Reply to: “How to decide about liver transplantation in patients with hepatocellular carcinoma: Size and number of lesions or response to TACE?”
Authors: Gerd Otto
Journal: Journal of Hepatology (2013)

How to decide about liver transplantation in patients with hepatocellular carcinoma: Size and number of lesions or response to TACE?Journal of HepatologyVol. 59Issue 2PreviewLiver transplantation is a curative treatment option for patients with hepatocellular carcinoma (HCC) and liver cirrhosis. To date, patient selection for transplantation is based on size and number of nodules as assessed by imaging before listing. We hypothesized that changes in tumour features resulting from pre-transplant transarterial chemoembolisation (TACE) is a superior criterion to predict tumour recurrence. Full-Text PDF How to decide about liver transplantation in patients with hepatocellular carcinoma: Size and number of lesions or response to TACE?Journal of HepatologyVol. 60Issue 2PreviewTo the Editor: Full-Text PDF Open Access We appreciate the interest of A. Paul et al. in our recent publication “How to decide about liver transplantation in patients with hepatocellular carcinoma: Size and number of lesions or response to TACE?” [[1]Otto G. Schuchmann M. Hoppe-Lotichius M. Heise M. Weinmann A. Hansen T. et al.How to decide about liver transplantation in patients with hepatocellular carcinoma: size and number of lesions or response to TACE?.J Hepatol. 2013; 59: 279-284Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar]. The point in this publication was to demonstrate the vagueness of size and number of HCC nodules in initial imaging to predict tumour recurrence when compared to the results of pretransplant transarterial chemoembolization (TACE). Based on a cohort of 136 patients uniformly treated by repeated TACE, the results of the radiological routine assessment before the first TACE and after the last TACE before liver transplantation (LT) were compared. Carcinomas remaining stable or responding to TACE during pretreatment had a favourable prognosis. Their reduced recurrence rate – when compared with tumours with progression during TACE – does clearly reflect favourable tumour biology, and the pre-treatment used in our cohort was obviously capable of separating two biologically different groups of patients. The question remains if response to TACE is really a surrogate of tumour biology or if proof of time is crucial in biological selection. If time before LT is crucial any other form of pre-treatment would yield similar results. Nothing more – but also nothing less – is claimed in our publication. We cannot see the “confusion” in this statement. Most other aspects criticised by the authors of the letter go beyond the scope of our publication. This applies for issues such as drop-out rate including the rate of patients functionally deteriorating during TACE [[2]Otto G. Heise M. Moench C. Herber S. Bittinger F. Schuchmann M. et al.Transarterial chemoembolization before liver transplantation in 60 patients with hepatocellular carcinoma.Transplant Proc. 2007; 39: 537-539Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar], comparison of LT with liver resection and with forms of HCC treatment such as radiofrequency ablation, TACE using drug eluting beads, 90Yttrium therapy, etc. We agree that liver resection may offer a similar survival benefit as LT. That is particularly true for Asian countries, less for the Western world [[3]Lim K.C. Chow P.K.H. Allen J.C. Siddiqui F.J. Chan E.S.Y. Tan S.B. Systematic review of outcomes of liver resection for early hepatocellular carcinoma within the Milan criteria.Br J Surg. 2012; 99: 1622-1629Crossref PubMed Scopus (162) Google Scholar]. This differential indication was, however, not the point of our publication. Likewise, the problem if labMELD, matchMELD, regular or rescue allocation impact prognosis was not intended to be addressed, as it deserves studies using a much greater cohort of patients and can, therefore, not be answered by a single centre analysis. Even if described in the publication we would stress the following aspects mentioned by the authors of the letter: TNM classification usually indicates pTNM and has, therefore, to be deduced from the surgical specimen (Table 2, [[1]Otto G. Schuchmann M. Hoppe-Lotichius M. Heise M. Weinmann A. Hansen T. et al.How to decide about liver transplantation in patients with hepatocellular carcinoma: size and number of lesions or response to TACE?.J Hepatol. 2013; 59: 279-284Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar]) not being available during the initial assessment. Considerations about the indication for LT in patients with T1 or T2 tumours are justified in scientific context but must be questioned in clinical practise due to the impreciseness of imaging (29 of 70 = 41%; [[4]Sotiropoulos G.C. Malago M. Molmenti E. Paul A. Nadalin S. Brokalaki E. et al.Liver transplantation for hepatocellular carcinoma in cirrhosis: is clinical tumour classification before transplantation realistic?.Transplantation. 2005; 79: 483-487Crossref PubMed Scopus (111) Google Scholar]). Of course, all patients were included in the overall survival analysis and time from first TACE to LT – the only period which is of interest in the study context – is demonstrated in Table 1, [[1]Otto G. Schuchmann M. Hoppe-Lotichius M. Heise M. Weinmann A. Hansen T. et al.How to decide about liver transplantation in patients with hepatocellular carcinoma: size and number of lesions or response to TACE?.J Hepatol. 2013; 59: 279-284Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar]. After all, we cannot recognize the “bias” challenged in the Letter as the authors ignore the issue of our publication. In one point we agree explicitly with the authors of the submitted letter: A change of the allocation rules based on our publication would be premature and the “…finding(s) should be verified in a larger prospective study…” as stated in the last sentence of the publication. The author declared that he does not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.