.

Modified Charlson comorbidity index as a survival prediction tool for older patients after liver transplantation

Purpose@#An increasing number of older patients now undergo liver transplantation (LT). Although the overall outcomes in older patients are not different from those of younger patients, there is no tool to predict LT prognosis in older patients.We hypothesized that a modified Charlson comorbidity index (mCCI) and 5-factor modified frailty index (mFI-5) can predict outcomes in older patients after LT. @*Methods@#This retrospective study included 155 patients (aged >65 years) who underwent LT at Seoul National University Hospital. The recipients were subcategorized into 2 groups based on the mCCI score and mFI-5: the low (0–1) and high (2–5) mCCI groups, and low (≤0.4) and high (>0.4) mFI-5 groups. The independent effect of each variable on post-LT survival was determined using the mCCI subgroup, age at transplantation, sex, Child-Turcotte-Pugh score, model for end-stage liver disease (MELD) score, and mFI-5 subgroup. @*Results@#The high-mCCI group (41 patients) showed significantly lower 1- and 3-month and 1-, 3-, and 5-year survival than the low-mCCI group. Using the Cox regression model, the mCCI, sex, and MELD score remained significant. The mFI-5 was not a significant factor to predict patients’ survival. @*Conclusion@#The mCCI and MELD scores could be used to predict post-LT survival in older patients.

Evaluation of the efficacy and safety of conversion from the tacrolimus capsule to tablet in stable liver transplant recipients with maintenance therapy: a 24-week, open-label, single-center, phase IV exploratory clinical study

Purpose@#The tablet form of tacrolimus is more convenient for drug ingestion than the capsule form. We examined the efficacy and safety of tacrolimus tablets and a satisfaction survey after formula conversion in liver transplant (LT) recipients. @*Methods@#This study was an open-label, prospective clinical trial for tacrolimus formula 1:1 conversion from capsule to tablet in 41 adult LT recipients with tacrolimus maintenance therapy of more than 1 month. The primary endpoint was incidence of biopsy-proven acute rejection (BPAR) within 24 weeks. Surveys 1 week before and 4 weeks after formula conversion were conducted for total daily dose of medication, number, scale of discomfort and satisfaction. @*Results@#The overall incidence of BPAR was 0% and there was no graft loss or patient death. The incidence of adverse effects was 34.1% (n = 14) after formula conversion. The most common severe adverse effect was abnormal liver function test (n = 5): biliary complications (n = 4) and alcoholic recidivism (n = 1). Total daily dose and number of tacrolimus doses were significantly lower after formula conversion (P < 0.05) without changes in trough level. According to survey analysis, there was no significant difference in discomfort and satisfaction scales from capsule to tablet conversion (P < 0.05). @*Conclusion@#The present study suggests that the new tablet formula can be a useful treatment option to maintain a consistent level of tacrolimus with a lower total daily dose and number in adult LT recipients.

The Clinical Course and Prognosis of Patients With Nontuberculous Mycobacterial Pulmonary Disease After Solid Organ Transplantation

Background@#Due to impaired cell-mediated immunity, solid organ transplantation (SOT) recipients are at increased risk of developing nontuberculous mycobacterial pulmonary disease (NTM-PD). However, the clinical course of NTM-PD in SOT patients and the impact of SOT on the prognosis of NTM-PD remain unclear. @*Methods@#We analyzed patients who developed NTM-PD after receiving SOT between January 2001 and December 2020, at a tertiary referral hospital in South Korea. Baseline characteristics, clinical course, and prognosis were evaluated. Propensity score-matched analysis was performed to assess the impact of SOT on long-term survival in patients with NTM-PD. @*Results@#Among 4,685 SOT recipients over 20 years, 12 patients (median age, 64 years;interquartile range [IQR], 59–67 years; men, 66.7%) developed NTM-PD. Seven (58.3%) and five (41.7%) patients underwent kidney and liver transplantation, respectively, before the diagnosis of NTM-PD. The incidence of NTM-PD was 35.6 cases per 100,000 person-years among kidney transplant recipients and 28.7 cases per 100,000 person-years among liver transplant recipients. The median time between transplantation and the diagnosis of NTMPD was 3.3 (IQR, 1.5–10.8) years. The most common mycobacterial species was Mycobacterium avium (50.0%). Antibiotic treatment was initiated in five (41.7%) patients, and two patients (40.0%) achieved microbiological cure. Two patients died during a median follow-up of 4.2 (IQR, 2.3–8.8) years and NTM-PD was assumed to be the cause of death in one patient. When matched to patients without a history of SOT, patients with a history of SOT did not show worse survival (P value for log-rank test = 0.62). @*Conclusion@#The clinical course of NTM-PD in SOT recipients was comparable to that of patients without SOT, and SOT did not increase the risk of all-cause mortality in patients with NTM-PD.

Pure laparoscopic versus open right donor hepatectomy including the middle hepatic vein: a comparison of outcomes and safety

Purpose@#Analyses on pure laparoscopy in donor hepatectomies, including the middle hepatic vein (MHV), are still scarce. This study aimed to compare the outcomes of donor right hepatectomy, including the MHV, when performed laparoscopically with conventional open surgery. @*Methods@#Data from living donors who underwent donor right hepatectomy between January 2012 and December 2020 were retrospectively analyzed. The intraoperative and postoperative complication rates of the pure laparoscopic donor right hepatectomy (PLDRH) with MHV inclusion (PLDRHM) group were compared with the conventional open donor right hepatectomy with MHV inclusion (CDRHM) group and the PLDRH without MHV inclusion [PLDRHM(–)] group. @*Results@#Compared to the CDRHM group, the PLDRHM group had a longer bench time (P < 0.001) and higher Δ%,calculated as [(preoperative value – postoperative value)/preoperative value] × 100, of AST (P < 0.001), ALT (P < 0.001), and total bilirubin (P = 0.023), but shorter hospital stay (P = 0.004) and a lower rate of complications (P = 0.005). Compared to the PLDRHM(–) group, the PLDRHM group had fewer male donors (P < 0.001) and a lower body mass index (P < 0.001), estimated total liver volume (P < 0.001), and real graft weight (P < 0.001). Results of laboratory changes, hospital stays, and complication rates were similar between the 2 groups. @*Conclusion@#PLDRH with the inclusion of the MHV in selected donors and recipients is feasible and safe when performed by surgeons experienced in laparoscopic surgery, with favorable complication rates compared to CDRHM and PLDRHM(–).

Impact of tumor size on hepatectomy outcomes in hepatocellular carcinoma: a nationwide propensity score matching analysis

Purpose@#The aim of this study was to compare surgical outcomes after liver resection for hepatocellular carcinoma (HCC) according to tumor size using a large, nationwide cancer registry-based cohort and propensity score matching. @*Methods@#From 2008 to 2015, a total of 12,139 patients were diagnosed with liver cancer and registered in the Korean Primary Liver Cancer Registry. Patients without distant metastasis who underwent hepatectomy as a primary treatment were selected. We performed 1:1 propensity score matching between the small (<5 cm), large (≥5 cm and <10 cm), and huge (≥10 cm) groups. @*Results@#Overall, 265 patients in the small and large groups were compared, and 64 patients each in the large and huge groups were compared. The overall and progression-free survival rates were significantly lower in the large group than in the small group (P < 0.001 and P < 0.001, respectively). Overall survival tended to be poorer in the huge group than in the large group (P = 0.051). The progression-free survival rate was significantly lower in the huge group than in the large group (P = 0.002). @*Conclusion@#Although primary liver resection can be considered even in patients with huge HCC, greater caution with careful screening for recurrence is needed.

Validation for models for tumor recurrence after liver transplantation in hepatectomy patients

Purpose@#Early recurrence of hepatocellular carcinoma (HCC) remains a challenging issue after hepatic resection (HR) because of the associated poor prognosis. Models for tumor recurrence after liver transplantation (MoRAL) have been designed to predict tumor recurrence in HCC patients in the liver transplantation setting. This study aimed to validate the predictability of MoRAL for HCC recurrence or patient death and to evaluate the predictors of early HCC recurrence in hepatectomy patients with treatment-naïve solitary HCC. @*Methods@#This study included 443 patients with HCC recurrence after HR from January 2005 to December 2011. Patients were stratified into early recurrence (n = 312) and late recurrence (n = 131) groups according to the development of recurrence either within or more than 2 years after hepatectomy. @*Results@#The median levels of alpha-fetoprotein and protein induced by vitamin K absence-II and the median MoRAL score were significantly higher in the early recurrence group than in the late recurrence group. Regarding pathologic characteristics, the median tumor size, prevalence of tumor grade 3 or 4, microvascular invasion, presence of tumor necrosis, and macrovascular invasion in the early recurrence group were greater than those in the late recurrence group.Multivariate analysis showed that tumor grade 3 or 4, microvascular invasion, and high preoperative MoRAL score were predisposing factors for early HCC recurrence after HR. @*Conclusion@#The MoRAL score can be used to predict early recurrence in patients with HCC who undergo curative HR.Using this model, other treatments could be considered for patients with early recurrence predicted after HR.

Predicting prognosis and evaluating the benefits of adjuvant chemotherapy depending on the tumor location in intrahepatic cholangiocarcinoma: focusing on the involvement of below 2nd bile duct confluence

Purpose@#Intrahepatic cholangiocarcinoma (ICC) has various characteristics according to anatomical, histologic classifications, and its prognoses are different. This study aimed to compare oncologic outcomes according to tumor location (second bile duct confluence) and evaluate the effect of adjuvant chemotherapy. @*Methods@#Clinical data of 318 patients who underwent curative resection for ICC was reviewed. Central type ICC (C-ICC) and peripheral type ICC (P-ICC) were defined when the tumor invades the intrahepatic secondary biliary confluence and when located more peripherally, respectively. @*Results@#A larger tumor size, higher rate of elevated CA 19-9 level, vascular invasion, R1 resection, advanced T stage, and lymph node metastasis were found in C-ICC. C-ICC had poorer overall survival (median, 33 months vs. 58 months; P = 0.001), and the difference was more prominent in the early stage. C-ICC had a higher recurrence rate (68.7% vs. 55.1%, P = 0.014); otherwise, there was no difference in the recurrence patterns. There were no survival benefits of adjuvant chemotherapy in the entire cohort, but there were benefits in advanced stages (T3–4, N1 stage), especially in C-ICC. @*Conclusion@#C-ICC has more aggressive tumor characteristics and poor survival compared to P-ICC. Adjuvant chemotherapy seems to have survival benefits in the advanced stages, especially in the central type.

Prevention and Management of Small-for-Size Syndrome of Liver Transplantation / 이화의대지

Small-for-size syndrome (SFSS) is a critical complication of partial liver transplantation, particularly in adult-to-adult living donor liver transplantation (ALDLT) using a small graft. Minimally required liver graft size for a successful ALDLT is classically 40% of a standard recipient’s liver volume or 0.8% of recipient body weight. Recent progress in perioperative care and technical improvement push the lower limit of safe graft size to 25% of the recipient’s standard liver volume or 0.6% of the graft versus recipient weight ratio although this is an ongoing debate. The clinical manifestations of SFSS include various symptoms and signs related to graft dysfunction and portal hypertension in patients with small grafts. The risk factors for SFSS include poor preoperative patient condition, including portal pressure, surgical techniques to reduce portal pressure, and graft quality and size. Hence, various approaches have been explored to modulate inflow and pressure to a small graft and to decrease the outflow block to alleviate this SFSS as well as the selection of a patient and graft. Additionally, recent research and efforts to prevent and treat SFSS are reviewed.

Liver Graft Failure after Plastic Stent Removal of an Anastomotic Biliary Stricture / 대한소화기학회지

A biliary anastomotic stricture developed 13 months after living donor liver transplantation in a 19-year-old male with congenital hepatic fibrosis. Endoscopic management with balloon dilation followed by the placement of a 7F plastic stent was performed for the anastomotic stricture. After 6 months of indwelling of the stent, the plastic stent was removed because the stenosis and cholestasis were improved. One month after stent removal, he was admitted for acute liver graft failure owing to cholestatic hepatitis, and required retransplantation secondary to graft loss.

Clinical impact of the treatment modality on small, solitary, recurrent intrahepatic hepatocellular carcinomas after primary liver resection

Purpose@#The aim of this study was to determine the survival benefit based on different treatment strategies in patients with small, solitary, recurring intrahepatic hepatocellular carcinomas (HCCs) that were defined as recurred Barcelona Clinic Liver Cancer stage O (reBCLC-O). @*Methods@#Among the 917 patients with HCC recurrence after primary hepatic resection, 394 patients with reBCLC-O were selected. Of these, 150 patients underwent curative treatment (re-resection, radiofrequency ablation, and liver transplantation) and 203 underwent transarterial chemoembolization (TACE) group for recurrent HCC. After propensity score matching (PSM), both the groups were well balanced (89 patients in each group). @*Results@#Before PSM, the 1-, 3-, and 5-year overall survival (OS) rates of patients in the curative treatment group (96.7%, 78.6%, and 70.5%, respectively) were significantly better than those in the TACE treatment group (95.6%, 53.7%, and 44.2%, respectively) (P < 0.001). After PSM, the 1-, 3-, and 5-year OS rates also differed significantly (92.0%, 79.6%, and 71.1% in the curative treatment group vs. 88.8%, 65.6%, and 57.9% in the TACE group) (P = 0.005). The independent predictors of worse OS were tumor number at the time of resection and treatment modality for the recurrence, time interval to recurrence, and prothrombin time international normalized ratio and alpha-fetoprotein levels at the time of recurrence. @*Conclusion@#The OS of patients in the curative treatment group was better than that in the non-curative treatment group after PSM. Based on our results, curative treatment should be strongly recommended in the patients with reBCLC-O recurrence for better survival.

Clinical impact of the treatment modality on small, solitary, recurrent intrahepatic hepatocellular carcinomas after primary liver resection

Purpose@#The aim of this study was to determine the survival benefit based on different treatment strategies in patients with small, solitary, recurring intrahepatic hepatocellular carcinomas (HCCs) that were defined as recurred Barcelona Clinic Liver Cancer stage O (reBCLC-O). @*Methods@#Among the 917 patients with HCC recurrence after primary hepatic resection, 394 patients with reBCLC-O were selected. Of these, 150 patients underwent curative treatment (re-resection, radiofrequency ablation, and liver transplantation) and 203 underwent transarterial chemoembolization (TACE) group for recurrent HCC. After propensity score matching (PSM), both the groups were well balanced (89 patients in each group). @*Results@#Before PSM, the 1-, 3-, and 5-year overall survival (OS) rates of patients in the curative treatment group (96.7%, 78.6%, and 70.5%, respectively) were significantly better than those in the TACE treatment group (95.6%, 53.7%, and 44.2%, respectively) (P < 0.001). After PSM, the 1-, 3-, and 5-year OS rates also differed significantly (92.0%, 79.6%, and 71.1% in the curative treatment group vs. 88.8%, 65.6%, and 57.9% in the TACE group) (P = 0.005). The independent predictors of worse OS were tumor number at the time of resection and treatment modality for the recurrence, time interval to recurrence, and prothrombin time international normalized ratio and alpha-fetoprotein levels at the time of recurrence. @*Conclusion@#The OS of patients in the curative treatment group was better than that in the non-curative treatment group after PSM. Based on our results, curative treatment should be strongly recommended in the patients with reBCLC-O recurrence for better survival.

Standard or Variant Meso-Rex Shunts for Children with Variceal Bleeding due to Extrahepatic Portal Vein Obstruction: A Report of Two Cases

Extrahepatic portal vein obstruction (EHPVO) is the most common cause of pediatric portal hypertension and can cause life-threatening variceal bleeding. MesoRex shunt (MRS) is a surgical procedure that restores physiological portal venous blood flow to the liver by using a graft to connect the superior mesenteric vein and the left portal vein within the Rex recess, and can relieve variceal bleeding and other complications associated with EHPVO. Although the MRS is regarded as an optimal and potentially curative treatment with good long-term patency, graft thrombosis or failure due to unknown causes is not rare, prompting the need for further research on the risk factors of graft failure or poor patency. Herein, we report two cases of EHPVO in patients with recurrent or uncontrolled variceal bleeding, one treated with the classic Rex shunt and the other with the modified Rex shunt, which resulted in a failure and success, respectively.

Bacterial Infections after Liver Transplantation in Children: Single Center Study for 16 Years

PURPOSE: Survival after liver transplantation (LT) has improved over the years, but infection is still a major complication. We aimed to identify the characteristics of bacterial infections in pediatric LT recipients. METHODS: This study is a retrospective review of 189 consecutive children undergoing LT between 2000 and 2015 at a single center. In this study, the incidence of infection was determined for the following periods: within 1 month, between 1–5 months, and between 6–12 months. Patients who underwent liver transplants more than once or multiple organ transplants were excluded. RESULTS: All patients had received postoperative antibiotic for 3 days. Only the maintenance immunosuppression with oral tacrolimus and steroids were performed. As a result, 132 bacterial infections developed in 87 (46.0%) patients (0.70 events per person-year). Bacterial infections occurred most frequently within the first month (n=84, 63.6%) after LT. In the pathogens, Staphylococcus aureus (15.2%), Enterococcus species (15.2%), and Klebsiella species (13.6%) were most common. Regarding the organ infected, bloodstream was most common (n=39, 29.5%), followed by peritoneum (n=28, 21.2%), urinary tract (n=25, 18.9%), and lungs (n=20, 15.2%). We changed prophylactic antibiotics from ampicillin-sulbactam to piperacillin-tazobactam at 2011, October, there were no significant effects in the prevalence of antibiotics resistant bacterial infections. The 1-year mortality was 9.0% (n=17), in which 41.2% (n=7) was attributable to bacterial infection; septicemia (n=4), pneumonia (n=2), and peritonitis (n=1). CONCLUSIONS: The incidence and type of bacterial infectious complications after LT in pediatric patients were similar to those of previous studies. Bacterial complications affecting mortality occur within 6 months after transplantation, so proper prophylaxis and treatment in this period may improve the prognosis of LT.

Kidney Transplantation in Patients with Atypical Hemolytic Uremic Syndrome due to Complement Factor H Deficiency: Impact of Liver Transplantation

BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a rare disease that is often associated with genetic defects. Mutations of complement factor H (CFH) are the most common genetic defects that cause aHUS and often result in end-stage renal disease. Since CFH is mainly produced in the liver, liver transplantation (LT) has been performed in patients with defective CFH. METHODS: The clinical courses of four kidney allograft recipients who lost their native kidney functions due to aHUS associated with a CFH mutation were reviewed. RESULTS: Subject A underwent kidney transplantation (KT) twice, aHUS recurred and the allograft kidney failed within a few years. Subject B received a KT and soon experienced a recurrence of aHUS coinciding with infection. Her allograft kidney function has worsened, and she remains on plasma infusion therapy. Subject C underwent LT followed by KT. She is doing well without plasma infusion therapy after combined LT-KT for 3 years. Subject D received KT following LT and is now recurrence-free from aHUS. CONCLUSION: In patients with aHUS associated with a CFH mutation, KT without LT was complicated with a recurrence of aHUS, which might lead to allograft loss. Conversely, LT was successful in preventing the recurrence of aHUS and thus might be another option for a recurrence-free life for aHUS patients associated with CFH mutation.

Postoperative Chemoradiotherapy for R1 Resected Intrahepatic Cholangiocarcinoma

BACKGROUND/AIMS: To investigative the potential role of postoperative chemoradiotherapy (CCRT) after R1 resection of intrahepatic cholangiocarcinoma (IHCC). METHODS: Between January 2000 and December 2012, medical records of 18 patients who underwent curative surgery with R1 resection for IHCC were retrospectively reviewed. RESULTS: Median age was 68 years and 12 patients (66.7%) were male. Median tumor size was 5.0 cm (range, 2.2–11.0) and 12 patients (66.7%) had T3 or higher disease. Lymph nodes were involved in four patients (22.2%). Vascular invasion and perineural invasion were present in 10 (55.6%) and 12 patients (66.7%), respectively. Postoperative CCRT given with 5-fluorouracil or gemcitabine were delivered to 7 patients (38.9%). Median radiation dose was 50.4 Gy (range, 45-54). Univariate analysis showed that median loco-regional recurrence-free survival (LRRFS), progression-free survival (PFS) and overall survival (OS) were prolonged for patients treated with CCRT (median LRRFS; 5.6 months vs. not reached, P < 0.001, median PFS; 5.6 vs. 8.3 months, P=0.047, median OS; 15.0 vs. 26.6 months, P=0.064). CONCLUSIONS: Postoperative CCRT improved the loco-regional control and PFS in IHCC patients with R1 resection. Further study is warranted to validate the role of postoperative CCRT for these patients.

A prospective randomized study comparing radiofrequency ablation and hepatic resection for hepatocellular carcinoma

PURPOSE: Although there are several prospective clinical studies comparing radiofrequency ablation (RFA) and hepatic resection (HR) for the treatment of hepatocellular carcinoma, there are few trials that have been performed in strictly homogeneous patients. METHODS: Patients who were newly diagnosed with a solitary hepatocellular carcinoma were randomized to the HR or RFA group. Inclusion criteria were as follows: age ≥ 20 years but ≤ 70 years, Child-Pugh class A, maximal diameter of the tumor ≥ 2 cm but ≤ 4 cm, no previous treatment history, and platelet count > 80,000/mm3. RESULTS: Although the study was early terminated, 29 and 34 patients were enrolled in the HR and RFA groups, respectively, and prospectively followed on an intention-to-treat basis. The 5-year overall survival rates were 83.4% and 86.2% in the HR and RFA groups, respectively, which were not significantly different (P = 0.812 by log-rank, P = 0.990 by Breslow). The 3- and 5-year disease-free survival rates in the HR group were significantly superior to those in the RFA group (66.7%, 44.4% vs. 44.1%, 31.2%, P = 0.071 by log-rank, P = 0.023 by Breslow). Intrahepatic local recurrence tended to develop more frequently in the RFA group (P = 0.042), while the frequency of intrahepatic distant and extrahepatic recurrence was similar bet ween the 2 groups. There were no significant differences in the frequency and severity of complications between the 2 groups. CONCLUSION: HR was significantly superior to RFA in terms of disease-free survival; however, the overall survival was excellent in both groups.

Assessment of the Surveillance Interval at 1 Year after Curative Treatment in Hepatocellular Carcinoma: Risk Stratification

BACKGROUND/AIMS: Guidelines recommend surveillance for hepatocellular carcinoma (HCC) recurrence at 3-month intervals during the first year after curative treatment and 6-month intervals thereafter in all patients. This strategy does not reflect individual risk of recurrence. We aimed to stratify risk of recurrence to optimize surveillance intervals 1 year after treatment. METHODS: We retrospectively analyzed 1,316 HCC patients treated with resection/radiofrequency ablation at Barcelona Clinic Liver Cancer stage 0/ A. In patients without 1-year recurrence under 3-monthly surveillance, a new model for recurrence was developed using backward elimination methods: training (n=582)/ validation cohorts (n=291). Overall survival (OS) according to risk stratified by the new model was compared according to surveillance intervals: 3-monthly versus 6-monthly (n=401) after lead time bias correction and propensity-score matching analyses. RESULTS: Among patients without 1-year recurrence, age and international normalized ratio values were significant factors for recurrence (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.00 to 1.03; p=0.009 and HR, 5.63; 95% CI, 2.24 to 14.18; p < 0.001; respectively). High-risk patients stratified by the new model showed significantly higher recurrence rates than low-risk patients in the validation cohort (HR, 1.73; 95% CI, 1.18 to 2.53; p=0.005). After propensity-score matching between the 3-monthly and 6-monthly surveillance groups, OS in high-risk patients under 3-monthly surveillance was significantly higher than that under 6-monthly surveillance (p=0.04); however, OS in low-risk patients under 3-monthly surveillance was not significantly different from that under 6-monthly surveillance (p=0.17). CONCLUSIONS: In high-risk patients, 3-monthly surveillance can prolong survival compared to 6-monthly surveillance. However, in low-risk patients, 3-monthly surveillance might not be beneficial for survival compared to 6-monthly surveillance.