Liver Transplantation Criteria For Hepatocellular Carcinoma Should Be Expanded

Abstract

This largest single institution experience with OLT for HCC demonstrates prolonged survival after liver transplantation for tumors beyond Milan criteria but within UCSF criteria, both when classified by preoperative imaging and by explant pathology. Measured expansion of OLT criteria is justified for tumors not exceeding the UCSF criteria.

Milan criteria in liver transplantation for hepatocellular carcinoma: An evidence-based analysis of 15 years of experience

“…For patients not meeting the MC, the rates of mVI and grade 3 and 4 tumors significantly increase (35%-56% and 38%-50%, respectively). 26,48 Similar rates of histological markers of tumor aggressiveness and poor prognoses have been detected in patients slightly exceeding the MC, such as patients meeting the University of California San Francisco criteria, 52,84 even though a significant proportion of patients meeting the University of California San Francisco criteria are meeting the MC as well. 24,34,47,51 We identified 10 studies 16,18,26,28,47,48,51,52,63,72 reporting frequency data for mVI and tumor grades in patients meeting or not meeting the MC, and a meta-analysis of the odds ratios was performed accordingly (Fig.…”

“…In this respect, the MC remain the benchmark for any other prognostic criteria proposed for expanding the use of LT in patients with cirrhosis and HCC. 24,40,80 or >1000 ng/mL 12,18,51 Up-to-7 criteria met 21,26 Tumor size >3 cm, 36 12,30,33 Total tumor volume >28 cm 3 35 or >115 cm 3 24 Total tumor diameter >8 cm 12,42 Bilobar nodules 66 Multiple nodules 52,71,76 Nodule number >3 25,26 and 13 level 2b studies 27,30,33,34,36,39,40,42,47,48,[51][52][53] have confirmed the likelihood of detecting mVI, grade 3 tumors, and microsatellites as the tumor size and number increase beyond the MC. In patients with HCCs meeting the MC, mVI is detected at a rate of 10% to 15%, poorly differentiated tumors are detected at a rate of 13% to 33%, and microsatellites are detected at a rate of 7% to 28%.…”

Evaluation of Patients With Hepatocellular Carcinomas That Do Not Produce α-Fetoprotein

“…[1][2][3] The prioritization of LT recipients with HCC by use of the Model for End-Stage Liver Disease (MELD) allocation system [4][5][6] has resulted in LTs for HCCs now accounting for nearly 25% of all transplants in the United States. 7 Despite continuous refinements in the HCC MELD exception policy, LT recipients with HCC continue to be overprioritized compared with patients with liver failure who do not have cancer, with many studies revealing higher transplant rates despite lower risks of waitlist dropout and inferior survival.…”

Living Donor Liver Transplantation Outcomes for Hepatocellular Carcinoma Beyond Milan or UCSF Criteria

“…Although the UCSF criteria have been shown to be associated with a longterm survival similar to the Milan criteria [23][24][25], little is known with regard to the outcomes of patients with HCC that exceed the UCSF criteria. In one of the largest series, Duff et al reported a 3-year survival of 83 % for those that met the UCSF criteria and 48 % for those exceeded the UCSF criteria [20]. A large series from an LDLT center showed that the overall 5-year survival rate, including perioperative mortalities, was 75.9 % for those that met the UCSF criteria and was 36.4 % for those exceeded the UCSF criteria.…”

“…In another study that involved deceased donor liver transplantation (DDLT), Duffy et al reported a 3-year survival of 89 % for patients with HCC that met the Milan criteria and 83 % for those that met the UCSF criteria [20]. Khashayar et al found a 5-year survival rate of 87.1 % for patients with HCC that met the Milan criteria versus 80 % for patients with tumors exceeded the Milan criteria, but met the UCSF criteria [18].…”