Affonso BB, Galastri FL, da Motta Leal Filho JM, Nasser F, Falsarella PM, Cavalcante RN, de Almeida MD, Felga GEG, Valle LGM, Wolosker N. Long-term outcomes of hepatocellular carcinoma that underwent chemoembolization for bridging or downstaging. World J Gastroenterol 2019; 25(37): 5687-5701 [PMID: 31602168 DOI: 10.3748/wjg.v25.i37.5687]
Corresponding Author of This Article
Breno Boueri Affonso, PhD, Medical Assistant, Research Scientist, Staff Physician, Surgeon, Teacher, Interventional Radiologist, Department of Interventional Radiology, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, São Paulo 05651-901, São Paulo, Brazil. breno.affonso@einstein.br
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Prospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastroenterol. Oct 7, 2019; 25(37): 5687-5701 Published online Oct 7, 2019. doi: 10.3748/wjg.v25.i37.5687
Table 1 Downstaging and bridging protocol
Downstaging and bridging protocol
Inclusion Criteria
Bridging
Patients who were within MC or UNOS T2
Downstaging subgroups (HCC exceeding MC)
Group 1 = 1 lesion > 5 and ≤ 8 cm
Group 2 = 2 or 3 lesions at least one > 3 and ≤ 5 cm with the sum of the maximal tumor diameters ≤ 8 cm
Group 3 = 4 or 5 lesions each ≤ 3 cm with the sum of the maximal tumor diameters ≤ 8 cm
Group 4 = 2 or 3 lesions at least one > 5cm with the sum of the maximal tumor diameters ≤ 8 cm
Group 5 = total tumor diameter > 8 cm
Absence of vascular invasion based on cross-sectional MRI or CT
Criteria for successful downstaging
Residual tumor(s) within MC for deceased donor liver transplant
In patients with 4 or 5 tumors, successful downstaging requires complete necrosis (based on cross-sectional MRI or CT) of at least 1 to 2 tumor(s), respectively, so that there will be no more than 3 lesions with viable tumor each ≤ 3 cm to meet MC
Criteria for downstaging failure and exclusion from liver transplant
Progression of tumor(s) to beyond inclusion criteria for downstaging and bridging based on tumor size and number
Vascular invasion based on cross-sectional MRI or CT
Lymph node involvement by tumor or extra-hepatic spread of tumor
Table 7 Influence of baseline characteristics on overall survival after liver transplant
Variável
HR (not adjusted)
95%CI
P value
HR (adjusted)
95%CI
P value
Inferior
Superior
Inferior
Superior
Age (yr)
1.02
0.97
1.07
0.469
1.01
0.96
1.06
> 0.05
Gender (male)
0.46
0.19
1.09
0.078
0.51
0.16
1.63
> 0.05
Etiology
Hepatitis B
1.00
1.00
Hepatitis C
1.92
0.25
14.61
0.529
1.31
0.14
12.29
> 0.05
Hepatitis B/C
1.50
0.09
23.93
0.776
1.14
0.06
22.88
> 0.05
Alcohol
2.92
0.34
25.16
0.330
2.58
0.24
27.33
> 0.05
Alcohol/Hepatitis
4.96
0.31
79.60
0.258
0.00
0.00
> 0.05
Other
1.73
0.18
16.66
0.636
1.60
0.14
18.40
> 0.05
Child-Pugh score
A
1.00
1.00
B
0.97
0.43
2.17
0.940
0.84
0.31
2.25
> 0.05
C
0.00
0.00
0.983
NA
> 0.05
MELD
0.99
0.86
1.14
0.875
1.07
0.90
1.27
> 0.05
Alpha-fetoprotein
< 10
1.00
1.00
10-100
1.47
0.62
3.49
0.383
1.37
0.47
3.97
> 0.05
100-1000
2.02
0.65
6.26
0.225
1.94
0.54
6.97
> 0.05
> 1000
NA
0.983
NA
> 0.05
Number of nodules
1.08
0.68
1.70
0.747
1.05
0.47
2.37
> 0.05
Maximal tumor diameter (cm)
0.96
0.76
1.21
0.733
1.10
0.66
1.86
> 0.05
Group (Bridging)
1.83
0.55
6.13
0.325
1.53
0.23
10.18
> 0.05
Table 8 Influence of baseline characteristics on recurrence-free survival after liver transplant
Variável
HR (not adjusted)
95%CI
P value
HR (adjusted)
95%CI
P value
Inferior
Superior
Inferior
Superior
Age (yr)
1.03
0.98
1.09
0.285
1.01
0.96
1.08
> 0.05
Gender (male)
0.53
0.21
1.32
0.174
0.69
0.20
2.41
> 0.05
Etiology
Hepatitis B
1.00
1.00
Hepatitis C
2.00
0.26
15.21
0.504
1.46
0.16
13.70
> 0.05
Hepatitis B/C
1.54
0.10
24.58
0.761
1.49
0.07
30.71
> 0.05
Alcohol
2.82
0.33
24.30
0.345
2.53
0.23
27.36
> 0.05
Alcohol/Hepatitis
10.15
0.91
112.71
0.059
6.07
0.26
142.70
> 0.05
Other
1.78
0.19
17.20
0.617
1.90
0.16
22.79
> 0.05
Child-Pugh score
A
1.00
1.00
B
1.21
0.55
2.64
0.642
1.01
0.36
2.81
> 0.05
C
NA
0.982
#
> 0.05
MELD
1.01
0.88
1.15
0.917
1.04
0.87
1.25
> 0.05
Alpha-fetoprotein
< 10
1.00
1,00
10-100
1.36
0.58
3.17
0.483
1.43
0.50
4.12
> 0.05
100-1000
2.15
0.70
6.61
0.182
2.38
0.65
8.70
> 0.05
> 1000
NA
0.982
NA
> 0.05
Number of nodules
1.28
0.83
1.98
0.261
1.34
0.61
2.94
> 0.05
Maximal tumor diameter (cm)
1.06
0.85
1.31
0.619
1.04
0.63
1.72
> 0.05
Group (Bridging)
1.04
0.39
2.76
0.935
1.15
0.20
6.78
> 0.05
Citation: Affonso BB, Galastri FL, da Motta Leal Filho JM, Nasser F, Falsarella PM, Cavalcante RN, de Almeida MD, Felga GEG, Valle LGM, Wolosker N. Long-term outcomes of hepatocellular carcinoma that underwent chemoembolization for bridging or downstaging. World J Gastroenterol 2019; 25(37): 5687-5701