Transcatheter hepatic arterial chemoembolization in cirrhotic patients with hepatocellular carcinoma before liver transplantation: the prognostic value of alpha-fetoprotein concentrations

Objective: to study liver transplantation (LT) outcomes in cirrhotic patients with hepatocellular carcinoma
(HCC), who underwent transcatheter hepatic arterial chemoembolization (THACE).

Materials and methods. From January 1998 to April 2020, we performed 245 orthotopic liver transplantation (OLTs) in 229 patients of which 25 (10.2%) had HCC in cirrhosis. In 9 (36%) patients, LT was performed without neoadjuvant therapy (Group 1). Group 2 consisted of 16 (66%) patients who underwent 49 THACE cycles before LT. 10 (62.5%) patients fell within the Milan criteria, while 6 (37.5%) were outside. According to the BCLC (Barcelona Clinic Liver Cancer) classification, 10 patients had A1–A4 stage, while 6 were in B stage. In 11 (68.5%) of 16 patients, increased serum alpha-fetoprotein (AFP) concentrations from 20 to 2463 (on average 493.8) ng/mL was revealed before treatment. In performing THACE, both the classical method (with lipiodol and hemostatic sponge) and the method with drug-eluting beads were performed 1 to 7 (on average 3) times. Doxorubicin was used in all cases.

Results. Group 2 recorded a 100% technical success. There were no complications. We performed radiofrequency ablation (RFA) in three patients as an adjunct. In two patients, we performed laparoscopic RFA-assisted atypical liver resection, and in one – sequential resection and RFA. Under the m-Recist criteria, complete response was observed in 6 (37.5%), partial response in 7 (43.75%), and stabilization in 3 (18.75%) patients. Change in AFP concentrations were as follows: in 5 out of 11 patients with increased concentrations, we were able to reduce their AFP concentrations to the reference values, their long-term outcomes are comparable to those of Group 1. Four patients showed a 13–84% decrease; a directly proportional relationship between the degree of AFP decrease and the time to tumor progression was  revealed. In 2 patients, there were 42% and 320% increase in AFP concentrations, the time to tumor progression was 3 and 1 month, both did not live up to 12 months. Among 9 (56%) of the living 16 patients, a maximum of 156 months and a minimum of 4 months (60.2 average) have elapsed since the surgery. Two of these nine have tumor progression (cases 4 and 14). Seven (44%) patients died within 9 to 54 months. The 1, 3, 5-year actuarial survival rates were 93, 50, 32%, two patients lived more than 10 years. The average life expectancy was 28.0 ± 3.0 months.

Conclusion. Serum AFP concentration is an important prognostic factor influencing the long-term outcomes of LT. Good biological response to THACE can be a positive predictor; LT outcomes in these patients are  comparable to those in patients who meet the Milan criteria. A decrease in AFP concentrations by less than  50% after neoadjuvant THACE is an unfavorable factor, and its increase is extremely adverse.  

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