Yonsei Med J.  2016 Sep;57(5):1276-1281. 10.3349/ymj.2016.57.5.1276.

Living Donor Liver Transplantation for Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis after Concurrent Chemoradiation Therapy

• Han DH
• Joo DJ
• Kim MS
• Choi GH
• Choi JS
• Park YN
• Seong J
• Han KH
• Kim SI

• KMID: 2374176
• DOI: http://doi.org/10.3349/ymj.2016.57.5.1276

Abstract

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.

Keyword

Concurrent chemoradiation; hepatocellular carcinoma; living donor liver transplantation; thrombus; down-staging

MeSH Terms

Adult
Carcinoma, Hepatocellular/complications/drug therapy/surgery/*therapy
*Chemoradiotherapy
Cisplatin/therapeutic use
Disease-Free Survival
Female
Fluorouracil/therapeutic use
Humans
Liver Neoplasms/complications/drug therapy/surgery/*therapy
*Liver Transplantation
*Living Donors
Male
Middle Aged
Neoplasm Recurrence, Local
*Portal Vein
Venous Thrombosis/*complications
Cisplatin
Fluorouracil

Figure

• 

  Fig. 1 Events leading to liver transplantation: overall, eight patients underwent living donor liver transplantation (LDLT) after concurrent chemoradiotherapy, followed by hepatic arterial infusion chemotherapy. Advanced status of tumor (with portal vein tumor thrombosis) was initially down-staged via pre-transplant regimen. In five patients, transplantations constituted rescue therapy for hepatic decompensation. *The patient underwent LDLT after down-staging for recurred HCC without decompensated liver failure. CCRT, concurrent chemoradiotherapy; HAIC, hepatic arterial infusion chemotherapy; HCC, hepatocellular carcinoma; PR, partial response.

• 

  Fig. 2 Radiologic tumor response (to concurrent chemoradiotherapy, followed by hepatic arterial infusion chemotherapy): computed tomography demonstrates bulky 12 cm hepatocellular carcinoma of right lobe (A), decreasing to 6 cm size, seen without enhancement in arterial phase (B). Voluminous ascites and splenomegaly developed, due to severe parenchymal atrophy and progressive hepatic dysfunction (B).

• 

  Fig. 3 Gross and microscopic views of liver specimen: note expansile necrotic mass 4.8 cm in size, with diffuse macronodular parenchymal cirrhosis (A). At high magnification, complete necrosis of hepatocellular carcinoma (near asterisk), inflammatory change (near arrow), and normal hepatocytes (near arrowhead) are observed (B; hematoxylin and eosin stain, ×100).

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