American Surgical Association
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Criteria For Liver Transplantation For Hepatocellular Carcinoma Should Be Expanded: A 22-Year Single Institution Study With 467 Patients
John P. Duffy*, Elizabeth Robinson, Andrew Vardanian, Melissa Watson*, Douglas G. Farmer, Rafik M. Ghobrial, Myron Tong, Hasan Yersiz*, Jonathan R. Hiatt, Ronald W. Busuttil
UCLA Medical Center, Los Angeles, CA

OBJECTIVE(S): To assess the efficacy of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) and to determine whether current staging criteria are too restrictive. The utility of OLT for all but early HCC remains controversial.
METHODS: All patients undergoing OLT for HCC from 1984-2006 (n=467) were evaluated using a prospective database. Outcomes were compared for patients who met Medicare-approved Milan criteria (single tumor < 5cm, maximum of 3 tumors with none > 3cm; n=173), met UCSF criteria (single tumor < 6.5cm, maximum of 3 tumors with none > 4.5cm, cumulative tumor size < 8cm; n=185), or exceeded UCSF criteria (n=109).
RESULTS: For the 467 patients, recurrence rate was 21% at mean followup of 6.6 ± 0.9 yr., with 1-, 3-, and 5-year overall survival of 82, 65, and 52%. Patients meeting UCSF criteria had five-year post-transplant survival similar to patients meeting Milan criteria by preoperative staging (64% vs 79%; p=0.061) or post-explant pathology (71% vs 86%; p=0.057). On multivariate analysis, tumor number (p<0.001), lymphovascular invasion (p<0.001), and poor differentiation (p=0.002) independently predicted poorer survival. Patients exceeding UCSF criteria from isolated tumors had better 5-year post-transplant survival than patients with multiple tumors (36% vs 12%, p=0.001).
CONCLUSIONS: In OLT for HCC, stratified by stage, this largest single institution experience to date demonstrates equivalent post-transplant survival for patients meeting Milan or UCSF criteria. OLT for select tumors beyond Milan criteria results in prolonged patient survival. Milan criteria are too restrictive and should be expanded to offer OLT to more patients with HCC.

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