N. Golse

A new definition of sarcopenia in patients with cirrhosis undergoing liver transplantation.

Although sarcopenia is a common complication of cirrhosis, its diagnosis remains nonconsensual: computed tomography (CT) scan determinations vary and no cutoff values have been established in cirrhotic populations undergoing liver transplantation (LT). Our aim was to compare the accuracy of the most widely used measurement techniques and to establish useful cutoffs in the setting of LT. From the 440 patients transplanted between January 2008 and May 2011 in our tertiary center, we selected 256 patients with cirrhosis for whom a recent CT scan was available during the 4 months prior to LT. We measured different muscle indexes: psoas muscle area (PMA), PMA normalized by height or body surface area (BSA), and the third lumbar vertebra skeletal muscle index (L3SMI). Receiver operating characteristic curves were evaluated and prognostic factors for post‐LT 1‐year survival were then analyzed. PMA offered better accuracy (area under the curve [AUC] = 0.753) than L3SMI (AUC = 0.707) and PMA/BSA (AUC = 0.732), and the same accuracy as PMA/squared height. So, for its accuracy and simplicity of use, the PMA index was used for the remainder of the analysis and to define sarcopenia. In men, the better cutoff value for PMA was 1561 mm2 (Se = 94%, Sp = 57%), whereas in women, it was 1464 mm2 (Se = 52%, Sp = 91%). A PMA lower than these values defined sarcopenia in patients with cirrhosis awaiting LT. One‐ and 5‐year overall survival rates were significantly poorer in the sarcopenic group (n = 57) than in the nonsarcopenic group (n = 199), at 59% versus 94% and 54% versus 80%, respectively (P < 0.001). In conclusion, pre‐LT PMA is a simple tool to assess sarcopenia. We established sex‐specific cutoff values (1561 mm2 in men, 1464 mm2 in women) in a cirrhotic population and showed that 1‐year survival was significantly poorer in sarcopenic patients. Liver Transplantation 23 143–154 2017 AASLD

A New Definition of Sarcopenia in Cirrhotic Patients Undergoing Liver Transplantation

Although sarcopenia is a common complication of cirrhosis, its diagnosis remains nonconsensual: computed tomography (CT) scan determinations vary and no cutoff values have been established in cirrhotic populations undergoing liver transplantation (LT). Our aim was to compare the accuracy of the most widely used measurement techniques and to establish useful cutoffs in the setting of LT. From the 440 patients transplanted between January 2008 and May 2011 in our tertiary center, we selected 256 patients with cirrhosis for whom a recent CT scan was available during the 4 months prior to LT. We measured different muscle indexes: psoas muscle area (PMA), PMA normalized by height or body surface area (BSA), and the third lumbar vertebra skeletal muscle index (L3SMI). Receiver operating characteristic curves were evaluated and prognostic factors for post‐LT 1‐year survival were then analyzed. PMA offered better accuracy (area under the curve [AUC] = 0.753) than L3SMI (AUC = 0.707) and PMA/BSA (AUC = 0.732), and the same accuracy as PMA/squared height. So, for its accuracy and simplicity of use, the PMA index was used for the remainder of the analysis and to define sarcopenia. In men, the better cutoff value for PMA was 1561 mm2 (Se = 94%, Sp = 57%), whereas in women, it was 1464 mm2 (Se = 52%, Sp = 91%). A PMA lower than these values defined sarcopenia in patients with cirrhosis awaiting LT. One‐ and 5‐year overall survival rates were significantly poorer in the sarcopenic group (n = 57) than in the nonsarcopenic group (n = 199), at 59% versus 94% and 54% versus 80%, respectively (P < 0.001). In conclusion, pre‐LT PMA is a simple tool to assess sarcopenia. We established sex‐specific cutoff values (1561 mm2 in men, 1464 mm2 in women) in a cirrhotic population and showed that 1‐year survival was significantly poorer in sarcopenic patients. Liver Transplantation 23 143–154 2017 AASLD

Liver Metastases From Breast Cancer: What Role for Surgery? Indications and Results

Abstract Liver metastases from breast cancer (LMBC) have long been considered as a systemic disease because of the hematological route of dissemination, requiring noncurative management. In fact, despite recent advances in drug therapies personalized to tumor phenotype, the chances of a cure are nil and there is little hope of long‐term survivors after nonsurgical management alone. By contrast, there is a growing evidence in the literature for satisfactory long‐term results after a combination of chemotherapy and liver resection, with 5‐year survival reaching >40% in some series. The surgical management of LMBC is still restricted to carefully selected patients, managed in high‐volume hepatobiliary surgery and cancer research centers. Under these conditions, resection can be performed at the price of very limited morbidity and near zero mortality. The best results after the resection of LMBC are obtained after applying selection criteria based on small metastases (<4‐5 cm), minor hepatectomy, radical resection (ideally R0, or R1), stable disease (ideally in regression) after neoadjuvant therapy, and a delay between primary and secondary lesions longer than 1 or 2 years (reflecting a favorable oncologic context). The age of the patient, her hormone receptor status, and HER2 overexpression are not strong predictors of survival. The role of radiological alternatives still needs to be defined (radiofrequency, microwave ablation, radioembolization), and these raise questions regarding a reliable pretreatment assessment of tumor spread. Finally, surgical results are based on scarce evidence and need to be confirmed by large‐scale studies so that they will be more widely accepted by the medical community.

Extreme large-for-size syndrome after adult liver transplantation: A model for predicting a potentially lethal complication

There is currently no tool available to predict extreme large‐for‐size (LFS) syndrome, a potentially disastrous complication after adult liver transplantation (LT). We aimed to identify the risk factors for extreme LFS and to build a simple predictive model. A cohort of consecutive patients who underwent LT with full grafts in a single institution was studied. The extreme LFS was defined by the impossibility to achieve direct fascial closure, even after delayed management, associated with early allograft dysfunction or nonfunction. Computed tomography scan–based measurements of the recipient were done at the lower extremity of the xiphoid. After 424 LTs for 394 patients, extreme LFS occurred in 10 (2.4%) cases. The 90‐day mortality after extreme LFS was 40.0% versus 6.5% in other patients (P = 0.003). In the extreme LFS group, the male donor–female recipient combination was more often observed (80.0% versus 17.4%; P < 0.001). The graft weight (GW)/right anteroposterior (RAP) distance ratio was predictive of extreme LFS with the highest area under the curve (area under the curve, 0.95). The optimal cutoff was 100 (sensitivity, 100%; specificity, 88%). The other ratios based on height, weight, body mass index, body surface area, and standard liver volume exhibited lower predictive performance. The final multivariate model included the male donor–female recipient combination and the GW/RAP. When the GW to RAP ratio increases from 80, 100, to 120, the probability of extreme LFS was 2.6%, 9.6%, and 29.1% in the male donor–female recipient combination, and <1%, 1.2%, and 4.5% in other combinations. In conclusion, the GW/RAP ratio predicts extreme LFS and may be helpful to avoid futile refusal for morphological reasons or to anticipate situation at risk, especially in female recipients. Liver Transplantation 23 1294–1304 2017 AASLD.

Recurrence of hepatocellular carcinoma after liver transplantation: Is there a place for resection?

Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) is widely considered as a terminal condition. Therefore, the role of surgery is uncertain in this case. The purpose of this study was to identify the prognostic factors of survival after post‐LT HCC recurrence and to evaluate the impact of surgery in this setting. All patients transplanted for HCC between 1991 and 2013 in a single institution and who further developed a post‐LT recurrence were included in this study. Univariate and multivariate analyses were performed to identify factors affecting postrecurrence survival. Of the 493 patients transplanted for HCC, a total of 70 (14.2%) consecutive patients developed a recurrence after a median disease‐free interval of 17 months. Median survival (MS) from the time of recurrence was 19 months, with a 3‐year postrecurrence survival of 26%. Most recurrences were extrahepatic (lung, lymph node, and bone; n = 51; 72.9%), whereas only intrahepatic recurrences were observed in 2 (2.8%) patients. Both intrahepatic and extrahepatic locations were found in 17 (24.3%) patients. A total of 22 (31.4%) patients underwent macroscopically complete resection of the recurrence (intrahepatic [n = 2] and extrahepatic [n = 20]). The MS for resected patients after transplantation was 35 months compared with 15 months for nonresected patients (P < 0.001). In multivariate analysis, the independent unfavorable factors of postrecurrence survival were alpha‐fetoprotein level > 100 ng/mL at relapse (hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.1‐4.1; P = 0.03), intrahepatic location (HR, 1.8; 95% CI, 1.0‐3.2; P = 0.05), and multifocal recurrence (HR, 1.8; 95% CI, 1.1‐3.1; P = 0.04). The management including surgery (HR, 0.4; 95% CI, 0.2‐0.7; P = 0.004) was identified as an independent favorable factor. In conclusion, recurrence of HCC after LT is associated with a poor prognosis. However, resection is associated with improved survival and should therefore be considered when feasible. Liver Transplantation 23 440–447 2017 AASLD.

Large hepatocellular carcinoma: Does fibrosis really impact prognosis after resection?

BACKGROUND Hepatectomy remains the standard treatment for large hepatocellular carcinoma (LHCC) ≥5cm. Fibrosis may constitute a contraindication for resection because of high risk of post-hepatectomy liver failure, but its impact on patient outcome and cancer recurrence remains ill defined. Our aim was to compare predictors of survival in patients with and without cirrhosis following hepatectomy for LHCC. METHODS The data on consecutive patients undergoing hepatectomy for LHCC in two tertiary centres between 2012 and 2016 were reviewed. The outcomes of cirrhotic (F4) and non-cirrhotic (F0-F3) patients were compared. Patients with perioperative medical (sorafenib) or radiological (transarterial chemoembolization, radiofrequency) treatments were excluded. RESULTS Sixty patients were included. Preoperative and intraoperative features were identical between both groups. Cirrhotics (n=15) presented more satellite nodules on specimens (73% vs. 44%; P=0.073) but better differentiated lesions than non-cirrhotics (P=0.041). The median overall survival of cirrhotics was 34 vs. 29months for non-cirrhotics (P=0.8), and their disease-free survival was 14 versus 18 months (P=0.9). Fibrosis stage did not impact overall (P=0.2) nor disease-free survivals (P=0.6). CONCLUSION Hepatectomy for LHCC in cirrhotics can achieve acceptable oncological results when compared to non-cirrhotic patients. Curative resection of LHCC should be attempted if liver function is acceptable, whatever the fibrosis stage.