Should we expand the criteria for liver transplantation for hepatocellular carcinoma--yes, of course!

Malatya and Other Criteria for Liver Transplantation in Hepatocellular Carcinoma

PURPOSE

Liver transplantation is a curative treatment option for hepatocellular carcinoma. In this review, we aimed to review liver transplantation criteria for hepatocellular carcinoma and patient survivals.

METHODS

We reviewed literature in terms of liver transplant criteria for hepatocellular carcinoma. Patient eligibility criteria, post-transplant survivals, tumor recurrence and expansion of Milan criteria rates were analyzed.

RESULTS

The Milan criteria, after being published in 1996, have become for deceased donor liver transplantation in hepatocellular carcinoma worldwide. Later, many transplant centers published their own liver transplant criteria. Most of the criteria consisted of morphological tumor characteristics based on tumor size and number. The newest published one is Malatya criteria. The 5-year overall survival according the all of the criteria is greater than 50%. There were just one paper which compare criteria according to survival and Malatya criteria were the best amongst extended criteria with 5-year OS 79.7% in that study.

CONCLUSION

It is clear that morphological criteria consisting only of tumor size and number are insufficient in patient selection for liver transplantation and should thus be combined with biological, inflammatory, radiological, pathological and genetic markers that predict the biological behavior of the tumor. Efforts to find the best criteria are still ongoing and 5-year overall survival should be greater than 60%.

Liver transplantation for hepatocellular carcinoma with live donors or extended criteria donors: a propensity score-matched comparison

Background

To compare patient survival after liver transplantation (LT) for hepatocellular carcinoma (HCC) from live donors (LD) or extended criteria donors (ECD).

Methods

Data from consecutive LT procedures for HCC involving either LD or ECD were reviewed. Patient survival was our primary outcome. Re-transplantation (Re-LT), ischemic type bile lesions (ITBL), and tumor recurrence represented secondary outcomes. The primary outcome was statistically analyzed using Kaplan-Meier estimates and Cox proportional hazards regression; logistic regression analyses were used for statistical analysis of the secondary outcomes. Propensity score was calculated based on patient age, sex, hepatitis C viral infection (HCV), laboratory model for end-stage liver disease (labMELD) score, bridging treatment, Milan criteria, α-fetoprotein levels, and tumor grade.

Results

The study evaluated 109 recipients undergoing LT from either LD (n=57) or ECD (n=52). LT procedure (hazard ratio [HR] 2.349, 95% confidence interval [CI] 1.151-4.794, P=0.0190), age (HR 1.075, 95%CI 1.020-1.133, P=0.0074) and labMELD score (HR 1.082, 95%CI 1.021-1.147, P=0.0075) reached significance by Cox proportional hazards regression. After adjustment with the propensity score (stratification with 5 strata), the LT procedure was still significant (HR 2.401, 95%CI 1.114-5.175, P=0.0253). Tumor grade (odds ratio [OR] 9.628, 95%CI 1.120-82.752, P=0.0391), labMELD score (OR 1.224, 95%CI 1.019-1.471, P=0.0306), and Milan criteria (OR 6.375, 95%CI 1.239-32.796, P=0.0267) gained statistical significance by logistic regression analysis for Re-LT, ITBL, and tumor recurrence, respectively.

Conclusions

LT for HCC showed superior patient survival with ECD rather than LD grafts. Re-LT, ITBL, and tumor recurrence showed no significant differences between the two groups. However, the diverging criteria for the definition of ECD grafts represent a considerable limitation for the wide application of this policy.

Liver transplantation for hepatocellular carcinoma within the Milan criteria versus the University of California San Francisco criteria: a comparative study

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Currently, liver transplantation (LT) for HCC is the only hope for cure from the tumor and from end-stage liver disease (ESLD). The organ pool shortage in deceased donor LT and the donor-related ethical concerns in living-donor LT necessitate the use of rigorous criteria for LT for HCC. In this respect, two main criteria for LT for HCC were implemented with good outcome, namely, the Milan and the University of California San Francisco criteria. Comparison of the outcome of LT for HCC using either of the two criteria has seldom been reported in the literature.

PATIENTS AND METHODS

Eighty-eight patients underwent LT between August 2003 and end of July 2013 for the presence of pathologically proven pure HCC lesions at our institution. Cases of pediatric LT or liver retransplantation were excluded from this study. Cases with mixed HCC and cholangiocarcinoma were excluded from this study.

RESULTS

Eighty-eight patients underwent LT between August 2003 and July 2013 for the presence of pathologically proven pure HCC lesions at our institution. The mean follow-up duration was 45±30.9 months. HCC recurrence was related significantly to the presence of vascular invasion and degree of differentiation of HCC lesion (P value of 0.0001 and 0.001, respectively).

CONCLUSION

Patient and tumor free survival did not differ significantly between patients within Milan or University of California San Francisco criteria or beyond both criteria. Vascular invasion and poor differentiation are still the most influential factors for post-transplant long-term outcomes in HCC patients.

Current challenges in liver transplantation for hepatocellular carcinoma

Liver transplantation (LT) is the best option of cure for hepatocellular carcinoma (HCC). Notwithstanding several alternatives, Milan Criteria remain the cornerstone for patient selection. Currently, expanded criteria patients are unsuitable for LT without taking downstaging approaches and response to therapies into consideration. Relative weight of HCC as indication to LT is increasing and that generates competition with MELD-described non-cancer indications. Allocation policies should be adjusted accordingly, considering principles of urgency and utility in the management of the waiting list and including transplant benefit to craft equitable criteria to deal with the limited resource of donated grafts. Maximization of cost-effectiveness of LT in HCC can be also pursued through changes in immunosuppression policies and multimodal management of post-transplant recurrences. This review is focused on those constantly mutating challenges that have to be faced by anyone dealing with the management of HCC in the context of liver transplantation.

Liver Transplantation for HCC: A Review

Hepatocellular carcinoma (HCC) often occurs in patients with chronic liver disease or cirrhosis. Liver transplantation for hepatocellular carcinoma has the potential to eliminate both the tumor as well as the underlying cirrhosis and is the ideal treatment for HCC in cirrhotic liver as well as massive HCC in noncirrhotic liver. Limitations in organ availability, necessitate stringent selection of patients who would likely to derive most benefit. Selection criteria have considered tumor size, number, volume as well as biological features. The Milan criteria set the benchmark for tumors that would benefit from liver transplantation but were found to be excessively restrictive. Modest expansion in criteria has also been shown to be associated with equivalent survival. Microvascular invasion is the single most important adverse prognostic factor for survival. Living donor liver transplantation has expanded donor options and has the advantage of lower waiting period and not impacting the non-HCC waiting list. Acceptable outcomes have been obtained with living donor liver transplantation for larger and more numerous tumors in the absence of microvascular invasion. Downstaging of tumors to prevent progression while waiting for an organ or for reduction in size to allow enrolment for transplantation has met with variable success.

FOXM1 expression predicts the prognosis in hepatocellular carcinoma patients after orthotopic liver transplantation combined with the Milan criteria

Molecular biomarker has been proposed to improve patient selection and post-transplant prognostication, but rare achievement has been made. In the present study, Forkhead box M1 (FOXM1) expression and its prognostic role have been investigated in hepatocellular carcinoma (HCC) treated by orthotopic liver transplantation (OLT). We found that the notably higher level of FOXM1 in tumors was associated with malignant pathological features of HCC and unfavorable outcome after OLT. The status of FOXM1 expression combined with the Milan criteria could make the prognostication more accurate and may be of particular interest for expanding the criteria in selecting transplant candidates.

Current controversies surrounding liver transplantation for hepatocellular carcinoma

Liver transplantation (LT) for hepatocellular carcinoma (HCC) has progressed rapidly over the last decade from a futile therapy to the first choice therapy for suitable patients. Excellent outcomes of LT for HCC can be largely attributed to the use of the Milan Criteria, which have restricted LT to patients with early stage tumors. These criteria may be conservative, and it is likely that a subset of patients with tumors beyond these criteria can have acceptable outcomes. However, there is currently insufficient data to accept more liberal criteria as a standard of care, and a higher quality evidence base must be achieved to prevent poor utilization of valuable donor liver resources. In the future, it is probable that more sophisticated selection criteria will emerge incorporating aspects of tumor biology beyond tumor size and number. Dropout from the waiting list due to tumor progression remains a clinical challenge particularly in regions with prolonged waiting times. Priority allocation using HCC MELD points is a practical and transparent solution that has successfully reduced waitlist dropout for HCC patients. Further refinements of the HCC MELD point system are required to ensure equity of access to LT for non-HCC patients and prioritization of HCC patients with the highest risk of dropout. Improving the evidence base for pre-LT locoregional therapy to prevent waitlist dropout is an urgent and difficult challenge for the LT community. In the interim transplant clinicians must restrict the use of these therapies to those patients who are most likely to benefit from them.

Beyond Milan criteria--chances and risks of expanding transplantation criteria for HCC patients with liver cirrhosis

Orthotopic liver transplantation (OLT) is, apart from resection, one important curative treatment for hepatocellular carcinoma (HCC) in liver cirrhosis, and especially attractive because it eliminates both the tumor and the underlying liver disease. The application of restrictive inclusion criteria for OLT in HCC patients resulted in favorable long-term recurrence-free survival. These criteria, however, exclude a subgroup of patients which, despite advanced tumor size, demonstrate an acceptable outcome. As a consequence, expansion of the strict Milan criteria has been discussed. However, this will also deteriorate the average outcome of OLT in HCC patients. Considering that we run short of donor organs, more sophisticated prediction models for survival after OLT for HCC patients are needed to identify patients who benefit best from OLT. Neoadjuvant treatment that is frequently applied as a bridging technique for patients on the waiting list for OLT could provide useful information on tumor behavior to better predict the risk of post-OLT tumor recurrence. This might also allow expansion of the Milan criteria to patients with good response to downstaging methods without negatively affecting post-OLT survival. Furthermore, alternative scoring systems have been suggested to identify HCC patients that might still benefit from resection instead of OLT, and molecular tools are being explored to provide predictive information on HCC biology. This review discusses the advantages and risks of extended inclusion criteria for OLT and the currently available data on alternative prediction models and bridging methods in HCC patients.

[Local therapy for hepatocellular carcinoma as a bridge to liver transplantation]

OBJECTIVE

To analyze the results of pre-operative local therapy for hepatocellular carcinoma in patients who were subjected to liver transplantation.

METHODS

Cadaveric and living-related liver transplants done in cirrotic patients with hepatocellular carcinoma within the Milan criteria were included. The nodules were analyzed according to its number and diameter before and after the institution of the local therapy and on the explant evaluation.

RESULTS

22 patients with 31 nodules that measured 28.8+/-12 mm in diameter were included. They were subjected to 21 sessions of percutaneous ethanol injection and 29 sessions of transarterial chemoembolization. After the local therapy, 29 nodules that measured 24.6+/-12 mm in diameter were detected. All of them were within the Milan criteria and there was no difference compared to the diameter before the treatment. The patients were subjected to 17 cadaveric and 5 living-related liver transplantations. In six cases the tumors exceeded the Milan criteria on the explant evaluation: 4 due to its number and 2 due to its diameter. Sixteen cases were within the criteria and there were 14 neoplastic nodules with 30+/-14 mm in diameter. In these cases no difference was observed compared to the diameter before and after the local therapy.

CONCLUSION

Local therapy for hepatocellular carcinoma with percutaneous ethanol injection and transarterial chemoembolization partially controlled tumor evolution considering the Milan criteria in patients waiting for liver transplantation. Significant differences were observed in terms of the Milan criteria on pre-operative examination compared to the explant evaluation.

Stereotactic Radiotherapy of the Liver: A Bridge to Transplantation

Patients with hepatocellular carcinoma (HCC) have limited curative therapeutic options. In North America, liver transplantation is one of the most commonly used curative therapies. Many potential transplant patients will be treated with another therapeutic modality to prevent local disease progression while awaiting organ donation.

We present the case of 60-years old male diagnosed with HCC and awaiting liver transplantation. Prior to registration on the transplant list, the patient had a significant increase of his serum alpha-fetoprotein level. Due to his vascular anatomy and tumor location, he was not a candidate for more standard local ablative therapies. He was thus offered stereotactic radiotherapy as a bridge to liver transplantation. He received 50Gy in 5 fractions using respiratory gating. Following this, he had a complete radiological and serological response without worsening of his baseline Child-Pugh class C cirrhosis. Following transplant, 13 months later, pathological examination of the liver explant revealed only scarring at the site of radiation. This case illustrated the fact that hepatic stereotactic radiotherapy is a promising and safe treatment for patients with HCC. In selected patients, it can be a bridge to transplantation and, on its own, has the potential to induce complete pathological response in non-surgical candidates.

A disease-based comparison of liver transplantation outcomes

An increasing demand for transplant donor organs has made optimal allocation of resources a priority. Our objective was to evaluate outcomes for orthotopic liver transplantation (OLT) performed in the United States. A query of the United Network for Organ Sharing registry between 1988 and 2007 was performed for patients who underwent OLT for all etiologies. Patients were stratified by pathology necessitating OLT and clinical and pathologic factors were compared. Multivariate Cox-regression analysis was used to assess the association of pathology with survival. Of 61,823 patients, 33 per cent (n = 20,305) of OLTs were secondary to hepatitis C virus, 21 per cent autoimmune disease, 17 per cent alcohol-induced injury, 11 per cent cryptogenic cirrhosis, 8 per cent hepatocellular carcinoma (HCC), 6 per cent hepatitis B virus, and 4 per cent metabolic disease. Patients with autoimmune disease and HCC demonstrated the best and worst survival, respectively, after OLT (median survival 16.0 vs 6.4 yrs, respectively, P < 0.001). By multivariate analysis, OLT for HCC was significantly associated with poorer overall survival (hazard ratio [HR] 2.19, 95% confidence interval [CI]: 2.02-2.37, P < 0.001). Our results indicate that outcomes for liver transplantation vary by primary hepatic pathology with HCC patients having the poorest overall survival. To optimize organ allocation for all patients with end-stage liver disease, a better understanding of poor survival for HCC is necessary.

A diagnostic paradigm for resectable liver lesions: to biopsy or not to biopsy?

BACKGROUND

Despite a growing body of evidence reporting the deleterious mechanical and oncological complications of biopsy of hepatic malignancy, a small but significant number of patients undergo the procedure prior to specialist surgical referral. Biopsy has been shown to result in poorer longterm survival following resection and advances in modern imaging modalities provide equivalent, or better, diagnostic accuracy.

METHODS

The literature relating to needle-tract seeding of primary and secondary liver cancers was reviewed. MEDLINE, EMBASE and the Cochrane Library were searched for case reports and series relating to the oncological complications of biopsy of liver malignancies. Current non-invasive diagnostic modalities are reviewed and their diagnostic accuracy presented.

RESULTS

Biopsy of malignant liver lesions has been shown to result in poorer longterm survival following resection and does not confer any diagnostic advantage over a combination of non-invasive imaging techniques and serum tumour markers.

CONCLUSIONS

Given that chemotherapeutic advances now often permit downstaging and subsequent resection of 'unresectable' disease, the time has come to abandon biopsy of solid lesions outside the setting of a specialist multi-disciplinary team meeting (MDT).

Liver transplantation, liver resection, and transarterial chemoembolization for hepatocellular carcinoma in cirrhosis: which is the best oncological approach?

The aim of the study was to evaluate our institutional experience with monotherapies for hepatocellular carcinoma (HCC) in the setting of cirrhosis. A retrospective cohort study was carried out at the tertiary care academic referral center and involved 185 consecutive HCC patients with cirrhosis and no previous treatment who underwent resection (n = 61), transarterial chemoembolization (TACE) (n = 64), or liver transplantation (LT) (n = 60). Long-term survival and survival according to the Milan criteria were the main outcomes measured. Median survival after resection, TACE, and LT was 11, 14, and 23 months, respectively. Five-year cumulative survival after resection, TACE, and LT was 23, 10, and 59%, respectively (P = 0.001). Five-year cumulative disease-free survival after resection and LT was 15% and 77%, respectively (P = 0.002). The presence of complications in the resection group (P = 0.004), MELD score (P = 0.0003), and maximum tumor diameter (P = 0.05) in the TACE group, and tumor grade (P = 0.01) and complications (P = 0.004) in the LT group were found to be independent predictors of survival. Five-year survival for patients within the Milan criteria after resection, TACE, and LT was 26, 37, and 66%, respectively. Five-year survival for patients outside the Milan criteria for patients undergoing LT was 53%. The results suggest that LT represents the best oncological treatment option for patients with HCC in the setting of cirrhosis, even for those beyond the Milan criteria. Considering the scarcity of available organs, liver resection remains the best alternative option. TACE remains a potential therapy in patients within the Milan criteria, where it may be more beneficial than resection.

Liberal policy in living donor liver transplantation for hepatocellular carcinoma: lessons learned

BACKGROUND

Living donor liver transplantation (LDLT) in cases of hepatocellular carcinoma (HCC) that do not fulfil accepted tumor criteria continues to be a matter of controversy. The aim of this study was to evaluate survival and prognostic factors associated with a liberal exclusionary policy.

MATERIAL AND METHODS

This is an analysis of data collected prospectively on 57 HCC patients who underwent LDLT at our institution between April 1998 and January 2007.

RESULTS

Overall 3-year survival was 62%; this increased to 71% when 45-day mortality was excluded from the analysis. Age proved to be a predictor of survival irrespective of the 45-day mortality. In contrast, the Model for End stage Liver Disease (MELD) score predicted survival only when 45-day mortality was included in the analysis, while alpha fetoprotein (AFP) level predicted survival only when it was excluded. Significant cut-off values were patient age of over 60 years, MELD score above 22, and AFP level greater than 400 ng/ml. A scoring system was developed. Survival rate at 3 years--including 45-day mortality--was 72% for score =2 and 41% for score >2 (P = 0.0146). When 45-day mortality was excluded, the survival rate at 3 years was 90% for score =2 and 32% for score >2 (P = 0.00002).

CONCLUSIONS

Our results could further enhance current guidelines on age, MELD score, and AFP level for patients with HCC being evaluated to undergo LDLT.

Liver transplantation for hepatocellular carcinoma: results of down-staging in patients initially outside the Milan selection criteria

Conventional criteria for liver transplantation for patients with hepatocellular carcinoma are single HCC <or= 5 cm or less than or equal to three HCCs <or= 3 cm. We prospectively evaluated the possibility of slightly extending these criteria in a down-staging protocol, which included patients initially outside conventional criteria: single HCC 5-6 cm or two HCCs <or= 5 cm or less than six HCCs <or= 4 cm and sum diameter <or= 12 cm, but within Milan criteria in the active tumors after the down-staging procedures. The outcome of patients down-staged was compared to that of Milan criteria after liver transplantation and since the first evaluation according to an intention-to-treat principle. From 2003 to 2006, 177 patients with HCC were considered for transplantation: the transplantation rate was comparable between the Milan and down-staging groups: 88/129 cases (68%) versus 32/48 cases (67%), respectively. At a median follow-up of 2.5 years after transplantation, the 1 and 3 years' disease-free survival rates were comparable: 80% and 71% in the Milan group versus 78% and 71% in the down-staging. The actuarial intention-to-treat survival was 27/48 patients (56.3%) in the down-staging and 81/129 cases (62.8%) in the Milan group, p = n.s. The proposed down-staging criteria provide a comparable outcome to the conventional criteria.

Tumour size and differentiation in predicting recurrence of hepatocellular carcinoma after liver transplantation: external validation of a new prognostic score

BACKGROUND

A new prognostic score including tumour differentiation--establishing two groups of patients: group A with >3 points and group B with >4 points--improved the accuracy of the Milan criteria in predicting recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) in a large multicentre study (Decaens 2007).

AIM

The aim of this study was to validate the new score in our HCC cohort.

METHODS

The study involved 100 consecutive patients with mean age 55 years (range 31-68 years) (M/F: 88/22) transplanted for known HCC: 60 unifocal and 40 multifocal (2-3 nodules in 32 and >or=4 nodules in 8) at pre-LT imaging. Survival differences were analysed by log-rank test. Patient/tumour variables before LT and tumour differentiation at explant were assessed by univariate/multivariate analysis.

RESULTS

Median follow-up was 29 months (range 1-145 months). HCC recurrence was recorded in 18 patients. Five-year recurrence-free survival rate was 67 +/- 7%. Patient survival at 3 months was 84 +/- 4% and at 5 years was 45 +/- 6%. Both recurrence-free survival and patient survival were not significantly different between groups A and B. Diameter of largest nodule was the sole pre-LT variable independently associated with recurrence [odd ratio (OR) 1.07; 95% confidence interval (CI) 1.01-1.12; P = 0.012]. Recurrence-free survival was significantly better in patients with diameter <30 mm compared with those with larger nodules (P = 0.0229). Number of nodules and tumour differentiation did not influence recurrence. There were three HCC recurrences with largest nodule size <30 mm, seven recurrences between 30-40 mm, and eight recurrences >40 mm.

CONCLUSION

Tumour differentiation did not add significantly to prediction of HCC recurrence in our cohort. Conversely, diameter of the largest nodule remained a significant risk for recurrence.

University of California at San Francisco criteria can be applied to living donor liver transplantation for hepatocellular carcinoma: single-center preliminary results in 27 patients

BACKGROUND

Living donor liver transplantation (LDLT) can provide life-saving therapy for many patients with hepatocellular carcinoma (HCC), who otherwise would succumb due to tumor progression. However, donor risk must be balanced against potential recipient benefit.

METHODS

From January 2002 to December 2006, a total of 27 LDLT were performed for HCC patients in our center, including 25 right lobe grafts, and 2 dual grafts. Twenty-four (88.89%) met the University of California at San Francisco (UCSF) criteria, whereas 3 (11.11%) did not.

RESULTS

Of our 29 donors, the overall complication rate was 17.24%. Two (6.90%) experienced major complications including intra-abdominal bleeding and portal vein thrombosis in 1, respectively; 3 (10.34%) experienced minor complications: wound steatosis, pleural effusion, and transient chyle leakage in 1, respectively. We did not observe any donor mortality; all donors fully recovered and returned to their previous occupations. No recipient developed small-for-size syndrome. The overall HCC patient survival rates at 1- and 3-years were 84.01% and 71.40%, respectively, similar to those of patients undergoing LDLT for various nonmalignant diseases during the same period (P > .05).

CONCLUSIONS

Although further study is needed to fully assess the risks and benefits of LDLT for both HCC patients and donors, our preliminary results suggested that LDLT offered an acceptable chance and duration of survival for HCC patients. It was not only a relatively safe procedure provided that every effort was taken to minimize donor morbidities, but also beneficial for HCC recipients.

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 for hepatocellular carcinoma

Background

Orthotopic liver transplantation (OLT) is the best available option for early hepatocellular carcinoma (HCC), although its application is limited by stringent selection criteria, costs, and deceased donor graft shortage, particularly in Asia, where living donor liver transplant (LDLT) has been developed.

Methods

This article reviews the present standards for patient selection represented by size-and-number criteria with particular references to Milan Criteria and novel prediction models based on results achieved in patients exceeding those limits, with consideration of the expanded indication represented by the UCSF Criteria.

Results

The expected outcomes after deceased donor liver transplant (DDLT) or LDLT are favorable if predetermined selection criteria are applied. However, selection bias, difference in waiting time, and ischemia-regeneration injuries of the graft among DDLT vs LDLT may influence long-term results. In the article, the differences between East and West in first-line treatments for HCC (resection vs transplantation), indications, and ethics for the donor, are summarized as well as possible novel predictors of tumor biology (especially DNA mutation and fractional allelic loss, FAI) to be considered for better outcome prediction.

Conclusions

Liver transplantation remains the most promising product of modern surgery and represents a cornerstone in the management of patients with HCC.

Liver transplantation for hepatocellular carcinoma: validation of the UCSF-expanded criteria based on preoperative imaging

We previously suggested that in patients with heptocellular carcinoma (HCC), the conventional Milan criteria (T1/T2) for orthotopic liver transplantation (OLT) could be modestly expanded based on pathology (UCSF criteria). The present study was undertaken to prospectively validate the UCSF criteria based on pretransplant imaging. Over a 5-year period, the UCSF criteria were used as selection guidelines for OLT in 168 patients, including 38 patients exceeding Milan but meeting UCSF criteria (T3A). The 1- and 5-year recurrence-free probabilities were 95.9% and 90.9%, and the respective survivals without recurrence were 92.1% and 80.7%. Patients with preoperative T1/T2 HCC had 1- and 5-year recurrence-free probabilities of 95.7% and 90.1%, respectively, versus 96.9% and 93.6%, respectively, for preoperative T3A stage (p = 0.58). Under-staging was observed in 20% of T2 and 29% of T3A HCC (p = 0.26). When explant tumor exceeded UCSF criteria (15%), the 1- and 5-year recurrence-free probabilities were 80.4% and 59.5%, versus 98.6% and 96.7%, respectively, for those within UCSF criteria (p < 0.0001). In conclusion, our results validated the ability of the UCSF criteria to discriminate prognosis after OLT and to serve as selection criteria for OLT, with a similar risk of tumor recurrence and under-staging when compared to the Milan criteria.

Current status of liver transplantation for hepatocellular carcinoma from living donors

The first successful living-donor liver transplantation (LDLT) was performed in a child in 1989 in Brisbane, Australia and in an adult in 1994 by the Shinshu group. Over the past few years, LDLT has increased worldwide and is now an established alternative to deceased-donor liver transplantation. Hepatocellular carcinoma is one of the major indications for LDLT. At present, however, there are no universally adoptedselection criteria in potential candidates for LDLT. In our institution, patients were selected based on a tumor number of five or fewer and a maximum diameter of less than 5 cm with 3-year survival of 82%.

Expanded criteria for liver transplantation in patients with hepatocellular carcinoma

Following the seminal publication by the group from Milan, Italy using a restrictive set of criteria for orthotopic liver transplantation in patients with hepatocellular carcinoma to limit the risk for tumor recurrence, excellent 5-year patient survival of greater than 70% after liver transplantation has been reported from many centers using criteria similar to or slightly exceeding the Milan criteria (single lesion of </=5 cm, or 2-3 lesions of </=3 cm). The growing experience and success of orthotopic liver transplantation for HCC have also fueled controversies related to expansion of conventional criteria for cadaveric or living-donor liver transplantation based on tumor size and number. The limitations of imaging studies, exemplified by tumor under-staging in up to 25% of patients,have been a major concern for liberalizing the current criteria for liver transplantation. The University of California, San Francisco criteria (single lesion of </=6.5 cm, or 2-3 lesions of </=4.5 cm with a total tumor diameter </=8 cm) have been independently tested in several studies, and undergone prospective evaluation based on preoperative imaging. This article provides an in-depth review of published data on expansion of current criteria for liver transplantation.

Predictors of graft and patient survival in hepatitis C virus (HCV) recipients: model to predict HCV cirrhosis after liver transplantation

BACKGROUND

Hepatitis C virus (HCV) recurrence after liver transplantation (LT) is almost universal, but the natural history of recurrent HCV in the allograft is highly variable. Our study had two aims: 1) to assess the impact of different pre- and postLT factors on graft and patient survival in HCV transplant recipients and 2) to create a model which may predict the patients at risk for HCV-related graft cirrhosis at 5 years postLT.

METHODS

A total of 168 LTs were considered for this study. Univariate and multivariate Cox proportional hazards regression model was used, as well as logistic regression analysis to create a model of prediction of HCV cirrhosis within 5 years after LT.

RESULTS

Predictive factors for both decreased graft and patient survival included patients recently transplanted (2000-2004), induction without azathioprine, short-term therapy with mycophenolate mofetil and prednisone (< or =6 months), presence of early cholestasis, histologically proven early recurrence of hepatitis C. Recipient human leukocyte antigen DR3 positivity, presence of early cholestasis, and donor age >50 years were identified as independent predictors of graft cirrhosis within 5 years. A predictive model was established in order to calculate at 6 months a risk score for graft HCV cirrhosis within 5 years postLT using a formula that included the identified independent predictors. The area under receiver operating characteristic curve was 0.83, indicating a good ability to predict medium-term HCV allograft cirrhosis.

CONCLUSION

This model may be a useful tool for better identifying high-risk HCV patients who should be selected for early initiation of antiviral therapy.

Living donor liver transplantation of the right lobe for hepatocellular carcinoma in cirrhosis in a European center

Living donor liver transplantation of the right lobe might offer the possibility to extend the eligibility criteria of patients with hepatocellular carcinoma (HCC) in cirrhosis without penalizing patients who are waiting for a graft from a deceased donor. From 1988 to 2005, surgical treatment of HCC was performed in 580 patients (187 transplantation, 393 resection) in a European center. In the transplantation group, 21 patients with HCC in cirrhosis underwent LDLT (11% of all transplantations for HCC; 22% of 96 LDLT). Solitary HCC were accepted irrespective of their diameter unless vascular invasion was detectable. Multiple HCC nodes were considered acceptable up to a diameter of the largest node of 6 cm and a total tumor diameter of 15 cm. The median follow-up period was 26 months (range, 1-65 months). Vascular invasion had occurred in 12 patients (57%). One patient (4.8%) died within 60 days after transplantation from sepsis. Rates of 3-year survival and 3-year recurrence-free survival were 68% and 64%, respectively. Overall 3-year survival rates in patients with HCC in cirrhosis not meeting the Milan criteria (n = 13) or the San Francisco criteria (n = 8) were 62% and 53%, respectively. LDLT is a safe procedure. However, small sample sizes do not yet permit a definitive comparison to be made between the former results obtained after cadaveric donation. So far, the outcome of the patients is in favor of a careful extension of the selection criteria for HCC in cirrhosis.

Adult living donor liver transplantation: living donation of the right liver lobe

BACKGROUND

Adult living donor liver transplantation (LDLT) has become a routine treatment option for patients waiting for liver transplantation. In European and North American countries, LDLT for adult recipients is mainly performed with right lobe grafts. Indications, when compared to deceased donor liver transplantation, are controversial.

MATERIALS AND METHODS

In our institution, patients suffering from hepatocellular carcinoma in cirrhosis, non-resectable hilar cholangiocarcinoma, viral hepatitis associated cirrhosis, as well as cholestatic liver and biliary disease are considered good candidates for LDLT.

RESULTS

In this overview, donor evaluation, graft selection, and the donor operation with special regard to operative techniques and strategies are discussed. For visualization, a 5-min video sequence of the standard donor operation as performed in our institution is attached.

CONCLUSION

Given the ongoing shortage of donor organs, adult LDLT has become a routine treatment option for patients waiting for liver transplantation. The associated inevitable risk for the healthy donor, however, remains ethically controversial.

Carcinome hépatocellulaire et transplantation hépatique : état des lieux

Hepatic transplantation offers the best treatment for cure for hepatocellular carcinoma arising in the cirrhotic liver as long as patients and indications are carefully selected. The Milan criteria which became established in the 1990's showed that the best results are obtained when there are three or fewer nodules less than 3 cm in size, or a single nodule less than five cm. in size. Today, these criteria seem to be too restrictive, and indications for surgery can be extended by employing criteria based on macroscopic findings, histology, and even molecular biology. It is necessary not only to better define the limits and indications of therapy but also to keep close watch on patients awaiting transplant to prevent exclusion from the list due to tumor progression. Results can also be improved by decreasing late tumor recurrence with an optimal post-operative immunosuppressive regimen and with adjuvant chemotherapy. The choice of using a living donor or transplanting a liver of marginal quality should also be weighed against the tumor characteristics and the anticipated waiting period for a donor liver. The increasing incidence of hepatocellular carcinoma imposes a need to offer curative therapy to more patients than we are able to do under current circumstances. The treatment strategies for hepatocellular cancer should be multidisciplinary from the start; the use of all available treatment tools including liver transplantation should be better evaluated by multicentric studies.

Patients without hepatocellular carcinoma progression after transarterial chemoembolization benefit from liver transplantation

AIM: To assess the outcome of patients, who under-went transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) and subsequently liver transplantation (OLT) irrespective of tumor size when no tumor progression was observed.

METHODS: Records, imaging studies and pathology of 84 patients with HCC were reviewed. Ten patients were not treated at all, 67 patients had TACE and 35 of them were listed for OLT. Tumor progression was monitored by ultrasound and AFP level every 6 wk. Fifteen patients showed signs of tumor progression without transplantation. The remaining 20 patients underwent OLT. Further records of 7 patients with HCC seen in histological examination after OLT were included.

RESULTS: The patients after TACE without tumor progression underwent transplantation and had a median survival of 92.3 mo. Patients, who did not qualify for liver transplantation or had signs of tumor progression had a median survival of 8.4 mo. The patients without treatment had a median survival of 3.8 mo. Independent of International Union Against Cancer (UICC) stages, the patients without tumor progression and subsequent OLT had longer median survival. No significant difference was seen in the OLT treated patients if they did not fulfill the Milan criteria.

CONCLUSION: Selection of patients for OLT based on tumor progression results in good survival. The evaluation of HCC patients should not only be based on tumor size and number of foci but also on tumor progression and growth behavior under therapy.

Who decides? Living donor liver transplantation for advanced hepatocellular carcinoma

Few effective treatment options are available for patients with advanced hepatocellular carcinoma (HCC). Some transplant centers have begun offering living donor liver transplantation (LDLT) for selected patients whose HCC exceeds Milan criteria by a small margin. However, this remains a controversial subject. In this article, we weigh the arguments for and against LDLT for advanced HCC. Because donor autonomy forms the crux of this dilemma, the real question becomes: to whom does the decision belong, the individual donors or the medical community? We argue that donor autonomy should not be paramount in settings where the recipient benefit is uncertain.

Liver transplantation for hepatocellular carcinoma beyond the Milan criteria: the controversies continue

Liver transplantation has now become a favored option for patients with early-stage hepatocellular carcinoma (HCC) with or without impaired hepatic function as a complication of underlying cirrhosis. To overcome the persistent donor organ shortage, the use of adult-to-adult living donor liver transplantation (LDLT) has recently increased, especially in Asian countries. In the use of LDLT, several controversies remain including the safety of living donation and expanding the current Milan criteria. Most physicians agree that criteria for transplanting patients with HCC should be expanded beyond the Milan criteria because the Milan criteria miss a number of patients who may benefit from LDLT; however, the expanded criteria proposed were different (the size and number of HCCs and the biologic markers) from one center to the other. When we consider LDLT as a treatment option for patients with HCC, donor safety should be kept in mind first, and the wishes of both patient and donor should be weighed against the potential (if small) risk for the donor. In contrast to deceased donor liver transplantation, the benefit of LDLT is better appreciated in terms of gain in life expectancy than in terms of survival when the wishes of both patient and donor outweigh the donor risk. Further research on the predictors of benefit of LDLT to HCC patients other than the size and number of HCC such as molecular profiling of HCC are necessary to finally reach a consensus.

Liver transplantation: experience at our center

Liver transplantation was pioneered by Starzl and his team in 1967. Since then, many difficulties have been overcome and this treatment modality has gained worldwide acceptance as the definitive treatment for end-stage liver disease. However, the current numbers of liver transplantations are still far below what is needed, the rising numbers on waiting lists have pushed transplant surgeons to search for new alternatives, and living related donors are considered one solution. At our center, the only living liver donors we accept are relatives and spouses of recipients. We have held the same policy for our kidney program from the beginning. In the past 3 years, we have increased the annual numbers of liver transplantations; our graft and patient survival rates for this period exceed 90%. Liver grafts donated by living related donors offer an extremely important, lifesaving alternative in urgent situations, such as acute liver failure, where there is limited time to wait for a deceased donor. Hepatocellular carcinoma is another important indication for living related liver transplantation. Availability of living donors allows us to perform transplantations even in recipients with advanced tumors who would not be accepted as appropriate transplant candidates according to widely used selection criteria. Liver transplantation is a lifesaving procedure that presents many challenges, and our experience has led us to develop an innovative technique for biliary reconstruction. We have used a method of "back-table guide-wire placement and intraoperative transhepatic biliary catheter insertion" in 44 patients since December 2004 to significantly decrease biliary complications and perform duct-to-duct anastomosis even in small pediatric recipients.

Impact of UCSF criteria according to pre- and post-OLT tumor features: analysis of 479 patients listed for HCC with a short waiting time

Orthotopic liver transplantation (OLT) indication for hepatocellular carcinoma (HCC) is currently based on the Milan criteria. The University of California, San Francisco (UCSF) recently proposed an expansion of the selection criteria according to tumors characteristics on the explanted liver. This study: 1) assessed the validity of these criteria in an independent large series and 2) tested for the usefulness of these criteria when applied to pre-OLT tumor evaluation. Between 1985 and 1998, 479 patients were listed for liver transplantation (LT) for HCC and 467 were transplanted. According to pre-OLT (imaging at date of listing) or post-OLT (explanted liver) tumor characteristics, patients were retrospectively classified according to both the Milan and UCSF criteria. The 5-yr survival statistics were assessed by the Kaplan-Meier method and compared by the log-rank test. Pre-OLT UCSF criteria were analyzed according to an intention-to-treat principle. Based on the pre-OLT evaluation, 279 patients were Milan+, 44 patients were UCSF+ but Milan- (subgroup of patients that might benefit from the expansion), and 145 patients were UCSF- and Milan-. With a short median waiting time of 4 months, 5-yr survival was 60.1 +/- 3.0%, 45.6 +/- 7.8%, and 34.7 +/- 4.0%, respectively (P < 0.001). The 5-yr survival was arithmetically lower in UCSF+ Milan- patients compared to Milan+ but this difference was not significant (P = 0.10). Based on pathological features of the explanted liver, 5-yr survival was 70.4 +/- 3.4%, 63.6 +/- 7.8%, and 34.1 +/- 3.1%, in Milan+ patients (n = 184), UCSF+ Milan- patients (n = 39), and UCSF- Milan- patients (n = 238), respectively (P < 0.001). However, the 5-yr survival did not differ between Milan+ and UCSF+ Milan- patients (P = 0.33). In conclusion, these results show that when applied to pre-OLT evaluation, the UCSF criteria are associated with a 5-yr survival below 50%. Their applicability is therefore limited, despite similar survival rates compared to the Milan criteria, when the explanted liver is taken into account.

Living donor liver transplantation

The introduction of living donor liver transplantation (LDLT) has been one of the most remarkable steps in the field of liver transplantation (LT). First introduced for children in 1989, its adoption for adults has followed only 10 years later. As the demand for LT continues to increase, LDLT provides life-saving therapy for many patients who would otherwise die awaiting a cadaveric organ. In recent years, LDLT has been shown to be a clinically safe addition to deceased donor liver transplantation (DDLT) and has been able to significantly extend the scarce donor pool. As long as the donor shortage continues to increase, LDLT will play an important role in the future of LT.

Living donor liver transplantation: present status and recent advances

The first successful living donor liver transplantation (LDLT) was performed in a child in 1989 in Brisbane and in an adult in 1994 by the Shinshu group. Over the past few years, LDLT has increased worldwide and is now an established alternative to deceased donor liver transplantation. The surgical procedures for LDLT are more technically challenging than those for whole liver transplantation. LDLT requires a full understanding of the hepatobiliary anatomy and continuous technical refinement of the procedure. Some of the technical highlights include selective vascular occlusion techniques for donor hepatectomy, hepatic arterial reconstruction under the microscope and the introduction of intraoperative ultrasound, graft volume estimation and hepatic venous reconstruction, all of which have improved the success rate of LDLT over the past few years. This review focuses on recent trends and surgical techniques for LDLT.