Liver Transplantation for Extended Criteria Hepatocellular Carcinoma Using Stable Response to Locoregional Therapy and Alpha-Fetoprotein as Selection Criteria.

INTRODUCTION

Current practice to only prioritize hepatocellular carcinoma (HCC) that fulfill the Milan criteria (IN) is changing, since it causes the exclusion of patients who could benefit from liver transplantation. To select patients outside MC (OUT) for transplantation, we implemented extended selection criteria without up-front morphometric restrictions containing surrogate parameters of tumor biology.

METHODS

OUT patients were considered without restrictions of morphometrics and received locoregional treatment after interdisciplinary consultation. Our dynamic selection criteria for OUT patients required (IN): (1) treatment response over (2) at least 6 months and (3) alpha-fetoprotein ≤400 ng/mL over the entire evaluation period. Patients with IN tumors served as control and internal validation cohort.

RESULTS

31 of 170 liver transplant candidates were OUT. Of these, 8 dropped out. The remaining 23 patients met the selection criteria and underwent transplantation. Recurrence-free survival was higher in patients transplanted IN compared to those OUT IN (92.2% vs. 70.8%; = 0.026) after 5 years of follow-up. Overall survival showed no significant difference ( = 0.552). With dynamic selection of transplant candidates, recurrence could also be predicted for the IN patients as internal validation cohort (c-index: 0.896; CI 0.588-0.981, = 0.005).

CONCLUSION

Dynamic selection criteria for the stratification of patients with OUT HCCs is feasible and allows for excellent long-term results and acceptable tumor recurrence rates comparable to IN patients.