Transplantation

Liver transplantation for unresectable hepatocellular carcinomain normal livers

Hynek Mergental1,39,�, Rene Adam2,�, Bo-Goran Ericzon3,�, Piotr Kalicinski4,�,Ferninand Mühlbacher5,�, Krister Höckerstedt6,�, Jürgen L. Klempnauer7,�,

Styrbjörn Friman8,�, Christoph E. Broelsch9,�, Georges Mantion10,�, Carlos Fernandez-Sellez11,�,Bart van Hoek12,�, Josef Fangmann13,�, Jacques Pirenne14,�, Paolo Muiesan15,�,

Alfred Königsrainer16,�, Darius F. Mirza1,�, Jan Lerut17,�, Olivier Detry18,�,Yves-Ptrice Le Treut19,�, Vincenzo Mazzaferro20,�, Florian Löhe21,�, Marina Berenguer22,�,

Pierre-Alain Clavien23,�, Xavier Rogiers24,�, Jacques Belghiti25,�, Laslo Kóbori26,�,Patrizia Burra27,�, Philippe Wolf28,�, Wolfgang Schareck29,�, Przemyslaw Pisarski30,�,

Aksel Foss31,�, Franco Filipponi32,�, Marek Krawczyk33,�, Martin Wolff34,�, Jan M. Langrehr35,�,Keith Rolles36,�, Neville Jamieson37,�, Wim C.J. Hop38,�, Robert J. Porte39,⇑,�

1Queen Elizabeth Hospital, Birmingham, United Kingdom; 2AP-HP, Hôpital Paul Brousse, University Paris Sud, Villejuif, France; 3KarolinskaInstitutet, Stockholm, Sweden; 4Children’s Memorial Health Institute, Warsaw, Poland; 5Medical University Vienna, Austria; 6HelsinkiUniversity Central Hospital, Finland; 7Medizinische Hochschule Hannover, Germany; 8Sahlgrenska University Hospital, Goteborg, Sweden;

9Universitatsklinikum Essen, Germany; 10Hôpital Jean Minjoz, Besanscon, France; 11University Juan Canalejo Medical Center, La Coruna, Spain;12Leiden University Medical Center, The Netherlands; 13Universitatsklinikum Leipzig, Germany; 14Universitaire Ziekenhuizen Leuven, Belgium;15King’s College Hospital, London, United Kingdom; 16Universitatsklinikum Tübingen, Germany; 17Cliniques Universitaires Saint-Luc, Brussels,

Belgium; 18University Hospital, Liege, Belgium; 19Hôpital de la Conception, Marseille, France; 20Istituto Nazionale Tumori, Milano, Italy;21Ludwig-Maximilians University Hospital Munich, Germany; 22Hospital Universitario La Fe, Valencia, Spain; 23Universitatspital Zurich,

Switzerland; 24Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany; 25University Hôpital Beaujon, Clichy, France; 26SemmelweisUniversity Hospital, Budapest, Hungary; 27Centro Trapianti di Fegato-Azienda Ospedaliera di Padova, Italy; 28Hôpital Universitaire de

Hautepierre, Strasbourg, France; 29Universitätsklinikum Rostock, Germany; 30Universitätsklinikum Freiburg, Germany; 31Oslo UniversityHospital Rikshospitalet, Norway; 32University of Pisa Medical School Hospital, Italy; 33Medical University of Warsaw, Poland; 34Universitätsk-

linikum, Bonn, Germany; 35Charité Campus Virchow-Klinikum, Berlin, Germany; 36Royal Free Hospital, London, United Kingdom;37Addenbrooke’s Hospital, Cambridge, United Kingdom; 38Erasmus Medical Center, Rotterdam, The Netherlands; 39University Medical Center

Groningen, Groningen, The Netherlands

See Editorial, pages 235–236

Background & Aims: The role of liver transplantation in the Methods: Using the European Liver Transplant Registry, we iden-

treatment of hepatocellular carcinoma in livers without fibro-sis/cirrhosis (NC-HCC) is unclear. We aimed to determine selec-tion criteria for liver transplantation in patients with NC-HCC.

Journal of Hepatology 20

Keywords: Hepatocellular carcinoma; Liver transplantation; Non-cirrhotic; Non-fibrotic; Unresectable; Recurrent; Hepatoma.Received 7 October 2011; received in revised form 21 March 2012; accepted 22 March2012; available online 18 April 2012q DOI of original article: http://dx.doi.org/10.1016/j.jhep.2012.05.005.⇑ Corresponding author. Address: Department of Hepato-Pancreato-Biliary Surgeryand Liver Transplantation, University Medical Center Groningen, P.O. Box 30.001,9700 RB Groningen, The Netherlands. Tel.: +31 50 361 28 96; fax: +31 50 361 1745.E-mail address: r.j.porte@umcg.nl (R.J. Porte).� For the European Liver and Intestine Transplant Association (ELITA).Abbreviations: HCC, hepatocellular carcinoma; NC-HCC, non-cirrhotic hepatocel-lular carcinoma; ELTR, European Liver Transplant Registry; ELITA, European Liverand Intestine Transplantation Association; LT, liver transplantation; primary-LT,primary liver transplantation; rescue-LT, rescue liver transplantation; CI, confi-dence interval; HR, hazard ration; AJCC, American Joint Committee on Cancer.

tified 105 patients who underwent liver transplantation for unre-sectable NC-HCC. Detailed information about patient, tumorcharacteristics, and survival was obtained from the transplantcenters. Variables associated with survival were identified usingunivariate and multivariate statistical analyses.Results: Liver transplantation was primary treatment in 62patients and rescue therapy for intrahepatic recurrences after liverresection in 43. Median number of tumors was 3 (range 1–7) andmedian tumor size 8 cm (range 0.5–30). One- and 5-year overalland tumor-free survival rates were 84% and 49% and 76% and43%, respectively. Macrovascular invasion (HR 2.55, 95% CI 1.34to 4.86), lymph node involvement (HR 2.60, 95% CI 1.28 to 5.28),and time interval between liver resection and transplantation<12 months (HR 2.12, 95% CI 0.96 to 4.67) were independentlyassociated with survival. Five-year survival in patients withoutmacrovascular invasion or lymph node involvement was 59%(95% CI 47–70%). Tumor size was not associated with survival.

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Transplantation

Conclusions: This is the largest reported series of patients trans-planted for NC-HCC. Selection of patients without macrovascularinvasion or lymph node involvement, or patients P12 monthsafter previous liver resection, can result in 5-year survival ratesof 59%. In contrast to HCC in cirrhosis, tumor size is not a predic-tor of post-transplant survival in NC-HCC.� 2012 European Association for the Study of the Liver. Publishedby Elsevier B.V. All rights reserved.

Introduction

Hepatocelullar carcinoma (HCC) represents the third most fre-quent cause of cancer-related death worldwide and the incidencein Western countries is rising [1]. More than 90% of all HCCsoccur in diseased livers, and chronic inflammation, liver fibrosis,and cirrhosis are well-known risk factors [2,3]. In less than 10% ofall cases, HCC occurs in patients without any evidence for anunderlying liver disease [2,4,5]. Those patients have no signs ofliver fibrosis or cirrhosis and no evidence of a current or previousinflammatory disease, such as hepatitis B or C virus infection. Theexact pathogenesis of HCC in a non-fibrotic and non-cirrhoticliver (NC-HCC) remains unclear, although studies suggest thatsome may have developed in a pre-existing liver adenoma [6].

The peak incidence of NC-HCC is in the fourth decade, which ismuch earlier than that for HCC in diseased livers. Because of the rel-atively young age, the absence of an underlying liver disease, andthe lack of early symptoms, most patients with NC-HCC presentat a relatively late stage when the tumor has reached a considerablesize or (intrahepatic) metastases have developed already [7–9].

The treatment of first choice in patients with NC-HCC is a par-tial liver resection [10–12]. Because of the late presentation andoften a large tumor size, a partial liver resection may not alwaysbe possible, despite the otherwise normal liver parenchyma.Although the development of innovative strategies in hepatic sur-gery have extended the possibilities of tumor resection during thepast decade, partial resection will be always limited by anatomicalfactors and the need of preserving a sufficient amount of liverfunction to avoid death from post-operative liver failure [13]. Incase of primarily unresectable NC-HCC, liver transplantationmay be the only alternative with a chance of cure. The same is truefor patients who develop intrahepatic recurrence after one ormore previous partial liver resection(s), and in whom another par-tial liver resection is no longer possible. The role of primary or res-cue liver transplantation in the treatment of NC-HCC, however, ispoorly defined and criteria for patient selection are lacking.

While liver transplantation is a well-established therapy forpatients with HCC in a fibrotic or cirrhotic liver that remainswithin the Milan criteria (i.e. one tumor with a diameter 65 cmor maximum of three tumors with a diameter 63 cm), it isunclear whether these criteria are also applicable to patients withNC-HCC [14]. In fact, the vast majority of patients with a NC-HCCthat meet the Milan criteria will be able to undergo a partial liverresection and do not need transplantation.

Previous reports based on small single center series or casereports have suggested that outcome after liver transplantationfor NC-HCC is poor [15,16]. Due to the lack of larger clinical expe-riences with detailed long-term follow-up, the role of liver trans-plantation for NC-HCC, therefore, remained controversial.

We aimed to determine outcome after liver transplantation forNC-HCC and to identify variables that are associated with survival.

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We, therefore, performed a detailed analysis of a large cohort ofpatients transplanted for NC-HCC and with a long-term follow-up.

Materials and methods

Study patients

To identify patients who underwent liver transplantation for NC-HCC, we usedthe European Liver Transplant Registry (ELTR), a regularly audited registry ofpatients who underwent liver transplantation in one of the 137 contributingEuropean centers [17,18]. All patients who were registered in the ELTR withthe diagnosis ‘‘HCC in a non-cirrhotic liver’’, and who underwent transplantationbetween January 1, 1994 and December 31, 2005, were selected. In addition, weidentified the following two subgroups: patients who underwent liver transplan-tation as a primary therapy for HCC in an otherwise completely normal liver (pri-mary-LT group), and patients who underwent liver transplantation as rescuetreatment for recurrent NC-HCC after a previous partial liver resection (rescue-LT group).

This study was approved by and performed under the auspices of the Board ofEuropean Liver and Intestine Transplant Association (ELITA), the governing soci-ety of the ELTR.

Data collection

Upon identification of patients within the ELTR, the individual transplant cen-ters were contacted to provide detailed patient data. A standardized caserecord form containing 89 items was used to record clinical variables, includ-ing information about patient demographics, pre-transplant HCC management,staging methods, details about the transplant procedure, pathology report,post-transplant treatment, methods of recurrence surveillance, and survivaldata (the case record form is provided as Supplementary material andavailable online). Case record forms were collected at the co-coordinatingcenter, the University Medical Center Groningen, reviewed for internal consis-tency and completeness and transferred into a SPSS database. Detailed tumorcharacteristics, including tumor size, number of nodules, and histologicalcharacteristics were obtained from pathology reports of the explanted livers.All presented data describing the tumor characteristics are based on thepost-transplant histopathological findings. In seven patients who had a histo-logically confirmed NC-HCC prior to treatment with transarterial chemoemb-olization, the final pathology after transplantation revealed completelynecrotic tumor. Only patients with histologically confirmed absence of anunderlying liver disease (i.e. no histological signs of inflammation, fibrosis,or cirrhosis) and negative serology testing for hepatitis B and C virus infectionwith a post-transplant follow-up of at least 12 months were included in theanalysis. Overall, there were less than 5% missing data values in all variablesexcept AFP levels (27 cases missing), information concerning adjuvant chemo-therapy (7 cases missing) intraoperative blood transfusion requirements (20cases missing) and details of immunosuppressive medication (10 casesmissing).

Statistical analysis

Categorical variables were presented as number and percentages. Continuousvariables were presented as median and range (unless indicated otherwise).When clinically relevant, median values of continuous variables were used ascut-off value to create subgroups for comparison. Differences in categoricalvariables between groups were analyzed using the Chi-square test or Fisher’sexact test. Continuous data were compared using the Mann–Whitney test. Sur-vival rates and 95% confidence intervals (95% CI) were determined using theKaplan–Meier method and groups were compared using the log-rank test. Incase the effect of a variable was not significantly different between the twotransplantation groups (as assessed by Cox-regression using appropriate inter-action terms), the prognostic effect of that variable was evaluated in the totalpopulation using the log-rank test stratified for the transplantation group. Forthe entire study population, all variables tested in the univariate survival anal-ysis with a p 60.10 were included in a multivariate Cox regression analysiswith backward elimination, and hazard ratios (HR) and 95% CI were calculated.p <0.05 (two-sided) were considered significant in all analyses. SPSS software,

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n = 147(time period 1/1/1995 to 31/12/2005)

Patients included into analysis n = 105

Primary transplantationn = 62

Rescue transplantationn = 43

Patients excluded upon histology reviewn = 28

• • Mixed cholangiocellular carcinoma, n = 4• Underlying liver disease, n = 4

Patients excluded upon serology reviewn = 8

• Hepatitis C infection, n = 5• Hepatitis B infection, n = 3

n = 6

Patients identified in ELTR

Liver fibrosis, n = 20

Patients excluded for insufficient data

Fig. 1. Selection of patients from the European Liver Transplant Registry(ELTR).

JOURNAL OF HEPATOLOGY

version 15.0 for Windows (SPSS Inc. Chicago, IL, USA) was used for all analyses.For presenting the results, percentages were rounded to whole numbers and pvalues to three decimals.

Results

Patient characteristics and pre-transplant treatment

Using the ELTR, we identified 147 patients who underwent livertransplantation for HCC in a non-cirrhotic liver. Twenty-eightpatients were subsequently excluded from the analyses becausemore detailed information about the pathological examinationof the explanted liver demonstrated presence of an underlyingliver disease, liver fibrosis, or presence of mixed type HCC/cholangiocarcinoma. Eight patients were excluded because theywere seropositive for hepatitis B or C, and 6 patients wereexcluded because we were unable to collect sufficient informa-tion about tumor staging or patient follow-up was incomplete(Fig. 1). The remaining 105 patients who were included in thestudy were transplanted in 38 European centers, with a rangeof 1–13 patients/center (list of centers is provided as Addendum).

In 62 (59%) patients, liver transplantation was used as primarytherapy (primary-LT) and in 43 (41%) patients transplantationwas performed as a rescue treatment for intrahepatic tumorrecurrence after previous partial liver resection (rescue-LT). Inthe rescue-LT group, the median time interval between partialliver resection and transplantation was 23 (2–127) months. Fif-teen patients in this subgroup (34%) underwent repeated liverresections prior to transplantation.

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Details about patient characteristics, tumor histology, as wellas surgical and post-transplant variables for the entire group andfor the two subgroups are provided in Table 1. Noteworthy werethe female preponderance, relatively young age, and the largetumor diameter. The median (range) diameter of the largesttumor was 8 (0.5–30) cm for the entire patient population, and11 (3–30) cm and 3 (0.5–12) cm for the primary-LT and rescue-LT subgroups, respectively. The majority of all 105 patients(63%) had more than one tumor nodule and only 12 patients(11%) had tumor characteristics that were within the Milan crite-ria. We classified all patients according to the TNM staging sys-tem of the American Joint Committee on Cancer (AJCC) Manual,7th Edition. However, we did not use other staging systems, suchas the Barcelona Clinic Liver Cancer Staging (BCLCS), the Okudasystem, or the Cancer of Liver Italian Program (CLIP), as these sys-tems have been developed for patients with fibrosis or cirrhosisand severity of underlying liver disease is an important discrim-inating factor in these scoring systems.

Survival analysis

The median (range) length of follow-up for the entire study pop-ulation was 75 (17–146) months. Overall 1-, 3-, and 5-yearpatient survival rates were 84%, 66%, and 49%, respectively.Tumor-free survival rates at 1-, 3-, and 5-year were 76%, 57%,and 43%, respectively (Table 2).

In the primary-LT group, overall 1-, 3-, and 5-year survivalrates were 80%, 62%, and 43%, respectively. In the rescue-LTgroup, overall survival rates at the same time intervals were86%, 68%, and 58%, respectively. Kaplan–Meier survival curvesare presented in Fig. 2A. There were no major differencesbetween overall patient survival and tumor-free survival in theentire study population or the two subgroups (Table 2).

The results of a univariate analysis of variables associatedwith 5-year patient survival in the entire population are pre-sented in Table 3. Variables significantly associated with 5-yearsurvival were macrovascular invasion, hilar lymph nodeinvolvement and number of tumors (Fig. 2B, D and Supplemen-tary Fig. 1F). Tumor differentiation (e.g. fibrolamellar versusnon-fibrolamellar type NC-HCC) was not associated with sur-vival (Supplementary Fig. 1B). There was a significant interac-tion between the largest tumor size and the indication fortransplantation (primary-LT versus rescue-LT). Therefore, tumorsize as a risk factor was analyzed only separately for eachsubgroup.

In the primary-LT group, no additional variables were identi-fied that were significantly associated with 5-year survival (Table3). In the rescue-LT group, the time interval between partial liverresection and transplantation was identified as an additional fac-tor that was strongly associated with 5-year survival (Table 3).Patients with a time interval of P12 months between liver resec-tion and transplantation had a 5-year post-transplant survivalrate of 71% (95% CI 54–87%), compared to 24% (95% CI 0–47%)in patients with an interval <12 months (Fig. 2F). Interestingly,there were no significant differences in 5-year survival rates inpatients with tumor characteristics within or outside the Milancriteria (Supplementary Fig. 1C and D). In the primary-LT group,5-year survival in patients with the largest tumor size up to themedian value of 11 cm was 55% (95% CI 38–73%, Fig. 2E).Kaplan–Meier survival curves for subgroups based on differentmaximum tumor diameters in patients in the primary-LT groupare presented in Supplementary Fig. 2.

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Table 1. Characteristics of all 105 patients as well as primary and rescue transplant subgroups.

All patients (n = 105)

Primary-LT (n = 62)

Rescue-LT (n = 43)

p value*

Situation before transplantationGender, male, No. (%) 45 (43) 30 (48) 15 (35) 0.229Age (yr), median (range) 40 (4-68) 39 (4-66) 41 (12-68) 0.691Repeated liver resection, No. (%) n.a. n.a. 15 (35) n.a.Time resection to LT (mo), median (range) n.a. n.a. 23 (2-127) n.a.TACE, No. (%) 37 (35) 15 (27) 22 (51) 0.007Neoadjuvant chemotherapy 27 (26) 18 (30) 9 (21) 0.370

Tumor characteristicsLargest tumor size (cm), median (range) 8 (0.5-30) 11 (3-30) 3 (0.5-12) <0.001Number of lesions, median (range)** 3.0 (1-7) 3.0 (1-7) 4.0 (1-7) 0.279Solitary tumor, No. (%) 37 (35) 28 (45) 9 (21) 0.0131-4 tumors, No. (%) 60 (57) 36 (58) 24 (56) 0.843Within Milan criteria, No. (%) 12 (11) 2 (3) 10 (23) 0.007Tumor differentiation, No. (%) 0.057

Fibrolamellar 11 (11) 7 (11) 4 (9)Well 45 (43) 33 (53) 12 (28)Moderate 33 (31) 15 (24) 18 (42)Poor 9 (9) 5 (8) 4 (9)Not assessable (only necrosis) 7 (7) 2 (3) 5 (12)

Microvascular vasoinvasion positive, No. (%) 48 (46) 30 (48) 18 (43) 0.554Macrovascular vasoinvasion positive, No. (%) 15 (14) 11 (18) 4 (9) 0.268Alpha fetoprotein (ng/ml), median (range) 12 (0-290,250) 49 (1-290,250) 8 (0-9213) 0.067Alpha fetoprotein above 100 ng/ml, No. (%) 24 (31) 19 (40) 5 (16) 0.026Lymph node involvement positive, No. (%) 12 (11) 8 (13) 4 (9) 0.757TNM tumor stage***, No. (%) 0.002

Stage I 19 (18) 14 (23) 5 (12)Stage II 37 (35) 12 (19) 25 (58)Stage III A 25 (24) 18 (29) 7 (16)Stage III B 12 (11) 10 (16) 2 (5)Stage IV A 12 (11) 8 (13) 4 (9)

Surgical variables and post-operative managementFull size graft, No. (%) 82 (78) 49 (79) 33 (77) 0.814Living donor, No. (%) 18 (17) 9 (15) 9 (21) 0.437Conventional transplantation, No. (%) 66 (64) 40 (66) 26 (61) 0.680RBC units given, median (range) 4 (0-35) 3 (0-35) 5 (0-28) 0.059Adjuvant chemotherapy, No. (%) 38 (39) 27 (47) 11 (28) 0.062Maintain immunosuppressive treatment, No. (%) 1.000

Calcineurin inhibitors 91 (95) 53 (95) 38 (95)Rapamycin 9 (10) 3 (5) 6 (15)

TACE, transarterial chemoembolization; RBC, red blood cells; LT, liver transplantation; n.a., not applicable.Missing values: overall, there were less than 5% missing data values in all variables except AFP levels (27 cases missing), information concerning adjuvant chemotherapy (7cases missing) peroperative blood transfusion requirements (20 cases missing) and details of immunosuppressive medication (10 cases missing).⁄p value for comparison between primary-LT and rescue-LT group.⁄⁄Highest number limited to ‘‘more than 6’’ on the case report form.⁄⁄⁄According to the 7th edition of the Tumor, Node, Metastasis staging system of the American Joint Committee on Cancer (there were no patients with TNM stage IIIC or IVB).

Transplantation

After multivariate Cox regression analysis, only thepresence of macrovascular invasion, involvement of hilarlymph nodes, and rescue-LT for intrahepatic recurrencewithin 12 months after partial liver resection were identi-

300 Journal of Hepatology 201

fied as independent risk factors for 5-year patient survival(Table 4).

Overall 5-year survival in patients without macrovascular inva-sion and hilar lymph node involvement was 59% (95% CI 47–70%),

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Table 2. Outcome after transplantation.

Outcome Survival rate(95% CI)

No. (%)

All patients (n = 105)1-year survival 84 (77-91)

1-year tumor-free survival 76 (68-85)5-year survival 49 (39-59)

5-year tumor-free survival 43 (33-53)Patient status

Alive, No. (%) 47 (45)Alive with recurrence, No. (%) 6 (6)Death 58 (55)HCC unrelated death, No. (%) 11 (11)

Primary transplantation subgroup (n = 62)1-year survival 80 (70-90)

1-year tumor-free survival 74 (62-85)5-year survival 43 (30-55)

5-year tumor-free survival 40 (26-53)Patient status

Alive, No. (%) 24 (39)Alive with recurrence, No. (%) 3 (5)Death 38 (61)HCC unrelated death, No. (%) 8 (13)

Rescue transplantation subgroup (n = 43)1-year survival 86 (76-97)

1-year tumor-free survival 80 (68-93)5-year survival 58 (43-73)

5-year tumor-free survival 48 (31-64)Patient status

Alive, No. (%) 23 (54)Alive with recurrence, No. (%) 3 (7)Death 20 (47)HCC unrelated death, No. (%) 3 (7)

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compared to 16% (95% CI 0–36%) in patients with these two mainrisk factors (Fig. 2D). Absence of these two major risks factors, inpatients undergoing rescue-LT for intrahepatic recurrencesP12 months after a previous partial liver resection, was associatedwith an even higher 5-year survival rate of 83% (95% CI 68–98%).

When patients were categorized based on the AJCC TNM stag-ing system also a clear difference in patient survival was notedwith significantly worse survival in patients with TNM stage IIIBor higher. Patients with TNM stage I to IIIA (any tumor size, butno macrovascular or lymph node involvement) had a 5-year sur-vival rate of 59% (95% CI 47–70%), compared to 17% (95% CI 1–34%) in patients with stage IIIB or higher.

Discussion

We here present the largest series of patients transplanted forHCC in an otherwise normal liver (NC-HCC). Patients with HCC

Journal of Hepatology 201

occurring in a liver without any proven underlying pathology,such as (chronic) inflammation, fibrosis, or cirrhosis and negativetesting for hepatitis B or C infection, represent a small subgroupof around 10% of all patients with HCC [2,4,5]. Although the exactpathogenesis of this type of HCC remains elusive, some studieshave suggested that some NC-HCC may develop in a preexistingliver cell adenoma [6]. The absence of any of the known riskfactors for HCC, in combination with the female preponderanceand relatively young age at presentation, suggests a differentpathogenesis and possibly also different tumor biology in NC-HCC, compared to HCC occurring in a diseased liver [19]. In thecurrent study, patient characteristics were very similar to thosereported in other series of patients with NC-HCC [23]. While par-tial liver resection is the treatment of first choice in patients withNC-HCC, this may not always be possible in individual casesbecause of late discovery and large tumor diameter or multiplic-ity of tumor nodules [2,10,15,20]. The role of liver transplantationas a primary therapy in these patients has remained controversialand specific selection criteria are lacking [15,21]. In addition, theindication for liver transplantation in patients who present withintrahepatic recurrence(s) after a previous partial liver resectionfor NC-HCC remains to be determined.

In the current study, we have analyzed outcome in a large ser-ies of 105 patients who underwent liver transplantation for NC-HCC. The study was based on a collaborative analysis of 38 Euro-pean transplant centers and the number of patients per centervaried between 1 and 13, emphasizing the unique character ofthis type of HCC. Conclusions on the role of liver transplantationfor this specific indication can, therefore, only be drawn from amulticenter study. It is important to emphasize that all patientsincluded in this study had no histological signs of liver fibrosisor cirrhosis, no evidence of any other underlying liver disease,and were all seronegative for hepatitis B and C.

The most important finding of this study is that a 5-year sur-vival rate of 59% can be obtained in patients without macrovascu-lar invasion or lymph node involvement, independent of tumorsize. This survival rate is well above the cut-off generally requiredto justify liver transplantation for patients with a malignancy [22].

Many patients who present with HCC in an otherwise normalliver are previously healthy and relatively young (median age inthis series was 45 years) and symptoms may not occur untiltumors have reached a considerable diameter. This is differentfrom patients who are known with a liver disease and who aregenerally screened at regular intervals for the development ofHCC, resulting in an earlier detection of tumors with a smallerdiameter. In the current series, the median largest tumor sizewas 8 cm for the entire group and 11 cm for the primary-LTgroup. Despite these large tumors, size was not identified as apredictor of survival after transplantation. In fact, the Milan crite-ria, generally used to select patients for transplantation with HCCin a cirrhotic liver, were not associated with post-transplant sur-vival in patients with NC-HCC. In patients with NC-HCC, tumorsize alone should therefore not be used to discriminate patientsin whom transplantation may or may not be justified.

Macrovascular tumor invasion and lymph node involvementwere identified as the two most important variables associatedwith poor survival. These findings are in line with data frompatients transplanted for HCC in cirrhotic livers [15,24–26]. Basedon these findings, we can conclude that the presence of macro-vascular invasion or the detection of tumor metastases in thehilar lymph nodes should be considered a contraindication for

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Fig. 2. Impact of selected variables on 5-year patient survival. (A) Kaplan–Meier estimates of patient survival after liver transplantation in 105 patients withhepatocellular carcinoma in an otherwise normal liver (NC-HCC). There was no statistically significant difference in overall survival between patients who underwent livertransplantation as primary therapy for NC-HCC (n = 62) and those who underwent liver transplantation as rescue therapy for intrahepatic recurrence after a previous partialliver resection (n = 43). Probability of survival in patients with or without evidence of micro- or macrovascular tumor invasion in the entire cohort is shown in (B), and inpatients with or without hilar lymph node involvement in (C). Kaplan–Meier estimates of patient survival after liver transplantation for all patients with NC-HCC, accordingto the combined presence or absence of macrovascular invasion and lymph node (LN) involvement is shown in (D). Kaplan–Meier estimates of patient survival after livertransplantation as primary therapy for NC-HCC, according to the largest tumor size (n = 62). Patient with a largest tumor size less than the median value of 11 cm had a 5-year survival rate of 55% (95% CI 38–73%), compared to 34% (95% CI 17–52%) in patients with a largest tumor size >11 cm as is shown in (E). The effect of a time intervalbetween a previous partial liver resection and liver transplantation of more or less than 12 months in the rescue therapy group (n = 43) is shown in (F).

Transplantation

liver transplantation in patients with NC-HCC. Nowadays, cross-sectional imaging in combination with endoscopic ultrasound-guided fine needle aspiration cytology can yield more than 90%accuracy of the preoperative HCC staging [27–29]. However, werecommend routine lymph node dissection and frozen sectionexamination as a first step in the transplant procedure and thecase should be aborted if these lymph nodes are positive. Thiswill require the need for a back-up patient on stand by in orderto avoid loss of a donor liver.

In contrast to macrovascular invasion, microvascular tumorinvasion was not associated with post-transplant survival. This

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is in contrast with a well described association between micro-vascular invasion and post-transplant survival in patients trans-planted for HCC in a diseased liver [30]. On the other hand, thecurrent findings are in accordance with studies in patients under-going partial liver resection for NC-HCC, which have also notshown an association between microvascular invasion andpost-operative survival [31,32]. In a recent study in patientsundergoing liver resection for NC-HCC, the investigators notedthat the frequency of vascular invasion was only 21%, which isunexpectedly low for the mean tumor size of 10.3 cm in this ser-ies [32]. Altogether, data suggest that microvascular invasion

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Table 3. Univariate analysis of variable effect on 5-year survival.

Variable 5-year survival rate (95% CI)

p value

All patients (n = 105)Pretransplant situationIndication for transplantation 0.231

Primary 45 (32-57)Rescue 57 (41-72)

Transarterial chemoembolization

0.942

Yes 46 (29-62)No 51 (39-64)

Neoadjuvant chemotherapy 0.121Yes 62 (43-80)No 46 (34-57)

Tumor characteristicsNumber of tumors 0.772

Solitary 47 (31-64)Multiple 51 (38-63)

Number of tumors 0.033Up to 4 nodules 57 (44-70)More than 4 nodules 39 (24-54)

HCC differentiation 0.435Fibrolamellar 55 (25-84)

49 (38-59)HCC differentiation 0.440

50 (36-63)Moderate 46 (29-64)Poor 39 (5-73)Not assessable (only necrosis)

71 (38-100)

Microvascular invasion 0.250Negative 57 (44-70)Positive 40 (25-54)

Macrovascular invasion 0.003Negative 55 (44-65)Positive 16 (0-36)

Lymph node involvement 0.007Negative 54 (43-64)Positive 17 (0-38)

Macrovascular invasion and lymph node involvement

0.002

Negative 59 (47-70)Positive 16 (0-36)

Variable 5-year survival rate (95% CI)

p value

Primary transplant subgroup(n = 62)Tumor size 0.461

Up to 11 cm 55 (38-73)Larger than 11 cm 34 (17-52)

Number of tumors 0.833Solitary 43 (27-62)Multiple 46 (29-63)

Milan criteria 0.153Within 33 (0-86)Outside 46 (31-56)

Rescue transplant subgroup (n = 43)Previous partial liver resection 0.986

One time 58 (32-84)Multiple 58 (40-76)

Time interval after partial liver resection to transplantation

0.005

Up to 12 months 24 (0-47)Longer than 12 months 71 (54-87)

Tumor size 0.096Up to 5 cm 59 (48-81)Larger than 5 cm 50 (3-64)

Number of tumors 0.929Solitary 53 (19-87)Multiple 58 (41-75)

Milan criteria 0.065Within 79 (57-100)Outside 50 (32-67)

Non-fibrolamellar

Well (including fibrolamellar)

JOURNAL OF HEPATOLOGY

may be a delayed feature in the growth of NC-HCC and, therefore,a less important risk factor in patients with NC-HCC, compared topatients with HCC in a cirrhotic liver. More research in this areawill be needed.

In the current study, tumor differentiation was not associatedwith post-transplant survival. This is in contrast with previouscase reports and small single center series suggesting an unfavor-able outcome in patients with a non-fibrolamellar type of NC-HCC and suggesting that liver transplantation should not be

Journal of Hepatology 201

offered to those patients [9,11,16,33,34]. In the current series,post-transplant survival was not different in patients with afibrolamellar or non-fibrolamellar type of NC-HCC [35]. There-fore, we conclude that non-fibrolamellar NC-HCC alone shouldnot be considered a contraindication for transplantation. Thereis still controversy about whether or not fibrolamellar HCC is adifferent tumor compared to non-fibrolamellar HCC in an other-wise normal liver. The results from this study did not show anydifference in outcome between these two patients groups, which

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Table 4. Multivariate survival analysis (Cox-regression) of various risk factors.

Factor Hazard ratio

95% CI p value

Macrovascular invasionNegative 1# - -Positive 2.55 (1.34-4.86) 0.005

Lymph nodesNegative 1# - -Positive 2.60 (1.28-5.28) 0.008

IndicationPrimary transplantation 1# - -Rescue transplantation ≤12 mo*

2.12 (0.96-4.67) 0.062

Rescue transplantation >12 mo*

0.47 (0.22-0.97) 0.041

#Reference category.⁄p = 0.002 for the difference.

Transplantation

is in line with the assumption that fibrolamellar HCC is not a bio-logically more favorable type of HCC in a non-cirrhotic liver [36].A literature review by Kakar et al. has shown that outcomes ofpatients with fibrolamellar and non-fibrolamellar HCC are similarwhen same-stage diseases are considered [36]. The questionwhether or not fibrolamellar HCC is a variant of NC-HCC or adifferent entity has not been completely settled in the literatureand our study cannot address this either.

One of the key aspects in selecting patients with HCC for livertransplantation remains the identification of reliable surrogatemarkers of tumor biology. Liver transplantation will be futile inthose patients with aggressive tumor biology whereas transplan-tation may be justified in patients with milder tumor behavior. Inpatients in whom liver transplantation is considered as rescuetherapy for intrahepatic recurrences after a previous partial liverresection, two important pieces of information will be availablethat can help physicians in differentiating relatively favorabletumor biology from aggressive and unfavorable tumor biology.These factors are: (a) the possibility of histological assessmentof the previously resected tumor and (b) the time intervalbetween partial liver resection and tumor recurrence. Unfortu-nately, we were unable to collect detailed information on thepathological examination of the previously resected liver tumorsas most of these resections were performed in another centerthan the transplant center. It appeared impossible to retrospec-tively identify the referring centers for all 43 patients who under-went partial liver resection prior to their transplant and to collectdetailed information on the pathology reports. However, it seemsreasonable to assume that presence of either macrovascular inva-sion or hilar lymph node involvement at the time of partial liverresection is associated with worse outcome after a subsequentliver transplantation. The other known risk factors for NC-HCCrecurrence after partial liver resection are incomplete tumorresection, multiple tumors, poor tumor differentiation, absenceof tumor capsule and perioperative administration of bloodtransfusion [10,32,35,37–39]. Interestingly, several reports havesuggested that outcome after partial liver resection for NC-HCCis not influenced by tumor size [38,40,41]. This is in line withthe findings in the current study.

The time interval between previous partial liver resection andtransplantation, however, was known for all patients in the res-

304 Journal of Hepatology 201

cue-LT group in the current study. It appeared that a time inter-val of P12 months was associated with significantly better post-transplant survival than transplantation for intrahepaticrecurrences within 12 months after a partial liver resection. Inthe former group, 5-year survival after transplantation was71%. Absence of macrovascular invasion and lymph node involve-ment, in patients undergoing rescue-LT for intrahepatic recur-rences P12 months after a previous partial liver resection, wasassociated with an even higher 5-year survival rate of 83%. Thesefindings are clinically very relevant as 75% of the recurrencesafter liver resection for NC-HCC occur exclusively in the liver[32].

This study has some limitations due to its retrospective, mul-ticenter design. First of all, it is likely that criteria to decidewhether a tumor was resectable or not were not uniform in allcenters. Threshold for resectability may also have changed overtime. However, the majority of patients included in this studywere transplanted in high volume centers with a large experiencein both liver surgery and liver transplantation and it is likely thatthe vast majority of patients included in this series had trulyunresectable tumors. Secondly, pre-transplant and post-trans-plant therapy has been different in the centers. Although we havecollected information on additional therapies, such as transarte-rial chemoembolization or (neo-) adjuvant chemotherapy for allpatients, we could not demonstrate any effect of these therapieson post-transplant survival. However, the numbers in these sub-groups were small.

In conclusion, our findings indicate that liver transplantationmay be justified as a curative treatment option in a selectedgroup of patients with unresectable HCC in an otherwise normalliver. Partial liver resection, however, should always be the treat-ment of first choice. In contrast to patients with HCC in a diseased(i.e. fibrotic or cirrhotic) liver, tumor size is not an important riskfactor for post-transplant survival in patients with NC-HCC. Infact, many of these patients have a tumor diameter that is alreadyoutside the Milan criteria at the time of first presentation. Selec-tion of patients without macrovascular invasion or hilar lymphnode involvement is associated with a 5-year post-transplantsurvival rate of 59%. Presence of any of these two risk factors,however, should be considered a contraindication for transplan-tation. Favorable results with a 5-year survival rate of 71% canalso be obtained after liver transplantation in patients with anintrahepatic tumor recurrence P12 months after a previous par-tial liver resection for NC-HCC.

Conflict of interest

The authors who have taken part in this study declared that theydo not have anything to disclose regarding funding or conflict ofinterest with respect to this manuscript.

Authors’ contribution

R.J.P. initiated this study and was the principal investigator. H.M.and R.J.P. prepared the study design, were responsible for thestudy management, data collection and interpretation, manu-script preparation and submission. H.M. and W.H. were responsi-ble for the statistical data analysis. All the other co-authors wereresponsible for data collection and completion of the case reportforms for patients included from their center. All co-authorsreviewed, amended the manuscript and approved the final ver-

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sion of it (the order of co-authors is based on number of patientsincluded from each center).

Acknowledgement

The authors thank Vincent Karam, data manager of the ELTR, forhis support in identifying patients for this study.

Supplementary data

Supplementary data associated with this article can be found, inthe online version, at http://dx.doi.org/10.1016/j.jhep.2012.03.022.

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