Reply to: “Patients with hepatocellular carcinoma and portal vein tumour thrombosis after successful downstaging may be candidates for liver transplantation: A meta-analysis”
Authors: Arvinder Soin, Mickael Lesurtel, Pierre A. Clavien
Journal: Journal of Hepatology (2024)

Patients with hepatocellular carcinoma and portal vein tumour thrombosis after successful downstaging may be candidates for liver transplantation: A meta-analysisJournal of HepatologyPreviewIn their recent review article, Soin et al. debated whether patients with hepatocellular carcinoma (HCC) and portal vein tumour thrombosis (PVTT) are candidates for liver transplantation (LT). They reported significant long-term survival benefits from LT in patients with HCC and PVTT after successful downstaging. However, the authors concluded that the current quality of evidence for LT in patients with HCC and PVTT is low and their survival rates are still below accepted thresholds for LT.1 Therefore, we conducted this meta-analysis to investigate the prognosis of patients with HCC and PVTT after LT. Full-Text PDF Are patients with hepatocellular carcinoma and portal vein tumour thrombosis candidates for liver transplantation?Journal of HepatologyVol. 78Issue 6PreviewIn this debate, the authors consider whether patients with hepatocellular carcinoma (HCC) and portal vein tumour thrombosis are candidates for liver transplantation (LT). The argument for LT in this context is based on the premise that, following successful downstaging treatment, LT confers a much greater clinical benefit in terms of survival outcomes than the available alternative (palliative systemic therapy). A major argument against relates to limitations in the quality of evidence for LT in this setting – in relation to study design, as well as heterogeneity in patient characteristics and downstaging protocols. Full-Text PDF We thank Liu et al.[1]Liu J. Qian J. Yang Z. et al.Patients with Hepatocellular carcinoma and portal vein tumour thrombosis after successful downstaging may be candidates for liver transplantation: a meta-analysis.J Hepatol. 2023 Nov 6; (S0168–8278): 5231-5235Google Scholar for their additional meta-analysis in favour of the benefit of successful downstaging approaches to facilitate liver transplantation with acceptable outcomes in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT). Their results should however be interpreted with caution since their meta-analysis considers only pooled survival data coming from retrospective studies missing matched control groups. While a few case series of highly selective patients with HCC-PVTT showed that successful downstaging according to pre-defined protocols enabled liver transplantation with overall 5-year survival rates of around 60%, there is a high level of heterogeneity among these studies. There is a need to standardize the selection of patients for these protocols, as several aspects are unclear: For example, a) there is no consensus on the ideal downstaging modalities, or definition of "successful downstaging treatment", and the recommended waiting periods between downstaging and transplantation remain speculative; b) the potential transplant benefit of downstaging HCC-PVTT followed by transplantation over current standard of care with systemic immunotherapy and/or targeted therapy remains unproven; c) there are only anecdotal reports[2]Katariya N.N. Lizaola-Mayo B.C. Chascsa D.M. et al.Immune checkpoint inhibitors as therapy to down-stage hepatocellular carcinoma prior to liver transplantation.Cancers. 2022; 14: 2056Crossref PubMed Scopus (21) Google Scholar,[3]Kumar P. Krishna P. Nidoni R. et al.Atezolizumab plus Bevacizumab as a downstaging therapy for liver transplantation in Hepatocellular carcinoma with portal vein thrombosis: the first report.Am J Transpl. 2024, January 12; https://doi.org/10.1016/j.ajt.2024.01.007Abstract Full Text Full Text PDF Scopus (0) Google Scholar of successful downstaging and transplantation in patients with HCC with immunotherapy, either alone or in combination with radiotherapy, but its efficacy is unclear in the setting of macrovascular invasion. The time is ripe for appropriately designed prospective controlled trials to define the best downstaging strategies, and to study the survival outcomes and transplant benefit in patients with HCC-PVTT offered either targeted radiotherapy, immunotherapy or a combination thereof, followed by liver transplantation. The authors did not receive any financial support to produce this manuscript. The authors of this study declare that they do not have any conflict of interest. Please refer to the accompanying ICMJE disclosure forms for further details. AS, ML and PAC equally contributed to the conception and writing of this letter and final approval of the letter. The following are the supplementary data to this article: Download .pdf (.16 MB) Help with pdf files Multimedia component 1