Expanded criteria for liver transplantation in patients with cirrhosis and hepatocellular carcinoma

Abstract

Orthotopic liver transplantation (OLT) selection for patients with hepatocellular carcinoma (HCC) is a matter of debate. The Milan criteria (MC) have been largely adopted by the international community. The main aim of this study was to evaluate the survival rates and recurrence probabilities of a new proposal for criteria (up to 3 tumors, each no larger than 5 cm, and a cumulative tumor burden Յ 10 cm). Patients with cirrhosis and HCC included on the waiting list (WL) from 1991 to 2006 were retrospectively analyzed. Outcomes in patients who had tumors within and beyond the MC were compared. The survival analysis was done (1) with the intention-to-treat principle and (2) among transplanted patients. A total of 281 patients were included in WL. Twenty-four cases did not undergo OLT (a dropout rate of 8.5%); all but 1 case had tumors within the MC. Of the 257 transplanted patients, 26 had tumors beyond the MC in the pre-OLT evaluation. Based on the intention-to-treat analysis, the 5-year survival was 56% versus 66% in patients who had tumors within and beyond the MC, respectively (P ϭ 0.487). Among transplanted patients, the 5-year survival was 62% versus 69%, respectively (P ϭ 0.734). Through multivariate analysis, microvascular invasion was an independent prognostic factor of poor survival (P ϭ 0.004). The recurrence probabilities at 1 and 5 years were 7% versus 12% and 14% versus 28% in patients with tumors within and beyond the MC, respectively (P ϭ 0.063). The multivariate analysis demonstrated that both poorly differentiated tumors (P Ͻ 0.001) and microvascular invasion (P Ͻ 0.001) increased the risk of recurrence. The expansion to up to 3 nodules, each up to 5 cm, and a cumulative tumor burden Յ 10 cm did not result in a reduction of survival in comparison with patients who had tumors within the MC.

Significance of Des-Gamma-Carboxy Prothrombin in Selection Criteria for Living Donor Liver Transplantation for Hepatocellular Carcinoma

“…However, few attempts have been made to properly clarify the usefulness of DCP as a predictor of HCC recurrence after OLT. In the field of transplantation as well as in other treatments, pathological findings such as portal invasion (23,(26)(27)(28)(29)(30)(31)(32) and poor differentiation of HCC (20,27,28,33) (35,36). The C-index for a cut-off point is defined as the area of the quadrilateral with vertices on the cut-off point on the ROC curve and points (0,0), (1,0) and (1,1) on the ROC graph.…”

The presence of bilobar tumor should be considered as a new limit for transplantation beyond the Milan criteria?

“…In Silva et al 22 paper, bilobar involvement and poor tumor differentiation were independent risk factors of radiological underestimation. Thus, histologic examination of HCC is desirable before LT as part of novel scoring systems to predict the risk of HCC recurrence.…”

Liver transplantation and expanded Milan criteria: does it really work?

“…P = pretransplant radiology; R = explant tumor pathology; NA = not available mor size and number) that can be determined by preoperative imaging, however, such criteria must consider the limitations of imaging studies (7,23,48,55,56,59,60) . The continued improvement in imaging techniques may decrease the gap between imaging and pathology of HCC, although some understanding will certainly continue to exist (53) . Silva et al (54) reported 281 cases of HCC in cirrhotic livers treated by OLT using a new criteria (up to three tumors, each no larger than 5 cm, and a cumulative tumor burden < 10 cm) with a 5-year survival rate of 57% based on the intention-to-treat principle.…”