Clinical Efficacy Of Salvage Liver Transplantation In The Treatment Of Recurrent Hepatocellular Carcinoma And Evaluation Of Immunosuppression After Liver Transplantation For Hepatocellular Carcinoma

Aim To evaluate the efficacy of salvage liver transplantation(SLT)in the treatment of recurrent hepatocellular carcinoma after hepatectomy and systematic evaluation of immunosuppression after liver transplantation for hepatocellular carcinoma.Methods 1.Clinical data of 63 patients who underwent liver transplantation treating for hepatocellular carcinoma from January 2005 to January 2018 in the923 Hospital of People's Liberation Army were analyzed retrospectively.Among Them,32 patients underwent primary liver transplantation(PLT),and 31 patients underwent SLT.Intraoperative situation was compared between two groups including operation time,time of anhepatic phase,volume of blood loss and blood transfusion.Time in intensive care unit(ICU)and total length of hospital stay were compared between two groups.The occurrence ofpostoperative complication was compared between two groups.And the survival curves were drawn by the Kaplan-Meier method according to the follow-up result between two groups.Cumulative survival rate and tumor free survival rate were compared by log-rank tests between two groups.2.Information up to January 2018 was retrieved from Cochrane library,Pubmed,EMBASE,WanFang Data,CBM,CNKI,VIP and other database.Collected publications were all about case-control study of salvage liver transplantation compared primary liver transplantation to hepatocellular carcinoma after hepatectomy.After evaluate the literatures' quality and extracting the data,used RevMan 5.3to analyze the data of each study.3.The data of 147 patients with recurrent hepatocellular carcinoma fulfilling Milan criteria or HangZhou criteria from January 2005 to January 2018 were retrospectively studied.According to different treatments,83 patients were divided into repeated radiofrequency ablation(RFA)group,33 patients were divided into repeated hepatectomy group,and 31 patients were divided into salvage liver transplantation group.The overall survival rates and disease-free survival rates after operation were evaluated by Kaplan-Meier method.COX proportional hazard was used for multivariate analysis to evaluate the risk factors for prognosis.4.Information up to 31 July 2018 was retrieved from Cochrane library,Pubmed,EMBASE,WanFang Data,CBM,CNKI,VIP and other database.Collected publications were all about case-control study of SLT compared repeated hepatectomy to recurrent hepatocellular carcinoma.After evaluate the literatures' quality and extracting the data,used RevMan 5.3 to analyze the data of each study.5.Information up to January 2018 was retrieved from Cochrane library,Pubmed,EMbase,CBM,CNKI,VIP.Collected publications were all about case-control study of sirolimus(SRL)compared calcineurin inhibitors(CNIs)tohepatocellular carcinoma after liver transplantation.After evaluate the literatures' quality and extracting the data,used RevMan 5.3 to analyze the data of each study.Results 1.The operation time,anhepatic time,volume of blood loss and blood transfusion of patients in SLT group were higher than those in PLT group(P<0.05 for all).There was no significant difference in the time in ICU and total length of hospital stay between two groups(P>0.05 for all).There was no significant difference in the occurrence of bleeding,infection,acute rejection,renal failure and biliary complication between two groups(P>0.05 for all).All the patients were followed up for 1-126 months with the average of 56 months.The cumulative survival rates of 1-,3-and 5-years were 93.55%,87.10%,77.42% in SLT group and 96.88%,84.38%,78.13% in PLT group respectively,and there was no significant difference by Kaplan-Meier analysis between two groups(P=0.688).And the tumor free survival rates of 1-,3-and 5-years were93.55%,77.42%,70.97% in SLT group and 96.88%,81.25%,71.88% in PLT group,and there was no significant difference by Kaplan-Meier analysis between two groups either(P=0.627).2.A total of 17 articles including 9335 patients were enrolled.There was no difference between SLT and PLT on 1-year overall survival,1-year disease-free survival(P>0.05 for all),however,on the 3-and 5-year overall and disease-free survival PLT is better than SLT.3.The 1-,3-and 5-year overall survival rates were 93.55%,87.10%,80.65% in SLT group and 96.97%,75.76%,72.73% in repeated hepatectomy group and 91.57%,71.08%,65.06% in the repeated RFA group respectively.There was no significant difference in the overall survival rates between three groups(P=0.428).The 1-,3-and 5-year disease-free survival rates were 96.77%,83.87%,80.65% in SLT group and 96.97%,75.76%,72.73% in repeatedhepatectomy group and 61.45%,42.17%,38.56% in the repeated RFA group respectively.There was a significant difference in the disease-free survival rates between the three groups(P=0.000).The multivariate analysis indicated that the time to recurrence less than 12 months,preoperative AFP>400ng/ml and multiple tumors were the independent risk factors to influence the survival.4.A total of 5 articles including 525 patients were enrolled.There was no difference between SLT and repeated hepatectomy on 1-,3-and 5-year overall survival rates(P>0.05 for all),however,on the 1-,3-and 5-year disease-free survival rates PLT is better than repeated hepatectomy(P?0.05 for all).5.A total of 13 articles including 4181 patients were enrolled.There was no difference between SRL and CNIs on 3-year and 5-year disease-free survival(RR=1.13,95%CI0.97-1.31,P=0.11;RR=1.07,95%CI 0.92-1.24,P=0.37),however,on the 1-,3-and 5-year overall survival and 1-year disease-free survival SRL is better than CNIs(RR=1.09,95%CI 1.03-1.15,P=0.005;RR=1.08,95%CI 1.02-1.14,P=0.006;RR=1.11,95%CI 1.00-1.23,P=0.05;RR=1.14,95%CI 1.05-1.24,P=0.001).Conclusion There was no significant difference between salvage liver transplantation and primary liver transplantation in terms of overall survival rates and tumor-free survival rates in our center.However,meta-analysis suggested that PLT was superior to SLT in 3-and 5-year overall survival rates and 1-,3-and 5-year tumor-free survival rates.The efficacy of SLT is superior to that of repeated hepatectomy or RFA in the treatment of recurrent hepatocellular carcinoma.However,considering the similar overall survival rate,repeated hepatectomy or RFA are still important options for recurrent hepatocellular carcinoma in the current situation of donor shortage.There was no difference between SRL and CNIs on 3-and 5-year disease-free survival,butin the 1-,3-and 5-year overall rates and 1-year disease-free survival rates,on the contrast of SRL is better than that of CNIs.