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Keywords:

  • Chemotherapy;
  • disease-free survival;
  • hepatocellular carcinoma;
  • liver transplantation;
  • overall survival

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

The aim of this prospective randomized study was to determine whether additional doxorubicin chemotherapy improves outcome in patients with hepatocellular carcinoma (HCCA) treated by liver transplantation. Stratification parameters were tumor stage (UICC I-IVa), gender, age 50 years, α-fetoprotein 20 ng/mL, cirrhosis and HbsAg status. For pre-operative chemotherapy doxorubicin (15 mg/m2) was given biweekly, intra-operative chemotherapy was a single dose administered before surgical manipulation. Post-operative chemotherapy from day 10 was as given preoperatively for a total dosage of 300 mg/m2. Outcome parameters were overall survival (OS) and disease-free survival. Of the 75 consecutive patients who received liver transplantation for treatment of HCCA, 62 patients were enrolled. Thirty-four patients were randomized in the chemotherapy group; 28 patients were in the control group and transplanted only. OS rates at 5 years were 38% in the chemotherapy group and 40% in the control group, disease-free survival rates at 5 years 43% and 53%, respectively. Tumor stage and vascular invasion were identified as independent risk factors for recurrence of disease. Doxorubicin chemotherapy did not improve organ survival and disease-free survival in patients undergoing liver transplantation for HCCA.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Hepatocellular carcinoma (HCCA) is an aggressive tumor that often occurs in the setting of chronic liver disease and cirrhosis. It is typically diagnosed late in its course, and the median survival following diagnosis is approximately 6–20 months (1). Although the mainstay of therapy is surgical resection, the majority of patients are not eligible because of tumor extent, or underlying liver dysfunction. A potential advantage of orthotopic liver transplantation (oLTX) is that it can achieve resection of the malignant tumor while replacing the cirrhotic liver. However, results of transplantation alone for advanced HCCA have been disappointing, with 5-year survival rates ranging from 18% to 25% (1,2). A more recent review revealed only a modest improvement of the 5-year survival rate to 32% for tumors larger than 5 cm (3). Therefore most centers do not offer oLTX to patients with large unresectable HCCA, leaving them only the option of palliative chemotherapy.

A change in the philosophy of transplantation for HCCA evolved with the finding that small, incidentally found HCCA in explanted livers did not adversely affect survival when compared to patients whose livers did not contain malignancy (4). Overall survival (OS) in carefully selected patients undergoing oLTX for HCCA is similar to survival in patients undergoing transplantation for non-malignant causes (5,6). When strict criteria are applied, excellent overall 3- to 4-year actuarial (75–85%) and recurrence-free survival rates (83–92%) can be achieved (7,8).

The value of adjuvant therapy has not been well studied (9). In theory, adjuvant therapy may particularly benefit patients undergoing liver transplantation because removal of the native liver requires extensive manipulation, and is likely to result in intra-operative dissemination of tumor cells. Several studies have shown promising preliminary results when combining oLTX with pre-operative trans-arterial chemoembolization and/or peri-operative systemic chemotherapy in the treatment of advanced HCCA that is not amenable to resection (10–14). Because of the lack of long-term results, treatment of large or advanced HCCA with oLTX and adjuvant therapy remains controversial. The aim of this first controlled prospective randomized study was to determine whether additional pre-, intra- and postoperatively applied systemic doxorubicin chemotherapy improves outcome in patients with HCCA treated by oLTX.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Beginning in January 1994, patients with unresectable HCCA were randomized to receive oLTX plus pre-, intra- and post-operative chemotherapy with doxorubicin versus oLTX only. Inclusion criteria required that the patient be free of extra-hepatic disease based on computertomography scans of the chest and abdomen and bone scan and have a patent main portal vein and major hepatic veins on duplex ultrasonography. Patients with regional lymph node involvement discovered by computertomography scan or at the time of surgery and with preoperatively biopsy proven grade 3 differentiation were excluded. Informed consent was obtained from all patients and all procedures performed were in accordance with the ethical standards of our institutional review board. We employed stratified randomization, which was performed by an external biometric department. Unit of randomization was the individual patient. Stratification parameters were tumor stage (UICC I-IVa), gender, age </> 50 years, α-fetoprotein (AFP) </> 20 ng/mL, cirrhosis and HbsAg status. Allocation concealment was warranted as the external biometric department was only contacted by telephone once a patient was to be randomized; this department was not involved in the study otherwise. Time between randomization and start of first chemotherapy was on average 7 days.

Chemotherapy regimen

On waiting list after indication for transplantation was given, ambulatory pre-operative chemotherapy with doxorubicin (15 mg/m2) was given biweekly at the Department of Oncology. Intraoperatively patients randomized in the chemotherapy group received a single systemic dose of doxorubicin (15 mg/m2) before surgical manipulation. Post-operative chemotherapy from day 10 was as given preoperatively depending on clinical course for a total of 20 cycles. Our trial was designed as open label study, no placebo was used in the control group for obvious reasons.

Immunosuppressive regimen

Post-operative immunosuppression was identical for patients in the chemotherapy group and in the control group and was performed with corticosteroids and cyclosporine or tacrolimus. Rejection episodes were treated with pulse steroids, and OKT3 was used for steroid-resistant rejection episodes.

Outcome parameters and follow-up

Primary outcome parameter was 5 year OS. Secondary outcome was 5-year disease-free survival (DFS). All patients were followed after randomization with computertomography scans of the chest and abdomen performed every 3 months for the first year and every 6 months thereafter. In addition, AFP was measured every 3 months for the first year and every 6 months thereafter. Date of recurrence was defined as the day, when suspicion of recurrence arose first in patients with verified disease.

Statistical analysis

Data are presented as median and 25–75% IQR or number and percentage as adequate. The study was designed to detect a clinically relevant difference of 20% (10% vs. 30%) in five year OS between the groups with a power of 78% at a significance level of 5% with a sample of 68 patients in both groups. The enrollment period was limited to 2 years for organizational reasons.

Primary analysis

Primary analysis of five year OS was performed according to the intention-to-treat principle. Actuarial survival was calculated using the Kaplan-Meier method. Differences in survival were examined using the log-rank test.

Secondary analyses

Subgroup analysis was performed to examine whether tumor stage influences the effect of chemotherapy. We performed sensitivity analyses post-hoc. OS and DFS were analyzed according to a per-protocol analysis. A two-sided p < 0.05 was considered statistically significant (15).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Patient characteristics and trial flow

Of the 75 consecutive patients who received oLTX for treatment of HCCA between 1994 and 1998, 62 patients (9 women, 53 men) were enrolled. Thirty-four patients were randomized in the chemotherapy group; 28 patients were in the control group (Figure 1). The chemotherapy group and the control group were comparable with respect to age, gender, AFP levels, stage and HbsAg status. There is potential for baseline differences regarding to presence of cirrhosis (71% vs. 97%, Table 1).

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Figure 1. Flow chart of patients screened for participation in the study.

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Table 1.  Stratification parameters for randomization
 Chemotherapy group (n = 34)Control group (n = 28)
Age
• <50 years; n (%)10 (29)9 (32)
• >50 years; n (%)24 (71)19 (68)
Gender
 Female; n (%)5 (15)4 (14)
 Male; n (%)29 (85)24 (86)
AFP
 <20 ng/mL; n (%)9 (26)7 (25)
 >20 ng/mL; n (%)25 (74)21 (75)
Stage (UICC)
   I; n (%)1 (3)1 (4)
   II; n (%)5 (15)4 (14)
   III; n (%)6 (17)9 (32)
   IVa; n (%)22 (65)14 (50)
 Cirrhosis; n (%)33 (97)20 (71)
 Without cirrhosis; n (%)1 (3)8 (29)
 HbsAg+; n (%)5 (15)0
 HbsAg−; n (%)29 (85)28 (100)

Chemotherapy

Two patients died on the waiting list because of tumor progression and did not receive chemotherapy at all, 32 patients received pre-operative chemotherapy to a median (Q1; Q3) of 4 (5; 1) cycles, 31 patients intra-operative and 25 patients to a median (Q1; Q3) of 13 (6; 15,5) cycles post-operative chemotherapy (Figure 1). Chemotherapy was postponed in 21 patients (66%). Causes of delay were leucocytopenia in 45%, thrombocytopenia in 22%, infection in 12%, diabetes in 5%, rejection, encephalopathy and fever in 4% each, and anemia and diarrhea in 2% each. Other side effects of chemotherapy were alopecia in five patients (16%), and nausea, dyspnea, cephalea and conjunctivitis in one patient each. According the WHO criteria grade I side effects were found in 25%, grade II side effects in 64% and grade III side effects in 11%. Occurrence of grade IV side effects was not observed. Seven patients (19%) did not receive post-operative chemotherapy secondary to progressive recurrent disease and one patient secondary to peri-operative death.

Characteristics of explanted organs

Tumor size was to a median (Q1; Q3) 5 cm (4; 13), macrovascular/microvascular invasion was found in 12 (7/5) patients (35%) in the chemotherapy group and 9 (5/4) patients (32%) in the control group. Multicentricity was found in 23 patients (82%) in the chemotherapy group versus 29 patients (85%) in the control group. Post-explant histologic examination revealed 14 patients (23%) with grade 3 differentiation (Table 2).

Table 2.  Patient and tumor characteristics
 Chemotherapy group (n = 34)Control group (n = 28)
Time on waiting list
Median months (IQR)1,6 (1,2/3,2)1,2 (1,1/3,1)
 Child A; n (%)19 (56)14 (50)
 Child B; n (%)15 (44)12 (43)
 Child C; n (%)02 (7)
 Grading 1; n (%)7 (21)8 (29)
 Grading 2; n (%)23 (67)13 (46)
 Grading 3; n (%)4 (12)7 (25)
Tumor size; median cm (IQR)4 (3/12)5 (4/13)
Vascular invasion; n (%)12 (35)9 (32)
 Macrovascular; n (%)7 (20)5 (18)
 Microvascular; n (%)5 (15)4 (14)
Multicentricity; n (%)23 (82)29 (85)

Primary analysis

Intention to treat analysis revealed 5-year OS rates of 35% (12/34; mean survival 46.2 months; 95%

CI: 32.4/60.0) in the chemotherapy group and 38% (11/28; mean survival 57.4 months; 95% CI: 40.2/74.6) in the control group (p = 0.53; Figure 2).

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Figure 2. Primary (intention to treat) analysis—overall survival (p = 0.53).

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Recurrence of disease

Thirty-four patients (55%) were diagnosed with recurrent HCCA after transplant, 18 (53%) in the chemotherapy group and 16 (57%) in the control group. Recurrences occurred in the liver (n = 18/29%), bone (n = 9/15%), lung (n = 7/11%), celiac nodes (n = 3/5%), cerebral (n = 3/5%) and peritoneal (n = 3/5%). Patterns of recurrence included 11 patients (18%) with intra-hepatic disease only, 15 (24%) with extra-hepatic only and 6 (10%) with both intra- and extra-hepatic.

Subgroup analysis

OS rates at 5 years were 78% (2/9; mean survival 80.8 months; 95% CI: 60.1/101.5) in (UICC) I-III staged patients and 24% (16/21; mean survival 37.1 months; 95% CI: 23.2/51.1) in (UICC) IV staged patients in the chemotherapy group versus 73% (3/11; mean survival 89.8 months; 95% CI: 66.7/112.9) and 19% (11/14; mean survival 41.0 months; 95% CI: 24.4/57.7) in the control group (p = 0.80, Figures 3 and 4). DFS rates at 5 years were 76% (2/9; mean survival 82.1 months; 95% CI: 57.6/106.7) in (UICC) I-III staged patients and 28% (15/21; mean survival 30.7 months; 95% CI: 16.0/45.3) in (UICC) IV staged patients in the chemotherapy group versus 81% (2/11; mean survival 95.3 months; 95% CI: 72.4/118.2) and 31% (9/14; mean survival 41.6 months; 95% CI: 20.7/62.4) in the control group (p = 0.37; Figures 5 and 6).

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Figure 3. Subgroup analysis. Overall survival of (UICC) I-III staged patients.

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image

Figure 4. Subgroup analysis. Overall survival of (UICC) IV staged patients.

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image

Figure 5. Subgroup analysis. Disease-free survival of (UICC) I-III staged patients.

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Figure 6. Subgroup analysis. Disease-free survival of (UICC) IV staged patients.

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Sensitivity analysis

The per-protocol analysis revealed that at 5 years OS rates were 40% (18/30; mean survival 52.1 months; 95% CI: 37.7/66.5) in the chemotherapy group and 43% (14/25; mean survival 64.2 months; 95% CI: 46.7/81.7) in the control group (p = 0.45; Figure 7). DFS rates were 43% (17/30; mean survival 49.8 months; 95% CI: 33.3/66.3) and 53% (11/25; mean survival 68.3 months; 95% CI: 48.6/88.0), respectively (p = 0.24; Figure 8).

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Figure 7. Sensitivity analysis. Overall survival (p = 0.45).

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Figure 8. Sensitivity analysis. Disease-free survival (p = 0.24).

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Other risk factors for survival

In a multivariate analysis recurrence of disease was identified as independent risk factors for OS (p = 0.000; HR 7.7; 95% CI: 3/19.9). Stage of disease (p = 0.005; HR 0.2; 95% CI: 0.1/0.6) and the presence of vascular invasion, micro- or macroscopic (p = 0.036; HR 2.2; 95% CI: 1.1/4.8) correlated significantly with DFS. Tumor size, grade of tumor and multicentricity had no correlation with tumor recurrence after transplant by multivariate analysis. Maximal single tumor size correlated significantly with presence of vascular invasion.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Liver transplantation is a logical treatment for HCCA in the absence of extra-hepatic spread because it addresses both the tumor and the underlying liver disease. The role of transplantation for the treatment of small, asymptomatic tumors in patients with cirrhosis has been well established (7). Despite isolated cases of prolonged survival, published results of liver transplant for advanced HCCA have been uniformly disappointing because of high rates of tumor recurrence (16–20).

The extent to which recurrence results from the presence of pre-existing micrometastases as opposed to intra-operative dissemination of tumor resulting from surgical manipulation, and whether tumor growth is accelerated by immunosuppression, remain controversial (21–24).

Several studies have reported improved post-transplant survival in HCCA patients with the use of pre-operative trans-arterial chemoembolization (13,25) or with systemic chemotherapy (9,11). Others have used both modalities (10,12). It is meaningless to compare the results of these reports with our patients because the majority of the subjects in these studies did not have tumors larger than 5 cm. In addition, the number of patients and the length of follow-up in these studies have been limited. In a number of uncontrolled studies, patients receiving adjuvant chemotherapy following oLTX for HCCA have shown improved results compared to historical controls. This study represents the first controlled prospective randomized series to determine whether additional doxorubicin chemotherapy improves outcome in patients with HCCA treated by oLTX.

Peri-operative chemotherapy has been used in attempts to eliminate micrometastases that might be present at the time of transplant or malignant cells that are shed during surgical manipulation of the tumor. Doxorubicin, the single most effective agent against HCCA, produces objective response rates, ranging from 15% to 20% in most studies (26–28). Stone et al. (11) found significant improvement from historical controls in 20 patients receiving pre- and post-operative doxorubicin in combination with liver transplant, with 3-year overall and recurrence-free survival rates of 59% and 54%, respectively. Results for these studies have shown significant improvements in survival, but the size of the studies and their follow-up have been limited.

At the time that this protocol was developed, extremely poor results were being reported for liver transplant in the treatment of large HCCA, and it was widely believed that transplanting such patients was not justified. The protocol attempted to address the issues of tumor progression during waiting time and micrometastasis that are the basis for failure.

The correlation of recurrence after transplant with stage and vascular invasion is not surprising (29). Several studies have identified patient and tumor-related variables associated with prognosis following oLTX (4,5,7,8,29–40). Important variables associated with prognosis in one or more of the studies included tumor number, tumor size, whether tumors were bilobar, stage of disease, degree of differentiation, macrovascular and microvascular invasion, and extra-hepatic spread. The most consistent association was tumor size, in our case significantly correlated to vascular invasion. In an analysis carried out on patients after oLTX at our department the influence of grading below or equal 2 showed a significantly longer disease-free period (41). Therefore, patients with unresectable HCCA and preoperatively biopsy proven grade 3 differentiation were primarily excluded from the study. Actually post-explant histologic examination revealed 14 patients (23%) with grade 3 differentiation in accordance to the expected sample error.

Optimal candidates for oLTX appear to be those with tumors less than or equal to 5 cm in diameter, with no macrovascular involvement and no identifiable extra-hepatic spread to surrounding lymph nodes, lungs, abdominal organs or bone. When these strict criteria are applied, excellent overall 3- to 4-year actuarial (75–85%) and recurrence-free survival rates (83–92%) can be achieved (7,8).

In conclusion, OS rates at 5 years were 38% and 40% in the chemotherapy group and in the control group, DFS rates at 5 years were 43% and 53%, without significant difference. These results fall short of the 83% recurrence-free survival rate at 4 years reported by Mazzaferro et al. (7) for transplant in patients with smaller tumors, but meet them in (UICC) I-III staged patients with calculated 5-year DFS rates of 76–80% in our study.

As a consequence we now use the same selection criteria, denying patients with tumor extent ≥stage IV. In 21 patients (62%) in the chemotherapy group chemotherapy was postponed, we found mainly WHO grade II side effects of chemotherapy, but no WHO grade IV side effects causing delay of oLTX. In spite of a high percentage (44%) of patients with Child B cirrhosis in the chemotherapy group, chemotherapy was well tolerated.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References