Treatment to Shrink Liver Cancer Tumors Helps Patients Become Eligible for Potentially Curative Transplant

Treatment that shrinks liver cancer tumors — a process known as downstaging — helps patients become eligible for a liver transplant, and leads to improved 10-year survival outcomes, according to recent research published in JAMA Surgery.

“The goal for us is to refine (transplant) candidate selection, trying to go beyond that traditional criteria and see if we can offer patients who would have not been eligible for transplantation a meaningful outcome and a curative treatment,” co-lead study Dr. Parissa Tabrizian, an associate professor of Surgery at the Icahn School of Medicine in Mount Sinai in New York City, said in an interview with CURE®.

Tabrizian explained that for the past two decades, liver transplantation eligibility criteria was guided by the Milan criteria, which states that patients are eligible for liver transplant if they have a single tumor that is 5 centimeters or smaller in diameter or with three or fewer tumors that are 4 centimeters or less in diameter. Patients must also not have any macrovascular invasion (cancer spread to the blood vessels) or metastases.

The researchers analyzed data from more than 2,000 patients who underwent a liver transplantation for the treatment of their cancer: 341 patients had their tumors downstaged so that they fit within the Milan criteria; 2,122 patients had disease that always fit within the criteria; and 182 patients did not have their tumors shrunk before transplant.

At the 10-year mark after transplantation, 52.1% of patients who underwent downstaging were still alive, as were 61.5% for those whose disease was always within the Milan criteria and 43.3% for those whose disease was not downstaged.

Recurrence rates 10 years after transplant were: 20.6% for those whose disease was downstaged; 13.3% for those whose disease always fit the Milan criteria; and 41.1% for those whose disease was not downstaged.

“Not surprisingly, those who failed downstaging (meaning those whose tumors never shrunk before transplant) had very poor outcomes and probably should not be transplanted,” Tabrizian said.

Tabrizian mentioned that it was not just the size or number of liver cancer tumors that affected post-transplant outcomes, but other characteristics of the disease as well.

“We also learned that the outcomes of these patients who are undergoing transplantation are not just limited by size and number (of tumors), so they’re not limited by the Milan criteria,” Tabrizian mentioned. “There are other factors, such as tumor biology, the response to pre-transplant treatment — which we continuously improve on over time — as well as wait time on the (transplant) list that are important.”

Considering the complexity of the disease, and the fact that liver cancer rates are increasing in the United States, Tabrizian urges patients diagnosed with liver cancer to seek out a care team that specializes in liver cancer and transplantation, if possible.

“I think that’s key (to find a specialized team) to make a diagnosis and better guide treatment,” she said. “It’s important to understand that transplantation can be a curative treatment in this select group of patients, and we can still achieve excellent outcomes. I think we can definitely make sure that these patients understand that there is hope.”

Looking forward, Tabrizian said that she hopes that this study, and others like it, will continue to refine liver transplant eligibility criteria, which could ultimately lead to better patient outcomes.

“I do think that our study and hopefully other larger studies will provide more robust data and will continue to increase the level of recommendation for downstaging policy,” she concluded.

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