Liver transplantation for hepatocellular carcinoma: Korean experience

Abstract

Hepatocellular carcinoma (HCC) is the second most common cause of male cancer death in Korea, where the major etiology, chronic hepatitis B virus infection, is endemic. With a high incidence of unresectable HCCs and a low cadaveric organ donation rate, the number of adult living-donor liver transplantations (LDLTs) has increased rapidly, by tenfold, over the past 10 years, as an alternative to deceased-donor liver transplantation (DDLT) in Asia, including Korea. Currently, HCC accounts for more than 40% of the indications for adult LDLT as the associated decompensation cirrhosis or unresectable HCC with 2.8% perioperative mortality at our institute. In determining eligibility for LDLT, the Milan criteria, which have a major aim of reducing the wastage of cadaveric liver grafts, still remain the gold standard. Our published results with 168 adult LDLTs show no difference from the results with DDLT for HCC that meets the Milan criteria. However, since a substantial proportion of adult LDLT patients not fulfilling the Milan criteria have been found to survive for longer than expected, and because a live donor organ is a private gift, most LDLT programs in Korea accept HCC patients beyond the Milan criteria, and the reported 3-year survival rates for such patients are approximately 63%. Our new proposal for expanded criteria (Asan criteria; tumor diameter B5 cm, number of lesions B6, no gross vascular invasion) in LDLT has focused on extending the number limits but keeping the maximum tumor size at 5 cm, because even modest expansion of tumor size limits beyond the Milan criteria adversely affected survival. The overall 5-year patient survival rates were 76.3 and only 18.9% within and beyond the Asan criteria, respectively; these criteria broaden the indications for patient selection and can more accurately identify patients who will benefit from LDLT than the conventional Milan criteria and the University of California at San Francisco criteria. In Asia, where the option for DDLT is minimal or negligible, LDLT with the modest expanded selection criteria will continue to provide a chance of long-term survival for some patients with advanced HCC.

Liver Transplantation for Advanced Hepatocellular Carcinoma

“…59 The correlation between PET positivity and poor outcomes after LT has been validated in many studies subsequently. [62][63][64][65][66][67][68] In particular, patients beyond the Milan criteria but with negative PET status could have good overall and recurrence-free survivals comparable to those within the Milan criteria. 65,67 However, PET has not been integrated into candidate selection process for LT for HCC yet.…”

Living vs. deceased-donor liver transplantation for patients with hepatocellular carcinoma

“…Kornberg et al (51) reported that tumor uptake of 18 F-FDG on preoperative PET scans is significantly associated with tumor grade as well as with microvascular invasion on explant pathology in recipients with HCC, and Lee et al (52) reported that 18 F-FDG-PET is a significant predictor of tumor recurrence in liver transplantation. NLR, which is a simple index of systemic inflammation, has been reported to be associated with prognosis in patients with various kinds of malignancies, including HCC (53,54).…”

Should the liver transplant criteria for hepatocellular carcinoma be different for deceased donation and living donation?

“…Thus, in Asia, many LDLT programs accept patients with HCC beyond the Milan criteria for LDLT because they view a living donor organ as a private gift and the reported 3-year survival rates for such patients are higher than 50%. [11][12][13][14] In North America, it is also considered ethically acceptable to use LDLT and DDLT for the treatment of patients with HCC tumors beyond the Milan criteria, particularly when the tumors have been successfully down-staged before transplantation 15 or the recipients do not have unfavorable biological markers such as an alpha-fetoprotein level greater than >1000 ng/mL. 16 The prognosis for patients with HCC with highly unfavorable factors (eg, macroscopic vascular invasion) is very poor, so these patients are poor candidates for either DDLT or LDLT outside clinical trials.…”

“…16 The prognosis for patients with HCC with highly unfavorable factors (eg, macroscopic vascular invasion) is very poor, so these patients are poor candidates for either DDLT or LDLT outside clinical trials. 11,17,18 Are there reasons to be cautious about preferentially or only offering LDLT for HCC? Yes, there are.…”