We suggest that HIV-infected patients must be offered the same liver transplant options for hepatocellular carcinoma treatment currently provided to HIV-uninfected subjects.
—Fabrizio Di Benedetto, MD, PhD, and colleagues
Liver transplantation for hepatocellular carcinoma is feasible for HIV-infected patients, with no differences in post-transplant survival or hepatocellular carcinoma recurrence rates compared with liver transplantation for hepatocellular carcinoma in HIV-uninfected patients. The study, published in The Oncologist,1 was led by Fabrizio Di Benedetto, MD, PhD, Associate Professor of Surgery, University of Modena and Reggio Emilia, Modena, Italy, and represents the largest multicenter study of liver transplant for hepatocellular carcinoma in HIV-infected patients to date.
Matter of Debate
Patients infected with HIV experience a more aggressive course of hepatocellular carcinoma, in part due to the tumor-enhancing effects of HIV proteins, including increased growth signaling and diminished antitumor immune response. Moreover, as highly active antiretroviral therapy (HAART) prolongs the life expectancy of HIV-infected patients, the progression of underlying liver disease toward hepatocellular carcinoma is increasingly a major cause of morbidity and mortality in this patient population. Liver transplantation for hepatocellular carcinoma in HIV-infected patients is a recent indication, and its viability as a treatment option has been a matter of debate.
In the current study, researchers evaluated post-transplant outcomes in 30 HIV-positive patients and 125 HIV-uninfected patients who underwent liver transplantation for hepatocellular carcinoma at three transplantation centers in northern Italy between 2004 and 2009. Two patients in the HIV-positive cohort (6.7%) and 18 uninfected patients (14.4%) experienced a recurrence of hepatocellular carcinoma during the follow-up period of approximately 32 months (P = .15). Overall survival was similar for HIV-infected and -uninfected patients at 1 year (77% vs 86.4%) and 3 years (65% vs 70%), respectively, after liver transplantation (P = .32).
“The key message of this study is that liver transplantation is a valid option for hepatocellular carcinoma treatment in HIV-infected patients,” Dr. Di Benedetto and colleagues wrote. “We suggest that HIV-infected patients must be offered the same liver transplant options for hepatocellular carcinoma treatment currently provided to HIV-uninfected subjects.”
All HIV-infected patients were given HAART until liver transplantation, and antiviral therapy was discontinued only until liver function stabilized. No patients developed AIDS-defining events during the follow-up period, which the study authors attributed to early HAART resumption following transplantation. In particular, ritonavir-boosted protease inhibitor therapy appeared to induce more rapid increases in immunosuppressive drug serum levels than unboosted protease inhibitor therapy, and is the preferred HAART regimen.
In the future, new options for antiviral therapy may further improve HIV control and post-transplantation outcomes in HIV-infected patients undergoing liver transplantation for hepatocellular carcinoma.
The transplantation centers used a multidisciplinary approach to patient care that included input from oncologists, radiologists, gastroenterologists, liver surgeons, and infectious disease specialists. Dr. Di Benedetto and colleagues urged clinicians to adopt a similar collaborative approach to optimize outcomes for HIV-infected patients undergoing liver transplantation for hepatocellular carcinoma. ■
Disclosure: The study authors reported no potential conflicts of interest.
1. Di Benedetto F, Tarantino G, Ercolani G, et al: Multicenter Italian experience in liver transplantation for hepatocellular carcinoma in HIV-infected patients. Oncologist. May 10, 2013 (early release online).