Liver transplantation
The Impact of Milan Criteria on Liver Transplantation for Hepatocellular Carcinoma: First 15 Years' Experience of the Hungarian Liver Transplant Program

https://doi.org/10.1016/j.transproceed.2011.03.077Get rights and content

Abstract

In addition to hepatitis C, hepatocellular carcinoma.1 is a leading indication for orthotopic liver transplantation (OLT). The indications for OLT in HCC remains a topic of debate. The successful Milan criteria are still accepted as the gold standard to select candidates with a good chance for long-term survival.2 The Hungarian Liver Transplant Program launched in 1995 reached 45 OLT/year in 2010.3, 4 Among 412 first OLTs, there were 49 cases of a malignant tumor, including 41 among which the indication was the tumor. Of the 412 patients, 154 (37.4%) were hepatitic C virus (HCV) positive, including 29 with HCC and 23 cases in which HCC was the indication itself. Half of the HCC patients were within the Milan criteria;15 50% exceeded the criteria.14 We observed a solitary HCC in 36% of cases: 2 foci in 18%; 3 in 7%, 4 in 14%, and ≥5 in 25%. Only 12 patients underwent a “down-staging” treatment before OLT: 8 radiofrequency ablation (RFA) and 4 transarterial chemoembolization (TACE). Cumulative 1-, 3-, and 5-year patient survivals were 62%, 54%, and 43%, respectively in HCC/HCV–positive patients and they were 74%, 67%, and 61% among non-HCC HCV-positive subjects. The cumulative HCC patient survival rates of 64%, 64%, and 53% among Milan criteria were superior to those of 57%, 40%, and 27% among subjects exceeding the Milan criteria (P = .01). Pre-OLT “down-staging” treatment increased the 1-year patient survival from 64% to 70%; however, it did not affect the long-term results. Among items of the Milan criteria tumor size had less impact on outcomes then number of foci. The majority of cases who exceeded the Milan criteria had been transplanted before 2003. Our results suggested that the Milan criteria should be applied for the selection of candidates in order to promise good survival after OLT for HCC.

Section snippets

Patients and Methods

We enrolled 412 first OLT patients, including 49 cases of a malignant tumor, 41 of which the neoplasm itself was the indication. Among the 412 patients, 154 (37.4%) were HCV-positive and 258 (62.6%) HCV-negative. We compared the cumulative outcomes of HCV-positive and HCV-negative patients. We also focused on HCC. Because HCC was found only in the HCV-positive group, we evaluated the impact of the Milan criteria on host survival. The following data were recorded: recipient demographics (age,

Results

Among the 412 patients, we verified a primary malignant tumor in 49 cases, including 41 in which the tumor was the indication and 8 in which it was an incidental finding. There were no verified metastases at the time of OLT. Locoregional lymph nodes (hepatogastric ligament) were tumor positive in 4 and negative in 12 cases, and not recognized in 33. Among all OLT patients, there were 154 HCV-positive individuals (37.4%). Hepatocellular carcinoma was verified in 29 cases (18%), including 23

Discussion

Liver transplantation has become a conventional tool to treat patients with hepatocellular carcinoma. HCC occurs mainly in HCV-infected livers, in addition to the majority of cases developing cirrhosis. The BCLC consensus5 presented a therapeutic approach to the different stages of cirrhosis and the tumor. The Milan criteria2 remain a gold standard to consider a patient as an OLT candidate. With the occurrence of various effective ablative techniques, such as RFA and TACE, the size of the HCC

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    Citation Excerpt :

    Liver transplantation provides optimal treatment of the tumor and underlying carcinogenic disease; however, it is hampered by limited organ supply and patients must meet strict criteria to be considered candidates. According to the Milan Criteria, patients with a single tumor less than 5 cm or three or fewer tumors smaller than 3 cm, without angioinvasion or extrahepatic involvement are eligible for transplantation.14 Therefore, surgical resection is the first line treatment for localized tumors according to the National Comprehensive Cancer Network (NCCN), European Association for the Study of the Liver (EASL), and American Association for the study of Liver Diseases (AASLD) guidelines.15–17

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