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versión On-line ISSN 1678-2674
Acta Cir. Bras. vol.27 no.6 São Paulo jun. 2012
7 ORIGINAL ARTICLE
Non-cancerous prognostic factors of hepatocellular carcinoma after liver transplantation1
Fatores prognósticos não oncológicos no carcinoma hepatocelular tratado com transplante hepático
Thales Paulo BatistaI; Luiz Eduardo Correia MirandaII; Bernardo David SabatIII; Paulo Sérgio Vieira de MeloIV; Olival Cirilo Lucena da Fonseca NetoV; Américo Gusmão AmorimVI; Cláudio Moura LacerdaVII
IMaster, Postgraduate Program of Health Sciences, UPE, Pernambuco, Brazil. Main author and responsible for manuscript preparation
IIPhD, Associate Professor, Department of Surgery, Division of Abdominal Surgery, UPE, Pernambuco, Brazil. Collection and processing of study information, analysis and interpretation of data and critical revision
IIIMaster, Assistant Professor, Department of Surgery, Division of Abdominal Surgery, UPE, Pernambuco, Brazil. Helped with technical procedures, collection and processing of study informations, interpretation of data and critical revision
IVPhD, Department of Surgery, Division of Abdominal Surgery, UPE, Pernambuco, Brazil. Helped with technical procedures, collection and processing of study information and interpretation of data
VPhD, Department of Surgery, Division of Abdominal Surgery, UPE, Pernambuco, Brazil. Helped with technical procedures, collection and processing of study information and interpretation of data
VIMaster, Assistant Professor, Department of Surgery, Division of Abdominal Surgery, UPE, Pernambuco, Brazil. Helped with technical procedures, collection and processing of study information
VIIPhD, Chairman and Head, Department of Surgery, Division of Abdominal Surgery, UPE, Pernambuco, Brazil. Supervised all phases of the study, interpretation of data and critical revision
PURPOSE: To explore non-cancerous factors that may be related with medium-term survival (24 months) after liver transplantation (LT) in this data from northeast Brazil.
METHODS: A cross-sectional study was carried out in patients who underwent deceased-donor orthotopic LT because hepatocellular carcinoma (HCC) at the University of Pernambuco, Brazil. Non-cancerous factors (i.e.: donor-, receptor-, surgery- and center-related variables) were explored as prognostic factors of medium-term survival using univariate and multivariate approachs.
RESULTS: Sixty-one patients were included for analysis. Their three, six, 12 and 24-month overall cumulative survivals were 88.5%, 80.3%, 73.8% and 65.6%, respectively. Our univariate analysis identified red blood cell transfusion (Exp[b]=1.26; p<0.01) and hepato-venous reconstruction technique (84.6% vs. 51.4%, p<0.01; respectively for piggyback and conventional approaches) as significantly related to post-LT survival. The multivariate analysis confirmed the hepato-venous reconstruction technique was an independent prognostic factor.
CONCLUSION: The piggyback technique was related to improved medium-term survival of hepatocellular carcinoma patients after liver transplantation in this northeast Brazilian sample.
Key words: Organ Transplantation. Liver Neoplasms. Carcinoma, Hepatocellular. Survival Analysis. Prognosis.
OBJETIVO: Explorar fatores prognósticos não oncológicos para a sobrevivência de médio prazo (24 meses) de portadores de carcinoma hepatocelular tratados com transplante hepático.
MÉTODOS: Estudo de corte incluindo pacientes submetidos a transplante ortotópico de fígado (doador-cadáver) pelo Serviço de Cirurgia Geral e Transplante Hepático da Universidade de Pernambuco, UPE. Exploraram-se variáveis relacionadas ao doador, receptor, procedimento cirúrgico e serviço transplantador, como potenciais fatores prognósticos para a sobrevivência de médio prazo dos transplantados, aplicando-se análise uni e multivariada.
RESULTADOS: Sessenta e um pacientes foram incluídos para análise. A sobrevivência cumulativa de três, seis, 12 e 24 meses observada foi de 88,5%, 80,3%, 73,8% e 65,6%, respectivamente. Por análise univariada, identificou-se a transfusão de hemácias (Exp[b]=1,26; p<0,01) e técnica cirúrgica empregada (84,6% vs. 51,4%, p<0,01; respectivamente, piggyback vs. convencional) como estatisticamente relacionadas à sobrevivência dos pacientes estudados. Por análise multivariada, confirmou-se a técnica empregada como fator prognóstico independente.
CONCLUSÃO: A técnica cirúrgica piggyback se relacionou a melhor sobrevivência de médio prazo de pacientes com carcinoma hepatocelular após transplante de fígado nesta casuística do nordeste Brasileiro.
Descritores: Transplante de Órgãos. Neoplasias Hepáticas. Carcinoma Hepatocelular. Análise de Sobrevivência. Prognóstico.
Hepatocellular carcinoma (HCC) is the sixth most common neoplasm worldwide and the third most common cause of cancer mortality, accounting for 9.2% of all cancer deaths1. Overall, its incidence has been estimated at 10.8 per 100.000 person-years; however, almost 85% of the cases occur in developing countries2. In 2008, about 750.000 new HCC cases were reported worldwide, with 13.300 HCC cases in North America and 57.900 in Europe1. All these rates increased from the previous global cancer statistics3. In Brazil, its clinical and epidemiological aspects widely vary amongst different regions4, where is considered a neoplasm of low prevalence in general5.
Liver transplantation (LT) represents the most promising product of modern surgery for treatment of patients suffering from chronic end-stage liver disease and remains a cornerstone in the management of patients with HCC6. On the other hand, recurrence of hepatocellular carcinoma after LT is common as 13.4%, which leads to an unfavorable prognosis with mortality rate about 56.3%7. Thus, as factors related to cancer alone are not enough to predict prognosis of patients with HCC undergoing surgical treatments8, to identify non-cancerous prognostic factors it may serve to improve outcomes, selecting appropriated approaches.
The aim of this study was to explore non-cancerous prognostic factors that may be related with medium-term survival among patients undergoing LT due to HCC at the University of Pernambuco, Brazil
A cross-sectional study was carried out including adults and adolescent patients (> 16 years) undergoing deceased-donor orthotopic LT at the Department of Surgery and Liver Transplantation of the Oswaldo Cruz University Hospital, University of Pernambuco, Brazil; between July 15, 2003 and July 14, 2009. Recipients of split-liver or sequential (domino) transplants were not eligible for this study as well as those patients with incomplete data in their medical records or transplanted because of fulminant hepatic failure. Finally, only patients suffering HCC were considered to this analysis. All of them were followed up to June 15, 2011. Descriptive statistics include non-cancerous donor-, receptor-, surgery- and center-related variables. MELD score was calculated using laboratory tests collected immediately prior to the LT with no adjustments to prioritize these patients on the waiting list. For descriptive analyses, we summarized the continuous variables using medians (interquartile range) and categorical variables as proportions. These variables were also compared between groups using Mann-Witney U test or chi-square tests. The survival probabilities were constructed using the KaplanMeier method.
Serum markers were used to confirm the diagnosis of viral hepatitis and the pre-operative diagnosis of HCC was based on Barcelona-2000 conference diagnostic criteria9 and confirmed by explants pathology. Decision about LT was discussed in a multidisciplinary meeting considering the Milan criteria10 and clinical parameters.
All procedures were performed by the same surgical team. Recipients of LT underwent hepatectomy with inferior vena cava preservation (piggy-back fashion) or conventional technique, both without veno-venous bypass. The use of conventional or piggy-back technique was the surgeon's choice based on anatomical and clinical findings. The pedicle elements were anastomosed using standard techniques. After LT, tacrolimus, mycophenolate (sodium or mofetil) and prednisone were used as immunosuppressive treatment, with no major changes in the protocols applied between 2003 and 2009. We weaned the patients off corticosteroids as soon as possible, based on clinical and laboratory evaluations
Non-cancerous variables were explored as medium-term (24 months) prognostic factors of patient survival using univariate and multivariate approachs. The association of each variable with post-LT survival was first tested using univariate Cox's model (continuous data) or log-rank test (categorical data). Then, factors whose association with survival showed a p-value < 0.20 were used in a multivariate Cox's proportional-hazards model in order to identify the independent prognostic factor. We additionally adjusted this multivariate analysis for transplantation era (quartiles) and allocation criteria (chronologic vs. MELD). Median follow-up of alive patients was 44.6 months (Q25=34.7Q75=51.6) and all of them was followed for at least 24-month in order to determine the primary endpoint (death).
The statistical analyses were performed using the STATISTICA Data Analysis Software System, Version 8.0 (Statsoft, Inc., Tulsa, OK, USA) and all analysis considered a two-tailed p-value of 0.01 as statistically significant. This study was registered in the Brazilian National System of Human Research SISNEP (CAAE - 0003.0.106.000/10) and approved by the HUOC Ethics Research Committee (protocol number 12/2010). All procedures complied with the standards of Declaration of Helsinki and current ethical guidelines.
From 15 July 2003 to 14 July 2009, 298 LT were performed in 288 patients at our Department. Two hundred-eight patients were initially selected, but only 61 received LT because a HCC diagnosis. Their baseline characteristics and descriptive statistics are summarized in Table 1.
Patient 3-, 6-, 12-, and 24-month overall cumulative survivals were 88.5%, 80.3%, 73.8%, and 65.6%, respectively (Figure 1A). Over the 94.5 months follow-up period, 26 liver allograft recipients died (42.6%) and none underwent re-transplantation. The main causes of death were infection, malignancy recurrent and liver failure/transplant rejection.
Our univariate analysis identified red blood cell transfusion (Exp[b]=1.26; p<0.01) and hepato-venous reconstruction method (84.6% vs. 51.4%; p<0.01) (figure 1B) as significantly related to 24-month post-LT survival. The multivariate analysis demonstrated that hepato-venous reconstruction technique was an independent prognostic factor of medium-term post-LT survival after adjusted for transplantation era (Exp[b]=5.92; p<0.01) and allocation criterion (Exp[b]=5.45; p<0.01). We found a borderline statistical significance (Exp[b]=4.17; p=0.01) for this variable in the unadjusted multivariate analysis (Table 2).
Standard surgical management of patients with HCC includes locoregional ablation, surgical resection or liver transplantation, depending on the status of the liver2. However, LT has been considered the treatment of choice for patients suffering of HCC, mainly due to its increasing rates of survival, lower rate of recurrence and preventing the emergence of new tumors (second primary tumors) by removing the cirrhotic liver6,11,12.
Exploring prognostic factor offers the opportunity to predict outcomes and may serve to improve the treatment for HCC patients who received ortothopic LT. By far, their main determinants of outcome have repeatedly been found to be lymphovascular invasion and poor differentiation, which reflects the biological aggressiveness of tumor2,13-17. Similarly, pre-transplantation treatments have been also described as prognostic factors of survival for this malignancy15,18. However, there is a lack of evidence if non-cancerous factors, beyond those described above, influence survival outcomes of HCC patient after LT.
The prognosis for HCC patients is usually very poor, unless patients can be identified at an early stage with preserved liver functions19,20. On the other hand, based in the MELD score, we did not confirm the critical role of cirrhosis severity for post-LT survival of HCC patients. This finding probably occurred because a large proportion of these patients do not have severe liver disease at the time of LT21-23, when the effect of their hepatic dysfunction may not be clinically relevant to translate into a survival outcome24,25. Accordingly, because HCC patients exhibit better liver function than non-HCC at the time of LT18,21,22,25,26, this preserved liver function may also attenuate the negative impact of transfusion-related immunomodulation (TRIM syndrome)27 on survival of patients with HCC and may explain our divergent results previously published, where red blood transfusion was found as a independent prognostic factor of survival into a sample including HCC and non-HCC patients21.
If survival of HCC patients is influenced by the etiology of the liver disease or patient sex remains controversial. According to our data, concurrent hepatitis C virus diagnosis and patient sex, do not appear significantly influencing survival of HCC patients after LT, in agreement with some previous data23,29. On the contrary, female patients and some liver disease may provide better prognosis to patients with HCC, but this is possibly more because of higher compliance with surveillance than to real biological differences28,29. Moreover, some of others donor-, receptor-, surgery- and center-related factors (i.e.: donor age, cold ischemia time, MELD score and hemocomponents transfusion) commonly linked to post-LT survival in general30-35, were not confirmed as significant prognostic factors of survival for HCC patients in this study.
Surprisingly, the piggy-back hepato-venous reconstruction technique appeared independent and positively influencing the medium-term survival in this study. This approach has been suggested as an alternative to the conventional method of LT and has become the preferred approach in many transplantation centers36. In a recent systematic review from Cochrane Database, the authors did not find significant difference in post-operative mortality, primary graft non-function, vascular complications, renal failure, transfusion requirements, intensive therapy unit or hospital stay between the conventional vs. piggy-back hepato-venous anastomosis. Nevertheless, this alternative technique was related to shorter warm ischaemic time and higher proportion of patients who developed chest complications. Nowadays, there is currently no clear evidence to recommend or refute the use of piggy-back method37.
In randomized Brazilian reports, the piggy-back approach was related to higher rate of pulmonary infiltrates38, but not to bacterial translocation39 or stimuli for the production of inflammatory molecules40, when compared to the conventional method. However, until publication of this study, there were no trials comparing piggy-back with conventional method without veno-venous bypass37. In our Department, our learning curve evolved initially with this last, which is performed with recognized swiftness and has been preferred whenever technical difficulty arose during performance of the hepatectomy41. Thus, also because same regional socio-economic limitations (i.e.: IDH=0.7), we have accumulated considerable experience with the management of marginal grafts42,43 and use of conventional technique without veno-venous bypass21,41,44. On the other hand, the piggy-back approach has been increasingly used at our Department because lower surgical and warm ischemia times, red blood cells and plasma transfusions, as well as lower 30-day mortality and better 1-year cumulative survival41.
The piggy-back technique has been suggested to be avoided in patients with HCC because an theoretical increased risk of a positive vena cava margin and the potential for metastatic spread of tumor in the native vena cava or through the hepatic veins, as well as because an increased operative manipulation of the diseased organ in this approach45. However, it remains controversial if the piggy-back technique violates the surgical cancer principles or if it matter in an organ transplantation settings46. Comparing survival outcomes in recipients with HCC who underwent liver transplantation using the piggy-back or conventional approachs, Mangus and colleagues45 found statistically similar survival for both techniques, suggesting the presence of HCC in liver transplant patients should not preclude the use of piggy-back approach. However, only 19 patients in that study underwent a piggy-back approach vs. 119 who were transplanted by the conventional technique. Moreover, as resection for HCC seems to follow the surgical cancer principles, further studies comparing techniques of liver transplantation for patients with HCC must be conducted in order to elucidate this important issue46.
In this sample, despite some differences in variables, only warm ischemia time was statistically significantly different between piggy-back vs. conventional techniques; however, this potential confounding factor did not significantly correlated with survival amongst HCC patients. Thus, how piggy-back technique may influence survival in HCC patients after LT or if this influence may supplant the cancer-related factors in a long-term follow-up remains unclear. Based in these findings, we are now planning a prospective trial (including cancer-related variables) in order to determine the best surgical approach for HCC patients.
Herein we have reviewed our experience with HCC patients underwent deceased donor orthotopic LT to explore if some non-cancerous factors (i.e.: donor-, receptor-, surgery- and center-related factors) impact on their survival. Notably, our sample has some special characteristics: first, the same surgical team performed all procedures using standard techniques without veno-venous bypass; second, our own database has been prospectively maintained and continuously updated. Lastly, our sample presented a better balanced proportion between piggy-back vs. conventional groups than previously reported45.
In line with recent recommendations and practice in observational research47, all analysis of this study considered a p-value of 0.01 to denote statistical significance. Furthermore, instead of categorising continuous variables, we prefer to keep them continuous in order to minimize some loss in the statistical power of our analysis and the occurrence of residual confounding factors48,49. Similarly, because a significant increase in the number of patients transplanted to treat HCC in our Department as result of MELD allocation policy and because better survival outcomes observed in the most recent periods of our transplantation activities, probably due to governmental efforts to encourage organ transplantation21; we also adjusted our multivariate analysis for the allocation criteria (chronologic vs. MELD) and transplantation eras (quartiles). In this approach, separate regression models were first fit to each group and the log-likelihoods for those models were summed up. This log-likelihood was then compared to that of the overall model (collapsed across groups).
We also point that analysis of additional donor-related variables may provide additional information, especially because a large proportion of extended-criteria donors were used at our Department21,34,42,43. However, despite our relative small sample size, the main scientific merit of this report was to add some evidence to determine if the surgical approach influence survival outcomes of HCC patients after LT. Our data suggests further studies are necessary to determine whether piggyback hepato-venous anastomosis should be preferred for patients candidate to LT because HCC.
The piggyback hepato-venous reconstruction technique was related to improved medium-term survival of hepatocellular carcinoma patients after liver transplantation in this northeast Brazilian sample.
The authors would like to thanks Ms. Tânia M. Xavier, Ms. Juliana S. Gomes and Dr. Isaac Esmeraldino for their helpful to data collection. We also thank Dr. Candice Santos for English review.
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Thales Paulo Batista
Rua Gois Cavalvante, 100/1206
52060-140 Recife PE Brasil
Tel.: (55 81)8886-1203/3184-1484
Fax: (55 81)3183-3514
Received: January 18, 2012
Review: March 14, 2012
Accepted: April 16, 2012
Conflict of interest: none
Financial source: none.
1 Research performed at Postgraduate Program of Health Sciences, University of Pernambuco (UPE), Brazil.
1. Comparisons between piggy-back vs. conventional techniques using the Mann-Witney U test for continuous variables or chi-square tests for categorical variables.
2. Fischer's exact test.
3. Categories were not mutually exclusive, so multiple diagnoses were possible.
4. Yates's correction.
5. Each era included 52 consecutive LT, but only those performed to treat HCC patient were counted.
* Statistically significant (p<0.01).
6. Univariate analysis using the log rank test (categorical data) or the Cox-proportional hazards model (continuous data).
7. Multivariate analysis using the Cox-proportional hazards model. This analysis was also adjusted to allocation criterion (Chronologic vs. MELD) and transplantation era (quartiles).
8. HCV vs. Non-HCV patients.