Can my patient with cirrhosis and hepatocellular carcinoma still qualify for a liver transplant?

 

Hepatocellular carcinoma (HCC) is the 3rd most common cause of cancer-related deaths1. Liver transplant removes the HCC tumor and addresses the underlying cirrhosis. Unfortunately, the demand for liver transplants exceeds the supply of available livers, making it necessary to select patients with the best recurrent-free survival following transplantation. .

Mazzaferro2 found that patients who had one lesion <5 cm, no more than 3 lesions each ❤ cm, and no extrahepatic involvement or vascular invasion had significantly higher rates of recurrent-free survival following liver transplant than patients with tumors exceeding this criteria (92% vs 59% at 4 years, respectively, P = .002). This criteria, also known as the Milan criteria, has been substantiated by numerous studies3 and widely adopted. Other more inclusive criteria has also been proposed, including the UCSF criteria4 (one tumor <6.5 cm, no more than 3 tumors, all <4.5 cm and cumulative size <8cm) which have good survival rates, but have not been adopted due to limited supply of available livers.

Interestingly, patients with HCC not initially meeting the Milan criteria but who receive treatment to meet the criteria have similar post-transplantation recurrence-free survival rates as those who meet the criteria without downstaging4,5.

 

References

  1. El–Serag HB, Rudolph KL. Hepatocellular carcinoma: epidemiology and molecular carcinogenesis. Gastroenterology. 2007 Jun 30;132(7):2557-76.
  2. Mazzaferro V, Regalia E, Doci R, et al. L. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996; 334: 693-699.
  3. Mazzaferro V, Bhoori S, Sposito C, et al. Milan criteria in liver transplantation for hepatocellular carcinoma: an evidence‐based analysis of 15 years of experience. Liver Transplantation 2011;17(S2): S44-S57.
  4. Yao FY, Ferrell L, Bass NM, et al. Liver transplantation for hepatocellular carcinoma: comparison of the proposed UCSF criteria with the Milan criteria and the Pittsburgh modified TNM criteria. Liver transplantation. 2002 Sep 1;8(9):765-74.
  5. Ravaioli M, Grazi GL, Piscaglia F, et al. Liver transplantation for hepatocellular carcinoma: results of down-staging in patients initially outside the Milan selection criteria. Am J Transplant. 2008;8:2547–2557.
  6. Yao FY, Kerlan RK, Hirose R, et al. Excellent outcome following down-staging of hepatocellular carcinoma prior to liver transplantation: an intention-to-treat analysis. Hepatology. 2008;48:819–827.

Contributed by Marissa Shoji, Medical Student, Harvard Medical School

Can my patient with cirrhosis and hepatocellular carcinoma still qualify for a liver transplant?

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