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Prognostic Prediction and Identification of Candidates for Salvage Liver Transplantation Among Patients With Early Hepatocellular Carcinoma

2014; Lippincott Williams & Wilkins; Volume: 20; Issue: 9 Linguagem: Inglês

10.1002/lt.23927

1527-6473

Edoardo G. Giannini, Alessandro Cucchetti, Alessandro Vitale,

Organ Transplantation Techniques and Outcomes

We read with interest the article by Tsuchiya et al.1 reporting the risk factors for exceeding the Milan criteria after successful radiofrequency ablation in patients with hepatocellular carcinoma (HCC). On the basis of the study results, they surmised that early (salvage) liver transplantation (LT) or combined treatments should be taken into consideration when patients display risk factors for a worse prognosis, such as a serum alpha-fetoprotein level >100 ng/mL at the diagnosis and HCC recurrence within 1 year of ablation. We agree with the general view that the identification of parameters that may guide the selection of HCC patients for LT should vigorously be pursued because of the increasing number of HCC patients who are potential candidates for LT and the limited availability of organs.2 In this respect, however, we feel that a surgical approach rather than an ablative one may be the more appropriate method for selecting HCC patients who can be treated with salvage LT. Indeed, surgery has the added benefit of providing data on characteristics predictive of HCC recurrence, such as microvascular invasion and microsatellites, that have been incorporated into algorithms aimed at the adequate identification of candidates for salvage LT.3 Furthermore, in Tsuchiya et al.'s study,1 61.3% of the patients were older than 65 years, and it remains to be demonstrated whether the observed results can be transferred to a younger population, for which there is a clear benefit of salvage LT for HCC recurrence. In fact, we have previously shown that the closer the age of surgery is to the age limit for LT, the higher the risk of harm is with salvage LT versus primary LT, and patients with more advanced HCC still within Milan criteria are those who benefit the most from salvage LT.4, 5 Lastly, we have recently shown that the time horizon examined for LT after the initial surgery (5- or 10-year scenario) is a fundamental factor in determining the benefit of primary LT versus surgery in patients with compensated cirrhosis and early HCC; this indirectly emphasizes the role of age in the selection of the initial treatment.5 In conclusion, we feel that the results of this study by Tsuchiya et al., although interesting and representative of a particular population, cannot be translated to other settings or used to evaluate the candidacy of patients for salvage LT because of the aforementioned limitations. Edoardo G. Giannini, M.D., Ph.D., F.A.C.G.1 Alessandro Cucchetti, M.D.2 Alessandro Vitale, M.D.3 1Gastroenterology Unit Department of Internal Medicine IRCCS-Azienda Ospedaliera Universitaria San Martino-IST University of Genoa Genoa, Italy 2Department of Medical and Surgical Sciences Sant'Orsola-Malpighi Hospital University of Bologna Bologna, Italy 3Hepatobiliary Surgery and Liver Transplant Unit Department of General Surgery and Organ Transplantation University of Padua Padua, Italy