American Surgical Association

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Topic: E. Clinical Pediatric Surgery/Transplantation/Endocrine/Plastics Surgery
Outcomes of Adjuvant Transarterial Chemoembolization (TACE) to Downstage Hepatocellular Carcinoma (HCC) Prior to Liver Transplantation
William C Chapman, Jourdan E Stuart, Jeffrey S Crippin, Jeffrey A Lowell, Surendra Shenoy, Majella Doyle, Christopher D Anderson, Daniel B Brown
Washington University School of Medicine, St. Louis, MO

OBJECTIVE(S): To evaluate outcomes of downstaging patients with advanced (AJCC Stage III/IV) HCC with TACE to allow eligibility for orthotopic liver transplant (OLT).
METHODS: From 1999-2006 202 patients with HCC were referred for transplant evaluation. 76 (37.6%) patients with stage III/IV HCC were potential transplant candidates if downstaging was achieved by TACE. OLT was performed based on follow-up imaging findings. The number of patients who were successfully downstaged within the Milan criteria, tumor response using Response Evaluation Criteria in Solid Tumors (RECIST) criteria, findings at explant, and outcomes after transplant were tracked.
RESULTS: 18/76 (23.7%) patients had adequate downsizing to qualify for OLT under the Milan criteria. By RECIST, 27/76 (35.5%) patients had a partial response, 22/76 (29%) had stable disease, and 27/76 (35.5%) had progressive disease. 17/76 (22.4%) patients who met other qualifications underwent OLT following successful downstaging (13/38 stage III;4/38 stage IV). Explant review demonstrated 28 identifiable tumors. Post TACE necrosis was greater than 90% in 21/28 (75%). At a median of 19.6 months (range 3.6-104.7), 16/17 (94.1%) patients who underwent OLT are alive. One patient expired 11 months after OLT secondary to medical comorbidities. 1/17 (6%) OLT patients has recurrent HCC. This patient underwent resection of a pulmonary metastasis and is alive 63.6 months from OLT.
CONCLUSIONS: Selected patients with Stage III/IV HCC can be downstaged to Milan criteria with TACE. Importantly, patients that are successfully downstaged have excellent midterm disease free and overall survival, similar to stage II HCC.


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