Does a patient qualify for liver transplantation after the down-staging of hepatocellular carcinoma?

Abstract

Our review of the literature suggests that uniform criteriaare needed for future studies investigating furtherthe efficacy and safety of HCC down-stagingbefore LT. Our recommendations are as follows:1. We define HCC down-staging as reducing the tumorsize with locoregional therapy specifically tomeet acceptable criteria for LT (grade D).2. The tumor response to down-staging treatmentsshould be based on radiological measurementsof the sizes of viable tumors, and the measurementshould not include the areas of necrosisresulting from locoregional therapy (grade D).3. We propose a goal of achieving a 5-year posttransplantsurvival rate of 60% to 70% after tumordown-staging. Whether intention-to-treatsurvival rates should be compared for thosemeeting the Milan criteria and those undergoingdown-staging remains a debatable issue(grade D).4. We propose using the Milan criteria as the endpointfor down-staging, and more data aboutlong-term outcomes are needed (grade C).5. Well-defined upper limits for the tumor size andnumber should be used to determine the eligibilityfor down-staging before LT (grade D). Otherfactors to be considered include an upper limitfor the AFP level; beyond this limit, down-stagingtreatments are not likely to be successful, andposttransplant outcomes may be significantlyworse.6. TACE is the most commonly used treatment modality,but there is no evidence that one treatmentis superior to others in achieving downstaging(grade D). More data on the safety ofdown-staging are needed.7. A minimal observation period of 3 monthsbetween successful down-staging and LT is recommended(grade D).8. We propose the following criteria for treatmentfailure for down-staging: (1) tumor progression toone or more of the endpoints resulting in permanentremoval from the waiting list (vascular invasion,extrahepatic spread, or tumor sizes andnumbers beyond the inclusion criteria), (2) deathdue to any cause before LT, and (3) the recurrenceof HCC after LT (grade D). Copyright © 2011 American Association for the Study of Liver Diseases.