HEGAZY SURGERY

1. Hepatocellular Carcinoma: Impact of Waiting
List and Pre-operative Treatment Strategies
on Survival of Cadaveric Liver
Transplantation in Pre-MELD Era in One
Center in Brazil
Alexandre Coutinho Teixeira de Freitas, MD; PhD
Mônica Beatriz Parolin, MD; PhD
Lucinei Stadnik, MD
Júlio Cezar Uili Coelho, MD; PhD
Liver Transplantation Program
Federal University of Paraná
Brazil

2. AIM
Analyse liver transplantation 3 month and 1 year
survival in:
Group 1 – patients with cirrhosis and
hepatocellular carcinoma
Group 2 – patients with cirrhosis only

3. MATERIAL AND METHODS
Liver transplants done between 2001 and 2006
Group 1
Cirrhosis + hepatocellular carcinoma
(diagnosed with the Barcelona criteria)
Group 2
Cirrhosis
Analysis comparing the 2 groups
•Recipient: age, sex, etiology of cirrhosis, Child-Pugh classification,
MELD score, warm ischemia time, transfusion of red blood cells (units),
hospital stay, intensive care unit stay and 3 months and 1 year survival
•Donor: age, sex and cold ischemia time

4. MATERIAL AND METHODS
Liver transplants done between 2001 and 2006
Group 1
Cirrhosis + hepatocellular carcinoma
(diagnosed through the Barcelona criteria)
Group 2
Cirrhosis
Specific considerations of group 1
•Local treatment – transarterial chemoembolization or percutaneous ethanol
injection according to localization and number of nodules
•Liver transplantation – according to Milan criteria

5. MATERIAL AND METHODS
Liver transplants done between 2001 and 2006
Group 1
Cirrhosis + hepatocellular carcinoma (HCC)
(diagnosed through the Barcelona criteria)
Group 2
Cirrhosis
Analysis done in group 1 only
•Time from diagnosis of HCC to transplant, number and diameter of the nodules
at the time of the diagnosis (imaging studies), number of sessions of the local
treatment, diameter of the nodules at the time of liver transplant (imaging
studies), pathological examination (diameter of the nodules, angiolynphatic
invasion, capsule invasion, Edmondson-Steiner classification)

6. STATISTICAL ANALYSIS
• Kaplan-Meier univariate survival analysis
with Log Rank test
• Student t test for mean values
• Qui-square test for proportions
• Level of significance 5% (p0,05)

7. RESULTS
N=146 patients analysed
75 excluded (incomplete data)
71 included in the study
Cirrhosis + hepatocellular carcinoma
N=12
Cirrhosis
N=59
The 2 groups were the same in terms of: age, sex,
cold isquemia time, warm isquemia time, hospital stay,
intensive care unit stay and transfusion of red blood cells
(units)

8. RESULTS
N=146 patients analysed
75 excluded (incomplete data)
71 included in the study
Cirrhosis + hepatocellular carcinoma
N=12
Cirrhosis
N=59
See next slide
More hepatitis C
Lower MELD score
More Child A
Transfusion of less red blood cells
More cholestatic diseases and
other etiologies
Higher MELD score
More Child B and C
Tranfusion of more red blood cells

9. Total Cirrhosis
+ HCC
Cirrhosis p
n 71 12 59 -
Etiology of cirrhosis
Cholestatic diseases 4 (5,6%) 0 4 (6,8%) 0,05
Hepatitis C 31 (43,7%) 9 (75%) 22 (37,3%) 0,05
Other etiologies 36 (50,7%) 3 (25%) 33 (55,9%) 0,05
MELD score 15,14 11,42 15,84 <0,01
Child-Pugh
Mean score 8,41 6,71 8,71 <0,01
Child A 6 (8,5%) 4 (33,3%) 2 (3,4%) <0,01
Child B 49 (69,1%) 8 (66,6%) 41 (69,4%)
Child C 16 (22,4%) 0 16 (27,2%)
Transfusion red blood cells
(units)
4,63 2,92 53 0,03
HCC – hepatocellular carcinoma

10. Time from diagnosis of HCC to transplant 19,316 months
Total number of nodules
Patients with 1 nodule
Patients with 2 nodules
Patients with 3 nodules
21 nodules
5 patients
5 patients
2 patients
Local treatment (mean number of sessions)
Transarterial chemoembolization
Transarterial chemoembolization+percutaneous ethanol injection
2,5 sessions
2,5 + 5 sessions
RESULTS LOCAL TREATMENT
Group cirrhosis + hepatocellular carcinoma (HCC)

11. RESULTS LOCAL TREATMENT
• Local treatment provided good size control of
the nodules
• The diameter of the nodules just before liver
transplant was smaller than the diameter at the
time of the diagnosis (19,3 16 months earlier)
• The diameter of the nodules of the explant was
the same than the diameter at the time of the
diagnosis and the diameter just before the
transplant

12. Diameter of nodules at the time of the diagnosis 3,31cm
Diameter of nodules just before liver transplant
Total remission of nodules
2,41cm*
3 cases
Diameter of nodules on explant examination
Angiolynphatic invasion
Capsule invasion
2,81cm**
1 case
Not observed
Edmondson-Steiner classification (explant examination)
Total remission of nodules
Class II
Class III
3 cases
7 cases
2 cases
*p=0,02 in comparison with the diameter at the time of the diagnosis
** Not different in relation to the diameter at the time of the diagnosis (p=0,13) and
the diameter just before the transplant (p=0,16).
Group cirrhosis + hepatocellular carcinoma (HCC)
RESULTS LOCAL TREATMENT

13. GENERAL CUMULATIVE 3
MONTHS SURVIVAL
Dias
Sobrevidacumulativa
-0,1
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
0 10 20 30 40 50 60 70 80 90
Days
Cumulativesurvival
77,4%
General cumulative 3 months survival was 77,4%

14. GENERAL CUMULATIVE
1 YEAR SURVIVAL
Dias
Sobrevidacumulativa
-0,1
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
0 50 100 150 200 250 300 350
Cumulativesurvival
Days
74,6%
General cumulative 1 year survival was 74,6%

15. CUMULATIVE 3 MONTHS
SURVIVAL (GROUPS)
Dias
Sobrevidacumulativa
-0,1
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
0 10 20 30 40 50 60 70 80 90
Não-portadoresdecarcinomahepatocelular
Portadoresdecarcinomahepatocelular
Cirrhosis = 72,8%
Cirrhosis + HCC = 100%
p=0,04
Cumulativesurvival
Days
Patients with cirrhosis and HCC presented better 3 month
survival than patients with cirrhosis only
HCC – hepatocellular carcinoma

16. CUMULATIVE 1 YEAR
SURVIVAL (GROUPS)
Dias
Sobrevidacumulativa
-0,1
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
0 50 100 150 200 250 300 350
Não-portadoreshepatocarcinoma
Portadoreshepatocarcinoma
Cumulativesurvival
Cirrhosis = 69,4%
Cirrhosis + HCC = 100%
p=0,02
Days
Patients with cirrhosis and HCC presented better 1 year
survival than patients with cirrhosis only
HCC – hepatocellular carcinoma

17. CONCLUSION
• Cirrhotic patients with hepatocellular
carcinoma presented better 3 month and 1
year survival than patients with cirrhosis
only.
• This is associated with transplantation at
an early stage of cirrhosis.
• Local treatment provided good size control
of the nodules