HCC in Living Donor Liver Transplantation: Can We Expand the Milan Criteria?

Abstract

Background: The tumor biology of hepatocellular carcinoma (HCC) affects recurrence after liver transplantation (LT), but most selection guidelines are based only on tumor size and number. The aim of the study is to evaluate the possibility of expanding the selection criteria in living donor LT (LDLT) without compromising patient survival by adding α-fetoprotein (AFP) in selection guideline. Methods: One hundred thirty-nine patients who received LDLT with the diagnosis of HCC and survived more than 3 months were enrolled. The operability was based on Milan criteria but LT beyond the criteria was performed when requested by the patients and/or the guardian after thorough explanation. Results: The median follow-up duration was 28 months. One-, three- and five-year survival rates were 92.2, 82.6, and 79.9%. There was no survival difference between patients within or beyond Milan (p = 0.76). Serum AFP level >400 ng/ml, tumor size >5 cm, and vascular invasion were significant on univariate analysis, but only vascular invasion was significant on multivariate analysis (p = 0.007). Patients with >3 tumor nodules had better survival compared to ≤3 nodules (p = 0.196). Patient selection using tumor size ≤5 cm and AFP ≤400 ng/ml without limitation of tumor numbers could expand patient selection and improve patient survival. Conclusion: Application of serum AFP level to selection of HCC for LT affords better patient selection criteria.

The impact of waiting list alpha-fetoprotein changes on the outcome of liver transplant for hepatocellular carcinoma

“…In an effort to assess the impact of AFP changes, patients were grouped according to AFP at listing and at transplantation, and to whether they were within or beyond the cut-off level of 400 ng/ml. This cut-off was chosen from previous studies [4,18,20,24]. Four groups were created and intent-to-treat survival was first assessed ( Fig.…”

“…Velocity variables were negative (showing an improvement) or positive (showing a worsening). For some analyses, previously published cut-offs of 400 ng/ml for AFP and 115 cm 3 for TTV were used [4,[17][18][19][20][21].…”

Hong Kong Consensus Recommendations on the Management of Hepatocellular Carcinoma

“…A growing number of cohort studies have shown that survival outcomes of transplant patients chosen under the UCSF criteria are comparable to that for Milan-qualified patients [34,35,36]. Other groups have proposed their own versions of expanded criteria [37,38,39,40,41], but the survival outcomes reported for patients chosen under these have yet to be validated in larger cohorts.…”

Role of Organ Transplantation in the Treatment of Malignancies – Hepatocellular Carcinoma as the Most Common Tumour Treated with Transplantation

“…Ito et al reported that in patients with HCC focus number ≤10, tumour size ≤5 cm, and desgamma-carboxy-prothrombin level ≤400 mAU (arbitrary units)/ml (Kyoto criteria), the 5-year patient survival after LDLT is 86.7%, while in patients with HCC exceeding these criteria 5-year patient survival was 34% only [35,65]. Many Asian centres use their selfdeveloped criteria [35,[66][67][68][69][70]. Western countries are also open to change.…”