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Surgery-led comprehensive treatment is an important consensus in the management of liver carcinoma. Hepatectomy and liver transplantation are the most important means for patients with liver carcinoma to achieve long-term survival. With the development of liver surgery techniques, liver surgery is no longer off-limits. Translational therapy offers the hope of surgical radical treatment for patients with initially unresectable liver carcinoma. This article discusses the conversion therapy for unresectable liver carcinoma with future liver remnant surgery, the downstaging conversion therapy of oncologically unresectable intermediate to advanced liver carcinoma, the timing of surgery after conversion, and safety and efficacy. Prospect for the formation of the standardization of translational therapy for liver carcinoma is made.
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Objective:To investigate the clinical efficacy of liver transplantation for intra-hepatic cholangiocarcinoma.Methods:The retrospective cohort study was conducted. The clinico-pathological data of 22 patients with intrahepatic cholangiocarcinoma who underwent liver trans-plantation in the 5 medical centers, including First Hospital of Jilin University, et al, from September 2005 to December 2021 were collected. There were 18 males and 4 females, aged 57(range, 38?71)years. Observing indicators: (1) clinicopathological characteristics of patients with intrahepatic cholangiocarcinoma; (2) follow-up; (3) prognosis. Measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers or percentages. The Kaplan-Meier method was used to draw survival curves. The Log-Rank test was used for survival analysis. Results:(1) Clinicopathological characteristics of patients with intrahepatic cholangio-carcinoma. Of the 22 patients, 20 cases were diagnosed as intrahepatic cholangiocarcinoma before liver transplantation, 7 cases had viral hepatitis type B, 1 case had primary sclerosing cholangitis, 7 cases had tumor treatment before liver transplantation, 7 cases, 6 cases and 9 cases were classified as grade A, grade B and grade C of the Child-Pugh classification, 16 cases had preoperative CA19-9 >40 U/mL, 14 cases had single tumor, 11 cases with tumor located at right lobe of liver, 6 cases with tumor located at both left and right lobe of liver, 5 cases with tumor located at left lobe of liver, 9 cases with tumor vascular invasion. All 22 patients were diagnosed as moderate-poor differentiated tumor. There were 9 cases with liver cirrhosis, 4 cases with tumor lymph node metastasis, 10 cases with tumor burden within Milan criteria. The tumor diameter of 22 patients was 4.5(range, 1.5?8.0)cm. (2) Follow-up. All 22 patients were followed up for 15(range, 3?207)months. Of the 22 patients, 9 cases had tumor recurrence and 8 cases died. (3) Prognosis. The 1-year overall survival rate and 1-year disease-free survival rate of the 22 patients was 72.73% and 68.18%, respectively. Results of subgroup analysis showed there were significant differences in overall survival and disease-free survival between the 10 patients with tumor burden within Milan criteria and the 12 patients with tumor burden beyond Milan criteria who underwent liver transplantation ( hazard ratio=0.13, 0.26, 95% confidence interval as 0.03?0.53, 0.08?0.82, P<0.05). Results of further analysis of the 12 patients with tumor burden beyond Milan criteria showed there were significant differences in overall survival and disease-free survival between the 5 patients with preoperative tumor down-staging treatment and the 7 patients without preoperative tumor down-staging treatment ( hazard ratio=0.18, 0.14, 95% confidence interval as 0.04?0.76, 0.04?0.58, P<0.05). Conclusions:Intrahepatic cholangiocarcinoma patients with tumor burden within Milan criteria have a better prognosis than patients with tumor burden beyond Milan criteria after liver transplantation. For patients with tumor burden beyond Milan criteria, active tumor down-staging treatment before liver transplantation can improve the prognosis.
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Liver diseases are common in China and the incidence and mortality of primary liver cancer are among the top in the world. As one of the therapeutic methods for hepatocellular carcinoma (HCC), liver transplantation has become an important technique in hepatic surgery. Most of patients with HCC have progressed to stage B or C of Barcelona Clinic Liver Cancer staging when diagnosed. How to reduce the dropout rate of HCC patients due to the progression of tumor when waiting for liver transplantation, develop individualized immunosuppressant plans for HCC patients after liver transplantation, and accurately manage patients with HCC recurrence after liver transplan-tation are the current hotspots of research. The authors review the relevant literature, summarize the treatment experience, and discuss the hot issues in liver transplantation for HCC, in order to provide reference for related treatment.
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Objective To evaluate the effect of microvascular invasion (MVI) on prognosis of recipients after liver transplantation for primary liver cancer (liver cancer). Methods Clinical data of 177 recipients after liver transplantation for liver cancer were retrospectively analyzed. All patients were divided into the MVI-positive group (n=64) and MVI-negative group (n=113) according to postoperative pathological examination results. Clinical data were statistically compared of all recipients between the negative and positive MVI groups. The prognosis and risk factors of liver transplantation recipients for liver cancer were analyzed. Results Among 177 recipients, 64 cases (36.2%) were positive for MVI and 113 (63.8%) negative for MVI. Compared with the MVI-negative recipients, MVI-positive recipients had significantly lower degree of tumor differentiation, higher preoperative alpha-fetaprotein (AFP) level, larger maximal tumor diameter, a larger quantity of tumors, more satellite lesions and more recipients who did not meet the Milan criteria (all P < 0.05). The 1-, 3- and 5-year overall survival (OS) and recurrence-free survival (RFS) of recipients after liver transplantation for liver cancer were 80.2%, 62.1%, 58.5% and 66.3%, 57.5%, 51.2%, respectively. The 1-, 3- and 5-year OS and RFS of MVI-positive recipients were 70%, 39%, 35% and 53%, 39%, 33%, significantly lower than 86%, 75%, 72% and 73%, 68%, 63% of their counterparts negative for MVI (all P < 0.05). Cox regression analysis showed that the maximal tumor diameter >8 cm, preoperative AFP level ≥20 ng/mL, low degree of tumor differentiation and positive MVI were the independent risk factors for OS of recipients after liver transplantation for liver cancer (all P < 0.05). Positive MVI, low degree of tumor differentiation and preoperative down-staging failure were the independent risk factors for RFS of recipients after liver transplantation for liver cancer (all P < 0.05). Conclusions MVI is of significant clinical value in predicting clinical prognosis of recipients after liver transplantation for liver cancer.
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Currently, several major challenges still exist in liver transplantation for hepatocellular carcinoma (HCC), including the opportunity of liver transplantation for HCC patients beyond selection criteria, drop-out from the waiting list for HCC patients within selection criteria due to tumor progression and the tumor recurrence after liver transplantation. In recent years, revolutionary efficacy has been achieved in treating advanced HCC by employing systemic drugs, such as lenvatinib and systemic drug-based comprehensive treatment, which also sheds light on the down-staging therapy and bridging therapy for HCC patients listed for liver transplantation, and prevention and treatment of tumor recurrence after liver transplantation for HCC individuals. Systemic drug-based comprehensive treatment probably has the potential to improve the clinical efficacy of liver transplantation for HCC, which deserves in-depth investigation. In this review, we summarize the progress on down-staging therapy, bridging therapy as well as prevention and treatment of tumor recurrence after liver transplantation for HCC individuals, aiming to provide reference for clinical managementof HCC.
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The 25th Annual Congress of International Liver Transplantation Society (ILTS) was held from May 15 to 18, 2019 in Toronto, Canada. Focusing on the special topic of liver transplantation for liver cancer, down-staging liver cancer and bridging therapy before liver transplantation, prediction of liver cancer recurrence after liver transplantation, individualized immunosuppressive scheme, prevention and treatment of liver cancer recurrence after liver transplantation were summarized in this article. In addition, the literatures published in recent two years related to the research progress were reviewed.
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Objective To propose a new suggestion for the clinical downstaging of nasopharyngeal carcinoma (NPC) in the era of intensity-modulated radiotherapy (IMRT) without changing the current T,N,and M staging system.Methods We reviewed the records of 536 NPC patients treated in Sun Yat-Sen University Cancer Center from January 2002 to December 2006.The Kaplan-Meier method was used to calculate the disease-specific survival (DSS) rate,and the log-rank test was used for survival difference analysis.The Cox regression model was used to calculate the hazard ratio (HR) of each subset.ResultsAccording to the 7th edition of UICC/AJCC staging system,the 5-year DSS rates of stage Ⅰ-Ⅲ patients (except T3N2M0) were all more than 85%(P>0.05),those of stage ⅣA and ⅣB patients were 71.8% and 46.2%,respectively (P=0.171),and that of stage ⅠVC patients was only 24.0%.In stage Ⅲ,the 5-year DSS rate of non-T3N2M0 patients (91.5%) was significantly higher than that of T3N2M0 patients (78.6%)(P=0.042),but there was no significant difference in DSS between T3N2M0 patients and stage ⅣA and ⅣB patients.Based on the above results,new stage Ⅰ included T1-3N0-1M0 and T1-2N2M0,new stage Ⅱ included T3N2M0,T4N0-2M0,and TxN3M0,and new stage Ⅲ included TxNxM1.The 5-year DSS rates of new stage Ⅰ,Ⅱ,and Ⅲ patients were 93.3%,72.7%,and 24.0%,respectively (P=0.000).Compared with new stage Ⅰ patients,new stage Ⅱ and Ⅲ patients had HRs of 4.01 and 16.76,respectively,for 5-year DSS.Conclusions In the era of IMRT,the new clinical staging system (stages Ⅰ,Ⅱ,and Ⅲ) helps with prognostic evaluation and clinical treatment.
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Background: The aim of the study is to assess the tumor response to neoadjuvant chemotherapy with cyclophosphamide, adriamycin, 5-fluorouracial (CAF regimen) in terms of decrease in breast tumor size (partial or complete clinically).To assess clinically the axillary lymph node status after neoadjuvant chemotherapy (conversion from palpable to nonpalpable). Methods: Thirty female patients of breast cancer were studied for down staging with two cycles of CAF regimen given at interval of 21 days. After 21 days of second cycle patient’s staging noted for effects. Results: Thirty female patients of breast cancer were studied. Maximum no. of patients between 31-40 years, mean age 46 years and median age 45 years, youngest patients 18 years, oldest patients 70 years, 22 patients responded to chemotherapy, out of 22, 1 (3.3%) showed a complete clinical response, 21 (70%) partial clinical response. Pre-menopausal 9/13 (69.2%) and post menopausal 13/17 (76.4%) showed clinical response, statistically not significant difference (df=1, x2=1.33, p>0.05). Change in tumor size 40.09±25.20 sq, cm mean size to 21.88±27.43 sq. cm after chemotherapy was highly significant change (t=6.242, p<0.001). Overall response to chemotherapy was 73.3%, in stage II-87.5%, stage IIIA-75% and stage IIIB-50%. The overall response to axillary lymph node was 56.6%, statistically highly significant (p<0.001). Main side effects nausea and vomiting (60%) and hair loss, 43.3%, but none necessitated stoppage of chemotherapy. As a consequence to primary chemotherapy, conservation surgery (lumpectomy with axillary clearance) could be done in 43.3% of patients.Conclusion: CAF Preoperative chemotherapy regime is a satisfactory modality of treatment for stage II and III breast cancer with positive response rate of 73.3%. The down staging thus obtained permits breast conservation surgery in 43.3% of patients. The chemotherapy regime is well accepted by patients.
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Locally advanced hepatocellular carcinoma (HCC) with portal vein thrombosis carries a 1-year survival rate <10%. Localized concurrent chemoradiotherapy (CCRT), followed by hepatic arterial infusion chemotherapy (HAIC), was recently introduced in this setting. Here, we report our early experience with living donor liver transplantation (LDLT) in such patients after successful down-staging of HCC through CCRT and HAIC. Between December 2011 and September 2012, eight patients with locally advanced HCC at initial diagnosis were given CCRT, followed by HAIC, and underwent LDLT at the Severance Hospital, Seoul, Korea. CCRT [45 Gy over 5 weeks with 5-fluorouracil (5-FU) as HAIC] was followed by HAIC (5-FU/cisplatin combination every 4 weeks for 3-12 months), adjusted for tumor response. Down-staging succeeded in all eight patients, leaving no viable tumor thrombi in major vessels, although three patients first underwent hepatic resections. Due to deteriorating liver function, transplantation was the sole therapeutic option and offered a chance for cure. The 1-year disease-free survival rate was 87.5%. There were three instances of post-transplantation tumor recurrence during follow-up monitoring (median, 17 months; range, 10-22 months), but no deaths occurred. Median survival time from initial diagnosis was 33 months. Four postoperative complications recorded in three patients (anastomotic strictures: portal vein, 2; bile duct, 2) were resolved through radiologic interventions. Using an intensive tumor down-staging protocol of CCRT followed by HAIC, LDLT may be a therapeutic option for selected patients with locally advanced HCC and portal vein tumor thrombosis.