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Expanding liver transplant criteria offers comparable survival

Select patients with hepatocellular carcinoma who surpassed traditional indications for living donor liver transplantation exceeded survival expectations, with rates comparable to patients within the Milan criteria, according to results of a prospective study.

“Despite some efforts to expand indications of transplant for HCC patients beyond Milan criteria — based on tumor size and number of nodules or successful down-staging after preoperative therapies — clinical practice guidelines have not adopted such extended criteria and the vast majority of transplant centers are still excluding this type of patients from liver transplantation with cadaveric grafts,” Josep M. Llovet, MD, from the Barcelona-Clínic Liver Cancer Group, Spain, and colleagues wrote.

The researchers enrolled 22 patients with HCC and Barcelona-Clínic Liver Cancer Group (BCLC) extended criteria to assess their survival and recurrence rates after liver donor liver transplantation.

Prior to transplantation, 12 patients underwent transarterial chemoembolization or percutaneous ethanol injection.

At the time of transplantation, four patients met Milan criteria, seven patients were beyond Milan criteria but inside the BCLC expanded criteria, and 11 patients were beyond the BCLC criteria.

Perioperatively, medical complications occurred in 16 patients and surgical complications occurred in 12 patients. Regarding long-term complications, nine patients presented with HCV-induced cirrhosis and one patient had chronic rejection of the donor liver.

After a median of 81 months (range, 7-188 months), eight patients died, of whom four died due to HCC recurrence. Actuarial probability of survival was 95.5% at 1 year, 86.4% at 3 years, 80.2% at 5 years and 66.8% at 10 years.

At the end of follow-up, HCC recurred in seven patients. Of those, four died within the first year after recurrence. All seven patients had HCV at initial enrollment in the study and cirrhosis recurred in five patients. Six of the seven patients had been outside BCLC extended criteria at the time of transplantation.

Patients who were within Milan criteria (n = 10) had better rates of survival at last radiological exploration prior to liver transplantation compared with those beyond the criteria (n = 12) at 5 years (90% vs. 90%; P = .046) and at 10 years (70% vs. 52.1%; P = .046).

“Overall, the results are positive, but certainly need to be validated prior being considered for consensus criteria. In addition, they should be carefully interpreted,” the researchers concluded. “Despite that the 10-yr recurrence is high, the outcome is counterbalanced by the long-term transplant benefit achieved. We propose, therefore, pursuing these extended criteria in other centers of excellence, since these results need further prospective confirmation before being adopted by clinical practice guidelines.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.