Progression of Hepatocellular Carcinoma Before Liver Transplantation: Dropout or Liver Transplantation?

Milan Criteria and UCSF Criteria: A Preliminary Comparative Study of Liver Transplantation Outcomes in the United States

“…Furthermore, while size-based criteria may be comparable and reproducible in pretreatment staging, they may not predict the biologic aggressiveness of the underlying HCC. Recent evaluation into expanded criteria both from the University of Pittsburgh and a European multicenter series suggests that pathologic characteristics, in particular tumor grade and microvascular invasion, may be more important determinants of recurrence-free survival than size criteria [11, 21, 22]. Additionally, biopsy samples provide the opportunity for genetic profiling and molecular analysis, which may shed further insight into the tumor's biology [14].…”

“…Current population based analyses and single institution series suggest drop-out rates of 12–18% secondary to tumor progression, while the intention to treat overall survival of all listed patients is approximately 50% [22, 25]. Patients exceeding Milan criteria do not receive prioritization in the current UNOS allocation system, thus limiting the ability to compare these two selection criteria objectively.…”

“…Given that population prediction models anticipate a 20% increase in candidates for transplantation with adoption of the UCSF criteria, the adoption of expanded criteria must be weighed heavily against the limited organ supply [26]. However, when one considers that the drop-off rate increases to 30–40% when Milan criteria are used as absolute criteria, further refinement seems warranted [22, 25]. …”

Liver transplantation for advanced hepatocellular carcinoma in patients with Child-Pugh A and B

“…However, in borderline decompensated cirrhotic CP B patients with advanced HCC, i.e., large tumors of ≥5 cm or multiple liver nodules, it may be beneficial to consider LDLT earlier, especially when considering the aforementioned excellent survival and recurrence rates after LDLT using the Kyoto criteria. Moreover, as the status of CP B changes to decompensation, approximately 53 % of the patients who meet the Milan criteria no longer meet the Milan criteria after 2 years [22,23]. In other words, these patients easily drop off the Milan criteria due to tumor progression when non-transplant conventional treatments are being repeatedly performed, each of which has its own morbidity and mortality risks, even in those with CP A/B cirrhosis [24].…”

Early Hepatocellular Carcinoma: Transplantation versus Resection: The Case for Liver Resection

“…In fact, the national median waiting times based on Organ Procurement and Transplantation Network (OPTN) data as of December 2010 range from 140 days for American Indians to 651 days for Hispanics [13], during which time patients may drop out because of tumor or comorbid progression, death, or other reasons. Depending on the time period, type of analysis, and dropout criteria [14], the 1-year dropout rate for patients with HCC awaiting liver transplantation ranges from 12% to 38% [14–18]. When these dropouts were considered in one of the first intention-to-treat analyses [19], the 2-year survival decreased significantly from 84% to 54%.…”