HEPATOCELLULAR CARCINOMA (HCC) IN THE ERA OF LIVER TRANSPLANTATION (LT): RECOGNITION OF CIRRHOSIS AND QUALITY OF CANCER SURVEILLANCE (SRV) AS DETERMINANTS OF OUTCOME.Room: 210
RT Stravitz, DM Heuman, N Chand, ML Shiffman, DG Maluf, AH Cotterell, MP Posner, BE Williams, RK Sterling, VA Luketic, AJ Sanyal, AA Mihas, A Habib, HS Gilles, RA Fisher. Liver Transplant Program, Virginia Commonwealth University, Richmond, VA; GI Section, McGuire Veterans Affairs Medical Center, Richmond, VA.
Since 1997, LT has been the preferred treatment for selected patients with cirrhosis (Cx) and early stage HCC. However, most patients with HCC do not undergo LT, and overall outcomes remain unsatisfactory. We hypothesize that the quality of Srv of patients with Cx affects HCC stage at diagnosis, which in turn may determine access to LT and ultimately survival. Methods: Patients with Cx and HCC evaluated and treated between 1997 and 2005 at our academic medical center and VA affiliate were categorized into 3 groups: SrvA, those who had undergone at least one negative liver imaging within the year prior to detection of HCC; SrvB, those with known Cx who had not had imaging in the preceding year; and SrvC, those not known to have Cx prior to presenting with HCC. Patients with incidental HCC discovered at LT were excluded. Results: Of 269 HCC patients, 86% were male, 62% Caucasian, and 76% less than 65 years of age. CTP class at HCC diagnosis was A/B/C in 51/33/15%, respectively. Only 60 (22%) underwent LT. Overall 3-year survival (Kaplan Meier) from the date of HCC diagnosis was 78% in LT recipients and 12% for non-LT patients. At diagnosis, the stage of HCC was I/II/III/IV in 9/41/19/31%, respectively. The proportion in each stage who received LT was 58/35/10/1%, respectively. The quality of Srv was SrvA in 62%, SrvB in 17% and SrvC in 21%. HCC was diagnosed at stage 1/2 in 70% of SrvA, 37% of SrvB, and 18% of SrvC (p < 0.001). Locoregional ablative therapy was administered to 89% of SrvA, 84% of SrvB, but only 61% of SrvC. LT was performed in 32% of patients in SrvA vs. 13% of SrvB and only 7% of SrvC (p<0.001). Overall 3-year survival from HCC diagnosis in SrvC patients (12%) was significantly lower than in SrvA (39%) or SrvB (27%) patients (p < 0.005 by Cox regression). Conclusion: The quality of Srv has a direct impact on HCC stage at diagnosis, the likelihood of LT, and long-term survival. The poorest outcomes were in patients not recognized to have Cx, and therefore not screened. Efforts at the primary care level to identify patients with Cx may lead to earlier diagnosis of HCC, improved access to LT and ablative therapies, and better outcomes.
Keywords: Hepatocellular carcinoma; Liver cirrhosis; Liver transplantation; Screening
Wednesday, July 26, 2006 11:20 AM
Concurrent Session 65: Transplant Associated Malignancy: Clinical Investigations (10:30 AM-12:30 PM)