Supporting liver transplantation by clinical pathway intelligence.

A reproducible and transparent quality of clinical treatments plays an important role in the performance of a hospital. In liver transplantation (LT), this is particularly important for patient safety, resource planning, documentation, and quality management. Thus, the clinical pathway for LT was documented in an electronic format within our research project PIGE. Data from clinical information systems were linked to this pathway, which allows for process monitoring (the assessment of the current state for every patient in the LT process) and a retrospective analysis of all treatments in addition to all data pertaining to the treatment, for example, cost, time, number of personnel, etc.

Long-term survival after recurrent hepatocellular carcinoma in liver transplant patients: clinical patterns and outcome variables.

BACKGROUND: The objective of this trial was to analyze the clinical patterns and outcome variables of recurrent hepatocellular carcinoma (HCC) in liver transplant patients. PATIENTS AND METHODS: Sixty patients after liver transplantation (LT) for HCC were analyzed. All of them received initially a calcineurin-inhibitor based immunosuppressive regimen. Recurrent HCC was treated by surgical intervention, if eligible, or adjuvant therapies. Furthermore, patients were converted to a Sirolimus (SRL)-based immunosuppressive regimen after tumor relapse. The impact of clinical and histopathological variables on post-recurrence survival was analyzed in uni- and multivariate analysis. RESULTS: Sixteen liver recipients developed HCC recurrence between 4 and 58 months (median: 23 months) post-LT. Sites of first tumor recurrence were lung (n = 5), liver (n = 4), bone (n = 4), cerebrum (n = 1), adrenal gland (n = 1) and peritoneum (n = 1). Seven patients were amenable for surgical resection, while 9 patients were only suitable for adjuvant treatment (n = 4) or general medical support (n = 5). Median survival rate post-recurrence was 65 months (range: 12-136 months) in patients amenable for surgical therapy, and 5 months (range: 1-52 months) in patients unsuitable for surgical intervention (P = 0.01). Multivariate analysis identified late (>24 months) posttransplant tumor relapse (P = 0.039) and surgical therapy (P = 0.014) as independent predictors of long-term survival after tumor relapse. Five patients are tumour-free alive for a median of 65 months after surgical resection of recurrent HCC and conversion to SRL. CONCLUSION: Liver transplant patients with HCC recurrence should be treated surgically, if eligible, since this is an independent predictor of long-term survival.

Increased 18F-FDG uptake of hepatocellular carcinoma on positron emission tomography independently predicts tumor recurrence in liver transplant patients.

The aim of this retrospective trial was to analyze the value of preoperative (18)F-fluoro-deoxyglucose positron emission tomography ((18)F-FDG PET) to predict parameters of tumor aggressiveness among liver transplant (OLT) patients with hepatocellular carcinoma (HCC). Fifty-five patients with HCC underwent (18)F-FDG-PET during evaluation for OLT. Nineteen patients demonstrated increased (18)F-FDG uptake on PET pre-OLT (PET(+)), and 36 patients revealed negative PET findings (PET(-)). PET(+) patients showed a relative risk of 9.5 and 6.4 for poor differentiation and for microvascular invasion (MVI) in the HCC at explant pathology, respectively. Of the 10 patients (18.2%) who developed HCC recurrences, 9 (90%) revealed increased (18)F-FDG uptake pre-OLT; only 1 (10%) showed a PET(-) status (P < .001). Apart from poor tumor differentiation, PET(+) status was identified as an independent predictor of tumor recurrence post-OLT (odds ratio, 23.9). Our study demonstrated that (18)F-FDG uptake on PET is a reliable preoperative predictor of tumor recurrence after OLT in patients with HCC, triggered by its high association with poor tumor differentiation and MVI.

18F-FDG-uptake of hepatocellular carcinoma on PET predicts microvascular tumor invasion in liver transplant patients.

Vascular invasion of hepatocellular carcinoma (HCC) is a major risk factor for poor outcome after liver transplantation (LT). The aim of this retrospective analysis was to assess the value of preoperative positron emission tomography (PET) using (18)F-fluorodeoxyglucose ((18)F-FDG) in liver transplant candidates with HCC for predicting microvascular tumor invasion (MVI) and posttransplant tumor recurrence. Forty-two patients underwent LT for HCC after PET evaluation. Sixteen patients had an increased (18)F-FDG tumor uptake on preoperative PET scans (PET +), while 26 recipients revealed negative PET findings (PET-) pre-LT. PET- recipients demonstrated a significantly better 3-year recurrence-free survival (93%) than PET + patients (35%, p < 0.001). HCC recurrence rate was 50% in the PET + group, and 3.8% in the PET-population (p < 0.001). PET + status was identified as independent predictor of MVI [hazard ratio: 13.4]. Patients with advanced PET negative tumors and patients with HCC meeting the Milan criteria had a comparable 3-year-recurrence-free survival (80% vs. 94%, p = 0.6). Increased (18)F-FDG uptake on PET is predictive for MVI and tumor recurrence after LT for HCC. Its application may identify eligible liver transplant candidates with tumors beyond the Milan criteria.