Assignment of liver allocation priority for hepatocellular carcinoma is predicated on accurate imaging staging. We analyzed radiographically defined stage (radiologic stage [RS]) at listing and most recent extension and pathologic stage (PS) data from 789 liver transplant recipients for whom no pretransplant ablative treatment was given. There were no predetermined imaging or pathological protocols in this retrospective analysis of wait list data. Seventy-two (9.1%), 690 (87.5%), and 27 (3.4%) were listed as stage 1, 2 and Ͼ2, respectively. Computed tomography (CT) scan alone (46.4%), magnetic resonance image scan alone (37.1%), ultrasound alone (1.3%), and multiple imaging studies (15.2%) were used with no difference in time to transplant for listing or most recent scan among the recipient groups. Overall accuracy (RS ϭ PS) was 44.1% and was not different if original listing RS or most recent RS was used for comparison with PS. No one type of imaging technique had superior accuracy (P ϭ 0.13); however, CT scan used alone or in combination compared to not being used at all, had higher odds of being accurate (odds ratio [OR] See Editorial on Page 1445Liver transplantation for early-stage hepatocellular carcinoma (HCC) is more likely to provide a potential cure and improve survival than other less radical techniques. 1 These excellent results for liver transplantation depend on selection of patients with early, favorable-stage disease. Mazzafero et al. indicated that patients with single tumors less than 5 cm in size or 3 or fewer tumors no larger than 3 cm in size have excellent long-term recurrence-free survival. 2 This staging was based on histologic criteria evaluated in the explanted native liver retrospectively. Although this report summarized relatively few cases, many subsequent reports have confirmed that these so-called Milan criteria consistently identify HCC disease with favorable prognosis after liver transplantation. 3,4 How-

The incidence of hepatocellular carcinoma (HCC), a frequent and incurable complication of cirrhosis, continues to rise. Orthotopic liver transplantation (OLT) has been proposed as a treatment for unresectable, intrahepatic HCC limited in extent to the Milan criteria adopted by the United Network of Organ Sharing (UNOS) in 1998. More recently, somewhat less restrictive University of California, San Francisco (UCSF) 10 , criteria were proposed. To examine the long-term outcomes of OLT for HCC patients and to assess the UNOS policy of assigning weighted allocation points to patients with HCC, we retrospectively analyzed 144 patients (113 after 1998) with HCC who underwent OLT over an 11-year period at 3 institutions from UNOS Region 1. We compared their outcomes with 525 patients (272 after 1998) who underwent OLT for nonmalignant liver disease. The 1-and 5-year survival rates were 80.3% and 46.7%, respectively, for patients with HCC and 81.5% and 70.6%, respectively, for patients without HCC (P ‫؍‬ .020). However, there was no difference in survival between HCC and non-HCC patients after implementation of disease-specific allocation for HCC in 1998. A higher proportion of the HCC cohort was older and male and had chronic HCV infection and alcoholic liver disease. In univariate analysis, having alpha-fetoprotein (AFP) levels of 10 ng/mL or less and meeting clinical and pathologic UCSF criteria were each significant predictors of improved survival (P ‫؍‬ .005, P ‫؍‬ .02, and P ‫؍‬ .03, respectively). AFP greater than 10 ng/mL and exceeding pathologic UCSF criteria were also significant predictors of recurrence (P ‫؍‬ .003 and P ‫؍‬ .02, respectively). In conclusion, taken together, our data suggest that OLT is an acceptable option for patients with early HCC and that UCSF criteria predict outcome better than Milan or UNOS criteria. Regardless of which criteria are adopted to define eligibility, strict adherence to the criteria is important to achieve acceptable outcomes.

Skin cancer is a well-recognized long-term complication of transplantation and immunosuppression. Although risk factors for the development of skin cancer in the general population are well defined, risk factors for the development of these lesions have not been identified clearly in the liver transplant population. We surveyed 151 liver transplant (LTx) recipients for risk factors associated with cutaneous malignancies in the general population. Variables included were: demographics, primary liver disease, severity of disease at LTx, immunosuppression history, complexion, hair color, eye color, tanning profile, number of moles, occupational history, sun exposure history, sunburn history, family history of skin cancer, and any history of removed skin lesions. All skin cancers were confirmed histologically. There were 86 documented skin cancers in 34 patients: 56 squamous cell, 23 basal cell and 7 melanomas. Median follow-up was 1490 days. In a univariate analysis, age, male gender, red hair, brown eyes, primary sclerosing cholangitis (PSC), primary biliary cirrhosis (protective), cyclosporine, number of second degree sunburns, and frequent lifetime sun exposure were associated with the development of new skin cancers. In a multivariate model, age, male gender, red hair, brown eyes, PSC, and cyclosporine remain the strongest predictors. The incidence of skin cancer after liver transplantation is underestimated. In particular, there is a higher incidence of squamous cell carcinoma compared with the general population. Recipients with identified risk factors may be candidates for prophylactic treatment and should be followed more intensively after liver transplantation. (Liver TranspZ2002;8:939-944.) T he incide,nce of skin cancer in the general population continues to rise, with more than 1.3 million cases of nonmelanoma skin cancer expected to occur in the United States alone this year.l Risk factors for skin cancer in the general population are well known and include exposure to ultraviolet radiation, sun exposure during childhood, a history of second degree sunburns, the tendency to sunburn easily, fair complexion, blonde or red hair, blue or hazel eyes, occupational exposure, and outdoor Skin cancer is the most common malignancy occurring after solid organ transplantation, with the incidence as high as 35% to 70% at 20 years in parts of the world in which sun exposure is more common.3 The incidence after liver transplantation (LTx) specifically has been reported at 1.6% to 2.2?40415 in two studies with a mean follow-up ranging between 35 and 77.8 months, but there are few published reports, and the length of follow-up in these studies is limited compared with the extensive longterm data in renal transplant patients. In addition, these studies often rely on retrospectively collected singlecenter data or composite registry data, information that patients may not provide spontaneously without specific direct questioning. Although skin cancer is a wellrecognized long-term complication of transplantation and immuno...

Seizures may occur after orthotopic liver transplantation. Antiepileptic drugs (AEDs) are used to treat these seizures, but the immunosuppressant regimen also may be altered. Levetiracetam is an attractive treatment because of its efficacy, lack of hepatic enzyme induction, and its rapid attainment of serum levels. Treatment with levetiracetam is efficacious, and levetiracetam-treated patients require significantly lower doses of immunosuppressant medications to achieve an equivalent antirejection effect.