Article

Liver transplantation for hepatocellular carcinoma: beyond the Milan criteria.

Division of Gastroenterology, University of California, San Francisco, CA 94143-0538, USA.
American Journal of Transplantation (Impact Factor: 6.19). 09/2008; 8(10):1982-9. DOI: 10.1111/j.1600-6143.2008.02351.x
Source: PubMed

ABSTRACT Liver transplantation represents a cornerstone in the management of early-stage hepatocellular carcinoma (HCC). Expansion beyond the Milan criteria for liver transplantation (1 lesion <or= 5 cm, or 2 to 3 lesions each <or= 3 cm) remains controversial. This review covers several key areas: (1) Recent developments and published data on expanded criteria for deceased donor and live-donor liver transplantation, with emphasis on criteria that have been applied to preoperative imaging. (2) Independent testing of expanded criteria, where published data are largely limited to the proposed University of California, San Francisco criteria (1 lesion <or= 6.5 cm, 2-3 lesions each <or= 4.5 cm with total tumor diameter <or= 8 cm). (3) Response to loco-regional therapy and tumor downstaging. (4) The fundamental questions and answers in resolving the controversy over expanded criteria. The key issue pertains to whether acceptable outcome can be achieved on a broader scale beyond single center experience, which appears to support modest expansion beyond the Milan criteria. The foundation of the debate over expanded criteria may rest upon what the transplant community would consider to be the acceptable threshold for patient survival using expanded criteria, without causing significant harm to other transplant candidates without HCC.

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    European Journal of Gastroenterology & Hepatology 12/2014; 27(3). DOI:10.1097/MEG.0000000000000272
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    ABSTRACT: To identify prognostic factors after hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT). We retrospectively reviewed the combined experience at Toronto General Hospital and Hospital Vall d'Hebron managing HCC recurrence after LT (n = 121) between 2000 and 2012. We analyzed prognostic factors by uni- and multi-variate analysis. Median follow-up from LT was 29.5 (range 2-129.4) months. Median follow-up from HCC recurrence was 12.2 (range 0.1-112.5) months. At recurrence, 31.4 % were treated with curative-intent treatments (surgery or ablation), 42.1 % received palliative treatment, and 26.4 % received best supportive care. The 1-, 3-, and 5-year survivals, respectively, after HCC recurrence were 75, 60, and 31 %, vs. 60, 19, and 12 %, vs. 52, 4, and 5 % (p < 0.001). By multivariate analysis, not being amenable to a curative-intent treatment [hazard ratio (HR) 4.7, 95 % confidence interval (CI) 2.7-8.3, p < 0.001], α-fetoprotein of ≥100 ng/mL at the time of HCC recurrence (HR 2.1, 95 % CI 1.3-2.3, p = 0.002) and early recurrence (<12 months) after LT (HR 1.6, 95 % CI 1.1-2.5, p = 0.03) were found to be poor prognosis factors. A prognostic score was devised on the basis of these three independent variables. Patients were divided into three groups, as follows: good prognosis, 0 points (n = 22); moderate prognosis, 1 or 2 points (n = 84); and poor prognosis, 3 points (n = 15). The 1-, 3-, and 5-year actuarial survival for each group was 91, 50, and 50 %, vs. 52, 7, and 2 %, vs. 13, 0, and 0 %, respectively (p < 0.001). Patients with HCC recurrence after transplant amenable to curative-intent treatments can experience significant long-term survival (~50 % at 5 years), so aggressive management should be offered. Poor prognosis factors after recurrence are not being amenable to a curative-intent treatment, α-fetoprotein of ≥100 ng/mL, and early (<1 year) recurrence after LT.
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