Liver Transplantation for Extended Criteria Hepatocellular Carcinoma using Stable Response to Locoregional Therapy and Alpha-Fetoprotein as Selection Criteria
The current practice to prioritize patients with hepatocellular carcinoma (HCC) within the Milan criteria (MC) on the liver transplant (LT) waiting list disregards many patients with more and larger tumors who would achieve almost similar outcomes when they would be transplanted. To assess the individual risk of tumor recurrence we have incorporated surrogates of tumor biology in our selection process for patients with outside MC HCCs.
170 liver transplant candidates with outside MC tumors without up-front restrictions of number and sizes of tumor lesions were prospectively enrolled in the selection protocol (Munich Criteria; MUC) All participants received locoregional therapy based on a case-by-case decision of a multidisciplinary tumor board. Patients with stable response (complete/ partial response, stable disease) for 6 month and AFP values <400 ng/ml over the entire evaluation period were listed and kept on the waiting-list for LT.
From these patients 8 were excluded and delisted due to tumor progression, 23 patients met the selection criteria and were transplanted. Patients transplanted with inside MC tumors during the same time period served as a control group. Tumor recurrence rate was higher in patients transplanted outside MC but inside the MUC (92.2% versus 70.8%; p=0.026). However, overall survival was similar between both groups (p=0.552).
Incorporating surrogates of tumor biology, response-to therapy, test of time and AFP values into the selection process of patients with outside MC HCCs allows for excellent long-term results and low tumor recurrence rates similar to patients presenting with inside MC tumors