Liver Cancer and Hepatocellular Carcinoma
When one of our liver fellows several years ago first pulled out our data from the early days of our transplant program, looking at patients who were transplanted for hepatoma in various stages, he discovered that this group who presented with a rising alpha-fetoprotein – and this was not a level necessarily associated with the lower values one might see with an active hepatitis C – these were patients who had significant values. Frequently over 400 nanograms per milliliter. When we looked at the survival on these patients, as you might expect, it was really quite good. In other words, we got these patients before the tumor became large or had a chance to progress. But when you looked at the data on any patient who had an identifiable mass lesion prior to transplantation, whether that was even a stage I or II-a patient, then the disease-free survival failed to a disappointing 50% at two years. So I think that hepatologists in our transplant clinic at that point felt that they had to drop back to the drawing board, and try to figure out how we can improve our selectivity on these patients because it seemed that probably most of these patients did poorly because they were simply inadequately staged. There was multicentric disease probably present at the time of transplant that simply had not been identified.
Cancer information
Of course this paper that came out in the New England Journal a couple of years ago was very encouraging for all of us, and showed that indeed when patients with a solitary tumor less than 5 centimeters in size -many of whom had tumors of less than 3 centimeters in size – long term survival could be obtained. It had nothing to do with a tumor node or mets stage, but had to do more with small tumors without evidence of macrovascular invasion, and had a very nice four-year survival rate about 82 or 83%. Many of these patients, by the way, received preoperative chemo-embolization before they were transplanted, but you may remember in their paper that when they’d looked at those patients and compared those patients with and without chemo-embolization, there really wasn’t much difference. So they really couldn’t make a strong case for treating patients preoperatively with chemo-embolization.
These data are from the more recent Mayo data. Now after that drop back that I mentioned to you a moment ago, they became more selective and began to triple-image patients and do a better job of trying to identify those patients who truly had limited disease. The effort paid off showing that actually the disease-free survival exceeds actuarial survival here because of a couple of patients who died without recurrence and now show a pretty much straight line after the one-year point. And we found this data very encouraging. All of these patients were treated with a protocol, by the way, that included preoperative chemo-embolization. As I mentioned to you, we have a bias at Mayo that preoperative chemo-embolization, by reducing the amount of disease that may be transferable or left or spilled at the time of transplant, may be helpful. But we really can’t say that for sure at this point, even though these data are certainly very encouraging.
Liver Cancer