Expanded criteria for liver transplantation in patients with hepatocellular carcinoma: a report from the International Registry of Hepatic Tumors in Liver Transplantation

Liver transplantation for colorectal liver metastases: revisiting the concept

Liver transplantation (Lt) for colorectal cancer (CRC) liver metastases is no more considered due to the poor outcome observed up to the 1990s. According to the European Liver Transplant Registry (ELTR), 1- and 5-year patient survival following Lt for CRC liver metastases performed prior to 1995 was 62% and 18%, respectively. However, 44% of graft loss or patient deaths were not related to tumor recurrence. Over the last 20 years there has been dramatic progress in patient survival after Lt, thus it could be anticipated that survival after Lt for CRC secondaries today would exceed from far, the outcome of the past experience. By utilizing new imaging techniques for proper patient selection, modern chemotherapy and aggressive multimodal treatment against metastases, long term survivors and even cure could be expected. Preliminary data from a pilot study show an overall survival rate of 94% after a median follow up of 25 months. While long term survival after the first Lt is 80% all indications confounded, 5-year survival after repeat Lt is no more than 50% to 55%. If patients transplanted for CRC secondaries can reach the latter survival rate, it could be difficult to discriminate them in the liver allocation system and live donation could be an option.

Model for End Stage Liver Disease and hepatocellular carcinoma: a moving target

The institution of the Model for End Stage Liver Disease (MELD) score has been a successful refinement to the allocation for cadaveric liver allografts. Likewise, transplantation for patients with hepatocellular carcinoma (HCC) within defined criteria (Milan) has been shown to be very efficacious. The placement of patients with HCC in the allocation scheme with a MELD exception score has been an ongoing process of adjustments. The most recent data would suggest that patients with HCC continue to benefit from enhanced access to transplantation compared with patients without HCC. Development of a continuous HCC score, similar to the MELD score, maybe a more consistent and impartial way to equate access to cadaveric liver allografts for candidates with HCC and those without HCC.

Report of a national conference on liver allocation in patients with hepatocellular carcinoma in the United States

A national conference was held to better characterize the long-term outcomes of liver transplantation (LT) for patients with hepatocellular carcinoma (HCC) and to assess whether it is justified to continue the policy of assigning increased priority for candidates with early-stage HCC on the transplant waiting list in the United States. The objectives of the conference were to address specific HCC issues as they relate to liver allocation, develop a standardized pathology report form for the assessment of the explanted liver, develop more specific imaging criteria for HCC designed to qualify LT candidates for automatic Model for End-Stage Liver Disease (MELD) exception points without the need for biopsy, and develop a standardized pretransplant imaging report form for the assessment of patients with liver lesions. At the completion of the meeting, there was agreement that the allocation policy should result in similar risks of removal from the waiting list and similar transplant rates for HCC and non-HCC candidates. In addition, the allocation policy should select HCC candidates so that there are similar posttransplant outcomes for HCC and non-HCC recipients. There was a general consensus for the development of a calculated continuous HCC priority score for ranking HCC candidates on the list that would incorporate the calculated MELD score, alpha-fetoprotein, tumor size, and rate of tumor growth. Only candidates with at least stage T2 tumors would receive additional HCC priority points.

Living donor liver transplantation for hepatocellular carcinoma: Increased recurrence but improved survival

In regions with a limited deceased donor pool, living donor adult liver transplantation (LDALT) has become an important treatment modality for patients with hepatocellular carcinoma (HCC) and cirrhosis. Studies have shown higher recurrence rates of HCC after LDALT in comparison with deceased donor liver transplantation (DDLT). The aim of our study was to examine the outcome results and recurrence rates for patients with HCC who underwent LDALT at our center. During an 8-year period, 139 patients underwent LDALT, of whom 28 (20.1%) had HCC in their explanted livers. The median follow-up was 40.8 months. The mean explant tumor size was 3.3 +/- 1.2, and the mean number of tumors was 1.5 +/- 0.8. Twenty-one patients (75%) had tumors within the Milan criteria, 5 patients had tumors outside the Milan criteria but within the University of California San Francisco (UCSF) criteria, and 2 patients were beyond the UCSF criteria. The overall 1- and 5-year patient and graft survival rates were 96% and 81%, respectively. Survival following LDALT was significantly better than survival following DDLT for HCC during the same time period (P = 0.02). Eight patients (28.6%) developed tumor recurrence. Poor differentiation of tumor cells was the most significant determinant of recurrence. Despite high recurrence rates of HCC following LDALT, overall 5-year survival appears to be excellent.

Liver transplantation for HCC: its role: Eastern and Western perspectives

Liver transplantation (LT) is the only treatment that offers a chance of cure for hepatocellular carcinoma (HCC) and the underlying liver cirrhosis simultaneously, but the availability of liver grafts and the aggressiveness of tumor recurrence are critical limiting factors of LT for patients with HCC. In most Asian countries, the serious shortage of deceased donors and the strong demand for LT has lead to the development of living-donor LT (LDLT) as a practical alternative replacing deceased-donor LT (DDLT). Grafts in Western countries are issued from DDLT and graft allocations are under the responsibilities of state agencies which apply strict rules based on the MELD (model for end-stage liver disease) score. Considering that HCC recurrence is the most common cause of post-transplant patient death, recipient candidates should be prudently selected through objectively established criteria. Points in addition to the MELD score can be allotted to patients with HCC providing that the HCC remains within the Milan criteria. The increasing number of LT candidates with HCC results in increasing waiting periods, which necessitate the consideration of pretransplant treatment of HCC, including partial liver resection. Both specific Western units and some Asian major LDLT centers have challenged the Milan criteria. The eligibility criteria of both DDLT and LDLT for HCC are likely to be expanded more than before, but this still requires further qualified risk-benefit analyses. The development of new effective treatment modalities before LT and for HCC recurrence might expand the selection criteria further without incurring an increased recurrence rate.

Significance of des-gamma-carboxy prothrombin in selection criteria for living donor liver transplantation for hepatocellular carcinoma

Des-gamma-carboxy prothrombin (DCP) levels reportedly correlate with histological features of hepatocellular carcinoma (HCC). We examined serum DCP as a predictor of HCC recurrence in 144 patients who underwent living donor liver transplantation. Receiver operating characteristics (ROC) analysis revealed superiority of DCP and AFP over preoperative tumor size or number for predicting recurrence. Multivariate analysis revealed tumor size >5 cm, > or =11 nodules, and DCP >400 mAU/mL as significant independent risk factors for recurrence. Incidence of microvascular invasion (62% vs. 27%, p = 0.0003) and poor differentiation (38% vs. 16%, p = 0.0087) were significantly higher for patients with DCP >400 mAU/mL than for patients with DCP < or =400 mAU/mL. In ROC analysis for patients with < or =10 nodules all < or =5 cm to predict recurrence, area under the curve was much higher for DCP than for AFP (0.84 vs. 0.69). Kyoto criteria were thus defined as < or =10 nodules all < or =5 cm, and DCP < or =400 mAU/mL. The 5-year recurrence rate for 28 patients beyond-Milan but within-Kyoto criteria was as excellent as that for 78 patients within-Milan criteria (3% vs. 7%). The preoperative DCP level offers additional information regarding histological features, and thus can greatly improve patient selection criteria when used with tumor bulk information.

Liver transplantation for hepatocellular carcinoma: Korean experience

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 <or=5 cm, number of lesions <or=6, 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.

Predictive factors of microvascular invasion in patients with hepatocellular carcinoma larger than 5 cm

BACKGROUND

Patients with hepatocellular carcinoma (HCC) who undergo liver resection and transplantation are predicted to have a poor outcome if the disease is associated with vascular invasion. This study aimed to identify preoperative predictors of microvascular invasion in patients with HCCs larger than 5 cm.

METHODS

From May 1992 to October 2005, 231 patients underwent curative hepatic resection for HCC. Of these, 96 patients had HCCs larger than 5 cm. Analysis was limited to patients without macroscopic vascular invasion (n = 65).

RESULTS

Multivariate analysis showed that patients with tumors larger than 7 cm and type 2 (single nodular type with extranodular growth) and type 3 (contiguous multinodular type formed by a cluster of small and contiguous nodules) tumors had an increased risk of microscopic vascular invasion. The overall incidence of microscopic vascular invasion was 46.2% (n = 30), but only 12.5% (2/16) in patients with type 1 tumors (single nodular type that is approximately round with a clear demarcation) measuring less than 7 cm.

CONCLUSION

Larger tumors (>7 cm) and type 2 and type 3 tumors are strong predictors of microvascular invasion in patients with HCCs larger than 5 cm.

Hepatocellular carcinoma and liver transplantation: a 12-year experience

BACKGROUND

Orthotopic liver transplantation (OLT) for patients with cirrhosis and concomitant hepatocellular carcinoma (HCC) in early stages is the treatment of choice, with an acceptable recurrence rate and excellent survival.

AIM

We sought to evaluate (1) the accuracy of preoperative imaging; (2) the impact of pre-OLT treatments on survival and recurrence; and (3) the influence of beyond Milan criteria selection on global outcomes.

METHODS

We studied a cohort of 65 patients with HCC among 300 consecutive OLTs over a single 12-year experience. We analyzed the overall outcomes of survival and recurrence, the accuracy of preoperative diagnosis and staging the influence of neoadjuvant treatment prior to OLT, and the effect on overall outcomes beyond the Milan criteria in our series.

RESULTS

The 65 transplants were performed for HCC, mostly in association with hepatitis C virus and alcoholic cirrhosis with HTP. At a mean follow-up of 40.32 months, the recurrence rate was 5.7% among the 61 HCC confirmed by histopathology. The overall survival was 30.07. Actuarial survivals at 1, 5, and 10 years were 82%, 77%, and 62%, respectively. Six retransplants occurred among the seven graft losses albeit with poor survival after the second graft. Most explants showed low pTNM stages with favorable microscopic features. Preoperative imaging tests failed to achieve an accurate diagnosis in 15.38% of the series. The role of alpha-fetoprotein (AFP) and hepatic biopsy was irrelevant. Unfavorable histopathologic factors predicted a greater recurrence rate, but had no influence on survival. Neither recurrence nor survival were modified by pre-OLT therapy.

CONCLUSIONS

In our series, AFP, hepatic biopsy, and pre-OLT treatment had limited roles. Radiological imaging techniques underestimated HCC staging and lead to a misdiagnosis to an expected degree. Despite these findings, this single institution experience with OLT for HCC showed excellent survivals with a low recurrence rate including cases of patients beyond the Milan criteria.

Liberal selection criteria for liver transplantation for hepatocellular carcinoma

Background

To help increase the number of transplants available for hepatocellular carcinoma in cirrhotic livers, this single-centre retrospective study compared the safety and feasibility of new, more liberal, selection criteria—no more than five tumours, with the largest tumour no greater than 5 cm (5/5 criteria)—with classical criteria.

Methods

Data from operations performed in 1990–2005 were extracted from preoperative radiological findings and postoperative specimen analyses, and four groups were constructed: Paul Brousse, Milan, University of California, San Francisco (UCSF) and 5/5 criteria. A fifth group comprised patients whose tumour load exceeded the 5/5 criteria. Survival and recurrence rates were compared.

Results

For the 110 patients in the study, survival rates (overall and disease-free) were 72·8 and 66·8 per cent at 5 and 10 years respectively, with a 5·5 per cent recurrence rate. The 5-year survival rate was 65, 77, 68 and 77 per cent for Paul Brousse, Milan, UCSF and 5/5 preoperative radiological criteria, with recurrence rates of 4, 4, 3 and 3 per cent, respectively. On multivariable analysis, the only factor that influenced survival was tumour load in excess of the 5/5 criteria.

Conclusion

Use of the more liberal 5/5 criteria for selecting patients for liver transplantation results in similar disease-free and overall survival rates to classical criteria.

Impact of des-gamma-carboxy prothrombin and tumor size on the recurrence of hepatocellular carcinoma after living donor liver transplantation

BACKGROUND

Because many patients who did not meet the Milan criteria have survived long after undergoing living donor liver transplantation (LDLT), extended criteria for recipient with hepatocellular carcinoma (HCC) are therefore considered to be necessary.

METHODS AND RESULTS

A total of 90 consecutive adult LDLT recipients with HCC between 1996 and 2007 were reviewed. The recurrence-free survival rates of all 90 patients were 86.0%, 81.3%, and 81.3% at 1, 3, and 5 years, respectively. Fourteen of 90 patients developed a recurrence of tumor after the LDLT. The tumor recurrences were diagnosed within 1 year after the LDLT in 11 (78.6%) patients. In a multivariate analysis, both the tumor size of less than 5 cm (P=0.0202) and the des-gamma-carboxy prothrombin (DCP) level of less than 300 mAU/mL (P=0.0001) were found to be favorable independent factors for the recurrence of HCC after LDLT. Therefore, the authors devised new selection criteria for HCC patients (a tumor size of <5 cm or a DCP of <300 mAU/mL). The 1-, 3-, and 5-year overall or recurrence-free survival rates of the 85 patients who met the new criteria were 92.3%, 85.9%, and 82.7%, or 90.5%, 87.0%, and 87.0%, respectively, which were significantly different from those of the five patients who did not meet the new criteria (P<0.0001).

CONCLUSIONS

A combination of two factors, namely the tumor size and the DCP level, was found to be useful for expanding the selection of LDLT candidates for HCC.

Modern diagnosis and management of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is rising, and the number of patients with HCC is expected to more than double over the next 1 to 2 decades. HCC meets the criteria for establishment of a surveillance program. Patients with cirrhosis, regardless of the cause, are at the highest risk for developing HCC and this is the population in which surveillance should be performed. (Alpha-fetoprotein and hepatic ultrasonography are the currently recommended surveillance tests. If a surveillance test is abnormal, there is a need for a recall test for diagnostic evaluation of HCC. Triple-phase imaging is recommended for evaluation at recall, with MRI being more sensitive and specific. Novel genetic markers can improve the histologic diagnosis of early HCC. The Barcelona staging classification is the best system for determining the prognosis of patients and it is linked to an evidence-based treatment algorithm. Resection, transplantation, and percutaneous ablation are considered curative interventions and are currently applied to about 30% of all patients with HCC.

The estimated number of patients with hepatocellular carcinoma selected for liver transplantation using expanded selection criteria

Recently, several groups have introduced expanded criteria for selection of patients with hepatocellular carcinoma (HCC) prior to transplant, but the exact number of potential newly recruited patients remains unclear. This registry-based study assessed 270 patients diagnosed with HCC. The potential number of transplant candidates was based on age (< or =65 years), absence of metastases and macro-vascular invasion, and on 12 previously published, expanded selection criteria. A wide range of increase in the number of transplant candidates was observed (12-63% when compared with the number of such candidates who would have been selected solely based on the Milan criteria). The most conservative criteria were Seoul (Kwon, 2007; increase of 12%), Valencia (Silva, 2008; 16%), total tumor volume/alpha-fetoprotein (Toso, 2009; 20%) and UCSF (Yao, 2007; 20%). This data will assist Centers and policy agencies in predicting the need for resources linked to an expansion of criteria.

Sirolimus-based immunosuppression therapy in liver transplantation for patients with hepatocellular carcinoma exceeding the Milan criteria

AIM

Sirolimus (SRL) acts as a primary immunosuppressant or antitumor agent. The aim of the present study was to evaluate the influence of SRL on the recurrence rate and survival of patients after orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) exceeding the Milan criteria.

MATERIALS AND METHODS

We retrospectively examined 73 consecutive patients who underwent OLT for HCC exceeding the Milan criteria from March 2004 through December 2005. Among them, 27 patients were treated with SRL-based immunosuppressive protocols after OLT, and 46 patients by an FK506-based protocol. Statistical analysis was based on the intent-to-treat method.

RESULTS

The 2 groups were comparable in all clinicopathologic parameters. The mean overall survival was 594 +/- 35 days in the SRL group and 480 +/- 42 days in the FK506 group (P = .011); the mean disease-free survival period was 519 +/- 43 days in the SRL group and 477 +/- 48 days in the FK506 group (P = .234). Multivariate analysis revealed Child's status (P = .004) and immunosuppressive protocol (P = .015) were the significant factors affecting overall survival. Only microvascular invasion (P = .004) was significantly associated with disease-free survival. Among 24 surviving patient in the SRL group, 2 patients had SRL discontinued for toxicity; 10 had SRL monotherapy immunosuppression.

CONCLUSION

The SRL-based immunosuppressive protocol improved the overall survival of patients after OLT for HCC exceeding the Milan criteria, probably by postponing recurrence and with better tolerability.

Management of hepatocellular carcinoma in the age of liver transplantation

Hepatocellular carcinoma is one of the most frequently encountered malignancies worldwide. Its association with cirrhosis increases the difficulty of diagnosis and therapy. Different approaches, ranging from medical treatment to highly complex ablative and surgical therapies, including liver resection and transplantation have significantly improved the outcome of this disease. This article reviews the current diagnostic challenges and the available surveillance and classification protocols. Available therapeutic approaches, indications, contraindications and outcome of liver resection, liver transplantation, living donor liver transplantation, are outlined in detail. Ablative procedures and their role and efficiency as "bridging" methods to liver transplantation are included in the review.

Multislice computed tomography using a triple-phase contrast protocol for preoperative assessment of hepatic tumor load in patients with hepatocellular carcinoma before liver transplantation

For evaluation of triple-phase multislice computed tomography (CT) for assessment of hepatocellular carcinoma (HCC) before liver transplantation. All HCC patients who underwent liver transplantation at our institution between 2001 and 2006 and had contrast-enhanced abdominal 4-/16-slice CT [unenhanced, arterial (20 s delay), portal venous (40 s), and venous (80 s) scan] within 100 days before transplantation were enrolled retrospectively. CT data were reviewed by two observers. Results were correlated to histopathologic findings by means of a lesion-by-lesion evaluation. Thirty-two patients with 76 HCC-lesions were included. The lesion-based sensitivity of observer 1 and 2 was 78% (59/76) and 83% (63/76) (false positives, n = 6 and n = 10). The sensitivity of observer 1/2 was 89%/95% for lesions >20 mm (n = 37), 94% for lesions 11-20 mm (n = 18), and 43%/53% for lesions <10 mm (n = 21). The mean detection rates of unenhanced, arterial, portal venous, and venous phase scans were 30%, 74%, 59%, and 40%. All detected lesions were visible on arterial and/or portal venous scans (arterial only, 24%; portal venous only, 9%). Arterial and portal venous phase scans are the strongest contributors to the high detection rate of triple-phase multislice-CT in HCC. However, the detection of small HCC measuring <10 mm and false positive findings remains a challenge.

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

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 </= 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 = 0.487). Among transplanted patients, the 5-year survival was 62% versus 69%, respectively (P = 0.734). Through multivariate analysis, microvascular invasion was an independent prognostic factor of poor survival (P = 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 = 0.063). The multivariate analysis demonstrated that both poorly differentiated tumors (P < 0.001) and microvascular invasion (P < 0.001) increased the risk of recurrence. The expansion to up to 3 nodules, each up to 5 cm, and a cumulative tumor burden </= 10 cm did not result in a reduction of survival in comparison with patients who had tumors within the MC.

Liver transplantation for hepatocellular carcinoma: beyond the Milan criteria

Liver transplantation represents a cornerstone in the management of early-stage hepatocellular carcinoma (HCC). Expansion beyond the Milan criteria for liver transplantation (1 lesion <or= 5 cm, or 2 to 3 lesions each <or= 3 cm) remains controversial. This review covers several key areas: (1) Recent developments and published data on expanded criteria for deceased donor and live-donor liver transplantation, with emphasis on criteria that have been applied to preoperative imaging. (2) Independent testing of expanded criteria, where published data are largely limited to the proposed University of California, San Francisco criteria (1 lesion <or= 6.5 cm, 2-3 lesions each <or= 4.5 cm with total tumor diameter <or= 8 cm). (3) Response to loco-regional therapy and tumor downstaging. (4) The fundamental questions and answers in resolving the controversy over expanded criteria. The key issue pertains to whether acceptable outcome can be achieved on a broader scale beyond single center experience, which appears to support modest expansion beyond the Milan criteria. The foundation of the debate over expanded criteria may rest upon what the transplant community would consider to be the acceptable threshold for patient survival using expanded criteria, without causing significant harm to other transplant candidates without HCC.

[Liver transplant in patients with hepatocellular carcinoma]

Liver transplant in patients with cirrhosis and hepatocellular carcinoma is indicated in the early stages of the disease, which can be achieved with early detection programs using liver ultrasound. Dynamic imaging techniques (ultrasound with contrast, magnetic resonance and tomography) are essential in the diagnosis of this tumour, being able to type the lesion clearly, and, in the majority of cases, lead to the therapy to follow. Surgery is the treatment of choice in these patients, and liver transplant, from a theoretical point of view, is the best. Currently, the size and number of nodes play an important role in the indication of a transplant. The best liver transplant results are obtained in these patients using the Milan criteria, with survivals that exceed 70% and recurrence indices of 15%, at 5 years. Nowadays we have the possibility of using neo-adjuvant treatments to transplant, such as arterial chemoembolisation, percutaneous ablation techniques, and even liver resection as a bridging technique. The survival of patients transplanted due to liver cancer is similar to that obtained for other non-tumour diseases. In Spain it is 1, 3 and 5 years and 82%, 70% and 60%, respectively. The recurrence is between 6.4% and 16%, micro- and macrovascular invasion being its highest risk variable.

Hepatocellular carcinoma: Defining the place of surgery in an era of organ shortage

Liver resection (LR) and transplantation offer the only potential chance of cure for patients with hepatocellular carcinoma (HCC). Historically, all patients were treated by hepatic resection. With the advent of liver transplantation (LT) patients with HCC were preferentially placed on the waiting list for LT. However, early experience with LT was associated with a high rate of tumour recurrence and poor long-term survival. The increasing scarcity of donor livers resulted in restrictions being placed on tumour size, and an improvement in patient survival. To date there have been no randomised clinical trials comparing LR to LT. We review the evidence supporting LR and/or LT for HCC and discuss the role of neoadjuvant therapy. The decision of whether to resect or transplant remains debatable and is often determined by centre experience, availability of LT and donor organs.

Expanded indication criteria of living donor liver transplantation for hepatocellular carcinoma at one large-volume center

The currently available indication criteria of living donor liver transplantation (LDLT) for patients with hepatocellular carcinoma (HCC) have high prognostic power but insufficient discriminatory power. On the basis of single-center results from 221 HCC patients undergoing LDLT, we modified the indication criteria for LDLT to expand recipient selection without increasing the posttransplant recurrence of HCC. Our expanded criteria, based on explant pathology, were largest tumor diameter < or = 5 cm, HCC number < or = 6, and no gross vascular invasion. One hundred eighty-six of the 221 HCC patients (84.2%) met our criteria, 10% and 5.5% more than those that met the Milan and University of California at San Francisco (UCSF) criteria, respectively. The overall 5-year patient survival rates were 76.0% and 44.5% within and beyond the Milan criteria, respectively; 75.9% and 36.4% within and beyond the UCSF criteria, respectively; and 76.3% and 18.9% within and beyond our expanded criteria, respectively. Although these 3 sets of criteria had similar prognostic power, our expanded criteria had the highest discriminatory power. Thus, these expanded criteria for LDLT eligibility of HCC patients broaden the indications for patient selection and can more accurately identify patients who will benefit from LDLT.

Liver transplantation: an update 2008

PURPOSE OF REVIEW

Expansion of the donor pool for liver transplantation is a priority. Management of hepatitis C and hepatocellular carcinoma has focused on decreasing recurrence rates after transplantation.

RECENT FINDINGS

Expansion of the pool of donors has focused on live donor liver transplantation and extended criteria donor grafts. The results of live donor liver transplantation are equivalent to those of deceased donor liver transplantation. The use of extended criteria donor grafts has increased significantly. The results are associated with decreased graft survival with the use of grafts that have multiple factors considered as extended criteria for transplantation, particularly in high-risk individuals such as critically ill recipients. Judicious matching of extended criteria donors with recipients is essential to reduce waiting list mortality without reducing posttransplantation survival. The role of pretransplant ablation therapy for hepatocellular carcinoma is evolving to reduce tumor progression and dropout on the list as well as to influence posttransplant recurrence rates. Antiviral and immunosuppressive strategies in reducing the severity of hepatitis C virus recurrence are discussed as is retransplantation for the disease.

SUMMARY

Expansion of the donor pool with the use of extended criteria donors and live donor liver transplantation is a major challenge. Transplantation for hepatocellular carcinoma and hepatitis C virus relapse are major areas of research.

Indications for liver transplantation

Patients should be considered for liver transplantation if they have evidence of fulminant hepatic failure, a life-threatening systemic complication of liver disease, or a liver-based metabolic defect or, more commonly, cirrhosis with complications such as hepatic encephalopathy, ascites, hepatocellular carcinoma, hepatorenal syndrome, or bleeding caused by portal hypertension. While the complications of cirrhosis can often be managed relatively effectively, they indicate a change in the natural history of the disease that should lead to consideration of liver transplantation. Referral to a liver transplant center is followed by a detailed medical evaluation to ensure that transplantation is technically feasible, medically appropriate, and in the best interest of both the patient and society. Patients approved for transplantation are placed on a national transplant list, although donor organs are allocated locally and regionally. Since 2002, priority for transplantation has been determined by the Model of End-Stage Liver Disease (MELD) score, which provides donor organs to listed patients with the highest estimated short-term mortality.

Hepatocellular carcinoma: latest developments

PURPOSE OF REVIEW

This review primarily focuses on new developments in the field of hepatocellular carcinoma.

RECENT FINDINGS

Potential preventive strategies in the development of hepatocellular carcinoma are being recognized. Novel molecular markers identified may aid in the diagnosis of early hepatocellular carcinoma in patients with chronic hepatitis C virus. Prognostic information gained by preoperative tumor biopsy is being investigated. Treatment of early hepatocellular carcinoma with resection versus primary or salvage transplantation continues to be debated. Expansion of selection criteria beyond the Milan criteria appears feasible. The role of living donor liver transplantation in hepatocellular carcinoma will require further study to determine the risk of recurrence. Improvements in chemoembolization with drug eluting beads appear promising.

SUMMARY

Further insight into the pathogenesis of hepatocellular carcinoma will result in the continued evolution of our approach and management of the disease. Tailored therapies based on tumor biology are needed to improve treatment response and ultimately patient survival.

A novel model measuring the harm of transplanting hepatocellular carcinoma exceeding Milan criteria

No empirical studies have defined the posttransplant survival that would justify expansion of the Milan criteria for liver transplantation of hepatocellular carcinoma. We created a Markov model comparing the survival benefit of transplantation for a patient with >Milan HCC, versus the harm caused to other patients on the waiting list. In the base-case analysis, the strategy of transplanting the patient with >Milan HCC resulted in a 44% increased risk of death and a utility loss of 3 quality-adjusted years of life across the pre- and posttransplant periods for a nationally representative cohort of patients on the waiting list. This harm outweighed the benefit of transplantation for a patient with >Milan HCC having a 5-year posttransplant survival of less than 61%. This survival threshold was most sensitive to geographic variations in organ shortage, with the threshold varying from 25% (Region 3) to >72% (Regions 1, 5, 7 and 9). In conclusion, expansion of the Milan criteria will require demonstrating high survival rates for the newly eligible patients-approximately 61% at 5 years after transplantation. In regions with less severe organ shortage, a more aggressive approach to transplanting these patients may be justified.

Hepatocarcinoma in viral and metabolic liver disease

It is becoming increasingly evident that children, like adults, with chronic viral or metabolic liver diseases are at risk for the development of hepatocarcinoma. The aims of this article are to review the risk factors for hepatocarcinoma in chronic viral or metabolic liver disease, outline potential pathogenic mechanisms of hepatocarcinoma, and describe surveillance strategies, clinical evaluation, and management of hepatocarcinoma in children.

Liver transplantation in patients with hepatocellular carcinoma across Milan criteria

Milan criteria are the most frequently used limits for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC), but our previous experience with expanded criteria showed encouraging results. The aim of this study was to investigate whether our expanded Clinica Universitaria de Navarra (CUN) criteria (1 nodule up to 6 cm or 2-3 nodules up to 5 cm each) could be used to select patients with HCC for LT. Eighty-five patients with HCC fulfilling CUN criteria were included as candidates for LT. Survival of transplanted HCC patients was compared with survival of patients without HCC (n = 180). After the exclusion of 2 patients with tumor seeding of the chest wall due to pre-LT tumor biopsy, survival and recurrence rates were compared according to tumor staging. Twenty-six out of 85 (30%) patients exceeded Milan criteria. Twelve patients had tumor progression on the waiting list. Patients exceeding Milan criteria had a higher dropout rate due to tumoral progression. One-, 3-, 5-, 7-, and 10-year survival rates of the 73 transplanted HCC patients were 86%, 74%, 70%, 61%, and 50%, respectively. Survival of patients with HCC was significantly lower than that of patients without HCC, but by multivariate analysis, HCC was not associated with lower survival. Tumor recurrence and survival rates were similar for patients fulfilling Milan and CUN criteria. Pathological staging showed 55 patients within Milan criteria, 7 patients exceeding them but within CUN criteria, and 9 patients exceeding CUN criteria. Tumor recurrence rates were 2/55 (4%), 0/7 (0%), and 4/9 (44%) in each of these groups, respectively. In conclusion, following CUN criteria could increase the number of HCC patients who could benefit from LT, without worsening the results. Because of the short number of patients in this series, these data need external validation.

Liver transplantation criteria for hepatocellular carcinoma should be expanded: a 22-year experience with 467 patients at UCLA

OBJECTIVE

To assess the efficacy of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) and the impact of current staging criteria on long term survival.

SUMMARY BACKGROUND DATA

HCC is becoming an increasingly common indication for OLT. Medicare approves OLT only for HCCs meeting the Milan criteria, thus limiting OLT for an expanding pool of potential liver recipients. We analyzed our experience with OLT for HCC to determine if expansion of criteria for OLT for HCC is warranted.

METHODS

: All patients undergoing OLT for HCC from 1984 to 2006 were evaluated. Outcomes were compared for patients who met Milan criteria (single tumor < opr =5 cm, maximum of 3 total tumors with none >3 cm), University of California, San Francisco (UCSF) criteria (single tumor <6.5 cm, maximum of 3 total tumors with none >4.5 cm, and cumulative tumor size <8 cm), or exceeded UCSF criteria.

RESULTS

A total of 467 transplants were performed for HCC. At mean follow up of 6.6 +/- 0.9 years, recurrence rate was 21.2%, and overall 1, 3, and 5-year survival was 82%, 65%, and 52%, respectively. Patients meeting Milan criteria had similar 5-year post-transplant survival to patients meeting UCSF criteria by preoperative imaging (79% vs. 64%; P = 0.061) and explant pathology (86% vs. 71%; P = 0.057). Survival for patients with tumors beyond UCSF criteria was significantly lower and was below 50% at 5 years. Multivariate analysis showed that tumor number (P < 0.001), lymphovascular invasion (P < 0.001), and poor differentiation (P = 0.002) independently predicted poor survival.

CONCLUSIONS

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.

Management of hepatocellular carcinoma

Hepatocellular carcinoma is the fifth most common cancer in the world and is the third cause of cancer-related death with varying prevalence according to endemic risk factors. Despite therapeutic advances, there has not been significant improvement in the overall survival of patients who have hepatocellular cancer in the last 2 decades. Treatment selection should be based on tumor characteristics and the underlying liver disease.