Massimo Malago 2

Liver transplantation in liver tumors
other than HCC
Massimo Malagó
The Ilse Bagel Professor of Surgery and
Transplantation
University of Duisburg-Essen
Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Therapy of liver tumors
History
Liver transplantation: a reality in the ’70-‘80
Resection AND / OR
Transplantation
Radicality Organ preservation, I/R
Preserved function Immunology
Multidisciplinarity
Cooperation
Oncology, RT, nutrition Hepatology, ICU, virolog
No Competition but
Sinergy!!!!

History - Liver transplantation
Rudolf Pichlmayr, Christoph Broelsch
Med.Kln. 78 (1983) 744-752
Radicality, locoregional control

Vs
Immunosuppression related recurrence
History - Liver transplantation
Oncological rationale
Radicality, locoregional control

Vs
Occult - „dormant“ metastases
In advanced secondary and primary

tumors

other than HCC
General Survey
Indications - Results
Organ allocation
Immunosuppression

Up to date sul trapianto di fegato
Hepatobiliary Tumors
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www.eltr.org/publi/results.

other than HCC
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ELTR
Primary Diseases leading to Liver 12/2005
Transplantion in Europe
01/1988 - 12/2005
Metabolic diseases : 3592 Acute hepatic failure : 5166
6% 9%
* Others : 1779
Cholestatic 3%
diseases : 6256
11%
Cancers : 7318 Cirrhosis : 33845

13% 58%
* Others : Budd Chiari : 567 Benign liver tumors or Polycystic diseases : 635
Parasitic
Klinik diseases
für Allgemein-, : 54und Transplantationschirurgie,
Viszeral- Other liver diseases : 523
Universitätsklinikum Essen
Primary Diseases leading to Liver Transplantion by Country
01/1988 - 12/2005
AUSTRIA
BELGIUM
CZECH REP.
DENMARK
FINLAND
FRANCE
GERMANY
GREAT BRITAIN
HUNGARY
Cirrhosis : 33845
IRELAND
ITALY Acute hepatic failure : 5166
MONACO
Cancers : 7318
NETHERLANDS
NORWAY Others : 7166
POLAND
PORTUGAL
ROMANIA
SLOVENIA
SPAIN
SWEDEN
SWITZERLAND
TURKEY
YUGOSLAVIA
0% 20% 40% 60% 80% 100%
other than HCC
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www.eltr.org/
publi/results.

LDLT for HCC
Organ pool „independent“ from allocation
Optimal timing: no waiting time
Pre-selected organ quality
Donor risks!!
Recipients: suboptimal results in
- advanced tumors
- severe cirrhosis
Liver Transpl. 2001 7:9217

other than HCC
Organ allocation
Maximal gain concept:

The sickest patients (High Meld) benefit more!!!
Evolution of Primary Diseases leading ELTR
12/2005
to Liver Transplantation in Europe
05/1968 - 12/2005
100%
80%
60%
40%
20%
0%
68- 83 86 89 92 95 98 2001 2004

80 Cirrhosis : 34684 Cancers : 7824
Acute hepatic failure : 5313 Others : 12088
other than HCC
Hepatobiliary Tumors
QuickTimeª and a

Organ shortage
Liver
Optimal use of the organ resources
NHBD
ECD
Marginal SPLIT Living Donor
donors
Domino

other than HCC
General Survey
Organ allocation
Immunosuppression

Live donor LT
for HCC - Adults
Extended criteria but not open end

Extension of radicality -
resectability
Primary liver tumors
Liver transplantation
Vs
Liver resection

HCC: Liver resection
Restricted function
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HCC: Liver resection

bentigt.

bentigt.

Leberresektionen
Essen Apr. 1998 - 2006
Hemihepatektomie 892
Erweiterte Hemihepatektomie 308
Anatomische Leberresektionen 341
Nicht-anatomische Leberresektionen 937
Hepatikusgabelresektionen 58
Leberlebendspender 174
___________
Leberresektionen
gesamt 2710

Klatskin tumors

Radical surgery for Hilar CCC
Avoiding unnecessary transplantations

R Trisegmentectomy + Whipple for Kltaskin
other than HCC
LTX for Hepatobiliary Tumors
(HCC)
Hepatoblastoma
CCC
Stroma Tumors - Mesenchymal (Liver sarcoma)

Epitheliod Hemangioendithelioma
neuroendocrine (NE)
Metastatic tumors
non NE Colorectal
LTX ESSEN April 1998 – October 2006
n = 881
Reduced Liver (8)
LDLT (185)
Split (115)
Standard-Tx (573)

LTX ESSEN April 1998 – October 2006
n = 881 Pediatric n = 143
Adults n = 738 Lebendspende OLTx reduzierte Leber Split
Lebendspende OLTx reduzierte Leber Split
37
53
1 61 148
7 46
ALDLT n =148
528 8
Right
Left
140

LTx for HCC - Adults
Essen 1998 - 2005
ALDLT n=121 Cadaver LTx n=530

HCC 34% HCC 10,1%
54 1
42
hcc
hcc
other tumors
other tumors
other disease
other disease
73
7 475
Mean F-up 28 mo.

other than HCC
Living Donor: 4.8%
Living Donor LTx Indications
AdenoCa
2 1 Hepatoblastoma HCC
50
Pseudo-Tumor
51 Mesenchymal
123 2
NeuroEndocrine
Non Tumor

other than HCC
Deceased Donor: 1.3%
Cadaveric LTx Indications
HCC Mesenchymal
AdenoCa
4 56 14 NeuroEndocrine
Non Tumor 632

Hepatoblastomaoma
Liver transplantation -
SIOPEL Protocol
Otte et al Ped Transpl 2005

Hepatoblastomaoma
Liver transplantation -
SIOPEL Protocol
Patients referred n=6
Not transplantable n=1
Liver resection n=4
LDLT n=1

Cholangiocarcinoma
[ Gallbladder (GBC) ]
Intrahepatic (ICC or peripheral CC)

without cirrhosis, without PSC*
with Caroli´s disease *
with cirrhosis (secondary biliary cirrhosis)
with PSC
Hilar (Klatskin-Tumor)
without cirrhosis, without PSC *
with PSC
*normal liver functional reserve
Cholangiocarcinoma
- without cirrhosis, without PSC
Extended Liver Resections

Scenario 5 -
Extended L Hepatectomy
QuickTimeª and a
TIFF (LZW) decompressor

Left Trisectionectomy

Extended - R trisectionectomy

Intrahepatic Cholangiocarcinoma
Liver Resection
Author/year n 1y 3y 5y median (mon.)
Berdah/1996 19 67 40 32 15
Chu/1997 39 57 24 16 12
Harrison/1998 32 76 56 42 59
Madariaga/1998 34 67 40 35 19
Roayaie/1998 16 86 64 21 43
Weimann/ 2000 95 64 31 21 18
Weber/ 2001 33 83 55 31 37
Lang/ 2005 27 65/88* 53/77% 46*
* R0 only


Liver Resection
Lang et al.,
Ann Surg 2005, 241-

Liver Transplantation
Weimann et al,
Br J Surg 2000

Cholangiocarcinoma
Liver transplantation
Shimoda et al, Liver Transplantation 2001

Hilar Cholangiocarcinoma
Transplantation
Treatment options
LTx alone
LTx plus Whipple
LTx plus cluster resection-transplantation
LTx plus neoadjuvant therapy

Transplantation
Concept: LTx alone
Pichlmayr et al,Ann Surg 1996

Transplantation
Concept: Whipple plus cluster Tx
n = 12
3-months mortality 2/12 (17%)
Survival: 3 pts. alive at time of report
52, 54, 59 months
Alessiani et al., J Am Coll Surg 1995

- with/ without PSC
Transplantation
Concept: LTx plus neoadjuvant therapy
Heimbach JK et al, Seminars in Liver

Disease 2004 Universitätsklinikum Essen
Klinik für Allgemein-, Viszeral- und Transplantationschirurgie,
- with/ without PSC
Transplantation
Concept: LTx plus neoadjuvant therapy
Heimbach JK et al, Seminars in Liver

Disease 2004 Universitätsklinikum Essen
Klinik für Allgemein-, Viszeral- und Transplantationschirurgie,
Author Year LTx operative neo- Hospital Survival
/adjuvant
(n) extension treatment mortality (months)

(n) (n) (n)
Alessiani 1995 12 (12) Cluster-Tx - - -

Cherqui 1995 2 (2) Whipple (2) RTx 0 23 med.
Anthuber 1996 10 (4) Whipple - 2 25 med.
Pichlmayr 1996 25 - - 3 15.5 med.
Beckurts 1997 5 - (5) IORT - 12 med.
Iwatsuki 1998 38 (11) Cluster-Tx (18) 8 12.7 cum.
RTx±5FU
Robles 1999 6 - - - 29 mean

De Vreede 2000 11 - (11) - 44 med.
RTx±5FU
Figueras 2000 8 - (8) RTx+5FU - -

Shimoda 2001 5 - - - -
Sudan 2002 11 - (11) BB+5FU 3 17 med.
Robles 2004 36 - - 3 55 cum.
Zheng 2005 5 - - 1 30 med.

LT for Cholangiocarcinoma
University of Essen: 1987-2006
Liver Transplantation n=19 Recipients
Sex: 11 male/ 8 female
Age: Mean 47 ± 2 (28-64 years)
Follow up: Mean 24,3 ± 0,92 (0,1-140,5 months)
ICC n=6
Klatskin n=9
CCC in PSC n=4
Cholangiocarcinoma
Liver Transplantation n = 19
Overall survival
1,0 1,0
0,9 0,9
0,8 0,8
0,7 0,7
Surviving
Surviving
0,6 0,6
0,5 0,5
0,4 0,4
0,3 0,3
0,2 0,2
0,1 0,1
0,0 0,0
0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120
Time (months) Time without hospital mortality (months)

Cholangiocarcinoma
Liver Transplantation n= 13 + 6 =19
2 series in 1: Early and Late
Early series: 1987 - 1998 n= 13/321( 4%)
Primary LTx: 1 stage procedure
CCC in PSC= 2/18
Late series: 1998 - 2006 n= 6/881 (0,68%)

Rescue LTx post resection: 2 stage procedure
LDLT for intention to treat cases
CCC in PSC=2/36
Cholangiocarcinoma
Liver Transplantation n= 13 + 6 =19
after 01.04.1998
before 01.04.1998
1,0 1,0
0,9 0,9
0,8 0,8
0,7 0,7
Surviving
Surviving
0,6 0,6
0,5 0,5
0,4 0,4
0,3 0,3
0,2 0,2
0,1 0,1
0,0 0,0
0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120
tumor free time (months) tumor free time without hospital mortality [months]

Cholangiocarcinoma
Liver Transplantation n = 19
n=6
Survival according to tumor type CCC
Klatskin n=9
PSC; CCC n=4
1,0 1,0
0,9 0,9
0,8 0,8
Surviving
Surviving
0,7 0,7
0,6 0,6
0,5 0,5
0,4 0,4
0,3 0,3
0,2 0,2
0,1 0,1
0,0 0,0
0 12 24 36 48 60 72 84 96 108 120 0 12 24 36 48 60 72 84 96 108 120
Time (months) Time without hospital mortality (months
p=0,234 p=0,357
Cholangiocarcinoma
Early diagnosis: Tumor Markers
Ca19-9 Cutoff value 129 U/l

Sensitivity 78,6 %
Specificity 98,5 %
Pos. Pred. Value 78,6 %
Change over time 63,2 U/l
p=0,0001
Levy C et al, Dig Dis & Sci 2005
Other Markers:
ERBB-2, COX-2
Endo K et al, Hepatology 2002
K-ras Kubicka S et al, Gut 2005
INK4a/ADP ARF…..?? Klump B et al, Clin Cancer Res 2003

CCC and LTx
- High recurrence rate also in T1-2 N0
- Low survival rates
- 1 year : 21% - 70%
- 2 years : 4% - 21 %
- 5 years : 0% - 18%
- Casavilla, J Am Coll Surg 1997

- Weimann, Br J Surg 2000

other than HCC
(HCC)
Hepatoblastoma
CCC
Stroma Tumors - Mesenchymal (Liver sarcoma)

Epitheliod Hemangioendithelioma
neuroendocrine (NE)
Metastatic tumors
non NE Colorectal
Epitheliod Hemangioendothelioma
Transplantation
Intermediate malignancy
Survival 2y 5y
80% 40%
Transplant also in presence of “limited” metastatic disease
Lafler et al Cancer 1996

Neoplasia non HCC: Stroma tumors
ALDLT - Essen n= 4
Wrong Pre-LTx *
diagnosis
Hemangioendothelioma
( Hemangioendothelioma ) -> Stroma T. G1 *
Liver Stroma Tumor (angiosarcoma)*
Met. Stroma Tumor - rectovaginal space
Follow-up 32,2 mos (11 mos - 4,4 yr)

Actual 1 yr survival 2/3 Overall 3/6
Quality of life: excellent!!

Cave pre-LT Diagnosis
Neoplasia non HCC: Stroma tumors
ALDLT - Essen n= 4
Wrong Pre-LTx *
diagnosis
Hemangioendothelioma AW 63 mo
( Hemangioendothelioma ) -> Stroma T. G1* AW 6 mo
Liver Stroma Tumor (angiosarcoma)* DWD 9 mo
Met. Stroma Tumor - rectovaginal space AWD 74 mo

Liver Transplantation for Non-Resectable Metastatic Liver Disease
Gastrointestinal Stromal
Tumors
GIST
 Favourable biological behaviour
 Prognostc parameters
-C-KIT mutations
 Liver metastases frequent
 Imatinib (Glivec) – adjuvant treatment
 One patient
-12 years tumor history
- 6 years after LDLT

A Surgeon,
when confronted with a problem

he cannot solve,
performs the operation he knows best
David B. Skinner MD
The Phemister Dallas Professor of Surgery

Colrectal Liver Metastases
Transplantation
Is orthotopic liver transplantation a feasible treatment for
secondary liver cancer of the liver ?
Mühlbacher F, Huck I, Steininger R et al.
Transplant. Proc. 1991, 23:1567 University Of Vienna
21 cases
High Recurrence/Mortality rate
Total 24 (30?) cases

Transplantation

Liver Transplantation for Non-Resectable Metastatic Liver
Disease
Hepatic Transplantation for Metastatic Cancer

Initial Experience
Autors Year Histology Number Survival

Muehlbacher 1987 Metastases- 16/60 1-year 68%, 2-year
Colorectal 10%
O´Grady 1987 Metastases 9/93 Median 3 Mo.
NET 2/93 7 Mo., 12 Mo.
Pichlmayer/ELTR 1988 Metastases 41/1218 2-year 14%
Ringe 1988 Metastases 9/95 Median 1.5 Mo.
Alsina 1990 NET 2 2-year 50%
Penn 1991 Metastases 32/637 2-year 38%
NET 9/637

Transplantation
*
*
LTx for
irresectable neuroendocrine (NE) liver
metastases
Indication :
Symptomatic Metastases
(neuroendrocrinological symptoms, pain, liver failure)
not responsive to conservative and surgical therapy

LTx for
irresectable neuroendocrine liver
metastases
Good symptomatic therapy

Long term palliation (5 yrs survival 82%*)
Often tumor recurrence (up to 80%)
Sometime curative
Lang H et al., Ann Surg 1997

*

LT for metastatic neuroendocrine tumors
Published single-center experiences with transplantation for metastatic
neuroendocrine tumors
Reference Year No. of Median 1-yr 5-yr Actual 5-yr

patients Follow-up survival survival Disease-free
(mo) (%) (%) survivors
Mount Sinai 2003 11 30 73 36 1
Olausson 2002 9 22 89 - 0
Rosenau 2002 19 38 89 80 3
Ringe 2001 5 22 80 - 0
Coppa 2001 9 39 100 70 -
Pascher 2000 4 42 100 50 1
Dousset 1996 9 29 33 33 0
Anthuber 1996 4 11 25 0 0
Alessiani 1995 14 - - - -
Routley 1995 11 - 82 57 -
Arnold 1989 4 30 50 - 0
Makowka 1989 5 32 60 - 0

 Pretransplant selection - Rationale

-Octreoscan
-Immunohistochemical parameters /
Ki67
 New surgical strategies

-LDLT
 New immunosuppressive drugs

-Antiproliferative effects
 Peptide receptor radiotherapy

Endocrine Liver Metastases

1992 - 2006
 146 Pts.
 34Pts.
evaluated
for OLT

Pretransplant Evaluation
 Standard pretransplant evaluation
 Octreoscan
 68Ga-DOTATOC-PET / CT
 Cardiac evaluation / Thoracic MRI
 Liver biopsy
- Ki67 > 10% negative predictor of
survival
 Exploratory laparotomy

Octreotide Scintigraphy scan

Carcinoid heart

Pretransplant Evaluation
- Results -
32 Pts.
Excluded Listed
11 21
10 extrahep.
1 died
tumor
1 waiting list
1 carcinoid heart

Results
 19 Patients transplanted
 11 Deceased donor OLT
 7 LDLT
 1 Cluster TX
 Liver weight 1.850g – 13.500g

(88% tumor)

Pt. Sex Age Tumor Clinical symptoms Primary tumor Treatment of LM

No. Y. site First degree resection before OLT
Chemotherapy
1 M 67 Bronchus Carcinoid syndrome Lung lobectomy
Octreotide
Chemotherapy
2 M 52 Bronchus Carcinoid syndrome Lung lobectomy
Octreotide
Adominal
3 F 59 Pancreas Distal pancreatectomy Octreotide
discomfort
Carcinoid syndrom
Upper abdominal Chemotherapy
4 M 37 Pancreas Abdominal
exenteration Octreotide
discomfort
5 F 44 Pancreas Diarrhoe Pancreatoduodenectomy Octreotide
Carcinoid syndrome Left hepatectomy
6 M 52 Colon Abdominal Right hemicolectomy Octreotide
discomfort Chemotherapy
Liver failure
7 M 46 Pancreas Abdominal Whipple- Procedure Chemotherapy
discomfort

Liver Transplantation for non-resectable metastatic liver disease
Pt. SEX Age Tumor site Clinical symptoms Primary tumor Treatment of LM before OLT
No. Y. First degree resection
8 F 42 Unknown Flush - Octreotide

Abdominal
discomfort
9 M 53 Pancreas Flush Subtotal pancreatectomy Chemotherapy
Abdominal Splenectomy Octreotide
discomfort Gastric resection Chemoembolisation
DOTATOC
10 M 47 Ileum Carcinoid syndrome Ileum resection Octreotide
Abdominal Alpha-Interferon
discomfort
11 M 48 Pancreas Carcinoid syndrome Distal pancreatectomy Chemotherapy
Abdominal Gastric resection Octreotide
discomfort Splenectomy Chemoembolisation
Colon resection
12 F 51 Pancreas Carcinoid syndrome Distal pancreatectomy Octreotide
13 M 52 Lung Carcinoid syndrome Lung lobectomy Octreotide
Abdominal
discomfort
14 M 46 Ileum Carcinoid syndrome Ileocolectomy Octreotide
Alpha-Interferon
15 F 51 Ileum Carcinoid syndrome Ileum resection Octreotide

Liver Transplantation for non-resectable metastatic liver disease
Pt. SEX Age Tumor Clinical symptoms Primary tumor Treatment of LM before OLT
No. Y. site First degree resection
16 F 42 Unknown Flush Carcinoid - Octreotide

syndrome
Abdominal
discomfort
17 F 53 Unknown Abdominal discomfort Pancreatico - Chemotherapy
Carcinoid syndrome duodenectomy Octreotide
Chemoembolisation
DOTATOC
18 M 47 Pancres Carcinoid syndrome Octreotide
Abdominal discomfort
19 F 48 Pancreas Carcinoid syndrome Subtotal pancreatectomy Chemotherapy

Abdominal Splenectomy Octreotide
discomfort

Postoperative Morbidity and
Mortality
Number of
patients
No complications 9
Re-transplantation 1
Morbidity
THA 1
Lymph fistula 1
Bile leakage 2
Mortality
Cardiac reasons 2
Sepsis, rejection 1
Sepsis 2
Tumor recurrence 1

Hamburg - Essen
Overall survival Tumor-free survival

Tumor-free survival

Tumor recurrence
- Invasive treatment -
Number of Localization Treatment

patients
1 Bone Resection
1 LN Resection
Disseminated 90
Y-DOTATOC
1 Bone 90
Y-DOTATOC
Disseminated


Conclusion
 Endocrine LM suitable for OLT
 High selection necessary
 Tumor-free 5-year survival low
 Excellent long-term palliation
 Aggressive approach for tumor

recurrence
 Radionuclide treatment
 GIST – further experience needed

other than HCC
General Survey
Organ allocation
Immunosuppression

other than HCC
Organ allocation
Fairness of allocation - Equal chance
Vs
Best utilization of (poor) resources

other than HCC
Organ allocation - USA
Sharma et al Liver Transplantation 2004
Freeman R Liver Transplantation 2004
No bonus for other tumors !

other than HCC
Organ allocation

other than HCC
Organ allocation

LDLT for HCC
Organ pool „independent“ from allocation
Optimal timing: no waiting time
Pre-selected organ quality
Donor risks!!
Recipients: suboptimal results in
- advanced tumors
- severe cirrhosis
Liver Transpl. 2001 7:9217

other than HCC
General Survey
Indications
Organ allocation
Immunosuppression

What‘s New
 New Molecules
 Immunosuppressive Strategies

What‘s New
Immunosuppressive drugs
QuickTimeª and a
TIFF (LZW) decompressor
Po st et al. Liver Tra nsp. No v 2005

Clinical Immunosuppression:
What‘s New, What‘s Hot
- Optimizing longterm outcomes

- Identification of new endpoints (organ
function, immune response, drug toxicity)
- Individualizing immunosuppression
Department of General Surgery and Transplantation,

University Hospital Essen, Germany
Immunosuppression and HCC recurrence
Vivarelli et al Liver transplantaion 2005

Immunosuppressive Drugs
Calcineurin nPHD Proliferation Antibody Other
inhibitors inhibitors signal
inhibitors
Novartis Cyclosporin MPA Everolimus Basiliximab FTY 720*
Fujisawa Tacrolimus FK 778*
Roche ISATx* MMF Daclizumab
Wyeth Sirolimus
Thymoglobulin
Genzyme
Alemtuzumab
BMS Belatacept*
Other Azathioprine ATGAM

OKT3
* product in development ** Off-label use (mostly in USA)

Individualized immunosuppression
- mTor inhibitor sirolimus (SRL) has antiproliferative and

anti-angiogenetic properties
- Advantage: usage for HCC - Tumor recipients → lower

incidence of reccurrence ?
- Disadvantage: delayed wound healing, higher

incidence of HAT
Department of General Surgery and Transplantation,

University Hospital Essen, Germany
Immunosuppression and tumor recurrence
Low CNI and Sirolimus - Edmonton
Milano vs Extended criteria
Kneteman N. et al. Liver Transplantation 2004
Extended Milan = single < 7.5 cm, multiple < 5 cm

Individualized immunosuppression
SILVER
A PROSPECTIVE RANDOMIZED, OPEN-LABELED TRIAL
COMPARING
SIROLIMUS-CONTAINING
VERSUS
mTOR-INHIBITOR-FREE IMMUNOSUPPRESSION
IN PATIENTS UNDERGOING LTX

FOR HEPATOCELLULAR CARCINOMA .

other than HCC
Conclusions
LTX for Liver malignancies: a double edge sword
Extremely rare and selected indications
Mesenchymal tumors (grade1-2) and NE metastases
Cholangiocellular - Adenoca. Metastases contraindications
LD (ECD?) as preferred modality
New drugs - new strategies of Immunosuppression
Biology and pathologic information needed: Investigation studies needed
IMPULSE TO EXPLORE NEW WAYS IN TRANSPLANT FO R

HEPATOBILIARY MALIGNANCIES
Conclusions
early/late overall
HCC + ± +
Hepatoblastoma + + + +
CCC + - -
Liver sarcoma - - -
Epitheliod Hemangioendithelioma + - ±
neuroendocrine + - ±
Metastatic tumors
non neuroendocrine - - -


Massimo Malago 2

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Liver transplantation in liver tumors

other than HCC

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Radicality, locoregional control

Radicality, locoregional control

In advanced secondary and primary

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

QuickTimeª and a QuickTimeª and a

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Cancers : 7318 Cirrhosis : 33845

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Maximal gain concept:

68- 83 86 89 92 95 98 2001 2004

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Extended criteria but not open end

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Zur Anzeige wird der QuickTimeª

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Zur Anzeige wird der QuickTimeª

Zur Anzeige wird der QuickTimeª

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Avoiding unnecessary transplantations

Stroma Tumors - Mesenchymal (Liver sarcoma)

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

ALDLT n=121 Cadaver LTx n=530

Mean F-up 28 mo.

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Non Tumor 632

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Otte et al Ped Transpl 2005

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Patients referred n=6

Not transplantable n=1

Liver resection n=4

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Intrahepatic (ICC or peripheral CC)

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Author/year n 1y 3y 5y median (mon.)

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Shimoda et al, Liver Transplantation 2001

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

LTx plus neoadjuvant therapy

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Concept: LTx alone

Pichlmayr et al,Ann Surg 1996