TY - JOUR
T1 - Controversies in criteria for liver transplantation in hepatocellular carcinoma
AU - Parikh, Neehar D.
AU - Yopp, Adam
AU - Singal, Amit G.
N1 - Publisher Copyright:
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
PY - 2016
Y1 - 2016
N2 - Purpose of review For patients with hepatic decompensation and hepatocellular carcinoma (HCC) within Milan criteria, liver transplantation provides the best long-term recurrence-free survival. However, there is controversy about the role of liver transplantation in other subgroups, including those with compensated cirrhosis, United Network for Organ Sharing (UNOS) T1 lesions, or HCC exceeding Milan criteria. Recent findings For patients with compensated cirrhosis, surgical resection provides similar recurrence-free survival as liver transplantation and is the most cost-effective approach. Although a 'Wait and not Ablate' approach can facilitate priority listing in most patients with UNOS T1 lesions, nearly 10% will have rapid tumor growth beyond transplant criteria, thereby missing an opportunity for curative therapy. Patients exceeding Milan criteria have higher posttransplant recurrence rates and worse survival than those within Milan criteria, and any potential benefit of liver transplantation to these patients must be weighed against harms to others on the waiting list, particularly in areas with limited donor availability. Although downstaging may help select a subgroup of patients beyond Milan with good tumor biology and better prognosis, limitations of the current literature preclude rigorous evaluation. Summary Until higher quality data become available that demonstrate transplant benefit in expanded criteria patients, liver transplantation should be reserved for patients within Milan criteria.
AB - Purpose of review For patients with hepatic decompensation and hepatocellular carcinoma (HCC) within Milan criteria, liver transplantation provides the best long-term recurrence-free survival. However, there is controversy about the role of liver transplantation in other subgroups, including those with compensated cirrhosis, United Network for Organ Sharing (UNOS) T1 lesions, or HCC exceeding Milan criteria. Recent findings For patients with compensated cirrhosis, surgical resection provides similar recurrence-free survival as liver transplantation and is the most cost-effective approach. Although a 'Wait and not Ablate' approach can facilitate priority listing in most patients with UNOS T1 lesions, nearly 10% will have rapid tumor growth beyond transplant criteria, thereby missing an opportunity for curative therapy. Patients exceeding Milan criteria have higher posttransplant recurrence rates and worse survival than those within Milan criteria, and any potential benefit of liver transplantation to these patients must be weighed against harms to others on the waiting list, particularly in areas with limited donor availability. Although downstaging may help select a subgroup of patients beyond Milan with good tumor biology and better prognosis, limitations of the current literature preclude rigorous evaluation. Summary Until higher quality data become available that demonstrate transplant benefit in expanded criteria patients, liver transplantation should be reserved for patients within Milan criteria.
KW - Downstaging
KW - Expanded transplant criteria
KW - Hepatocellular carcinoma
KW - Liver transplantation
KW - Milan criteria
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U2 - 10.1097/MOG.0000000000000264
DO - 10.1097/MOG.0000000000000264
M3 - Review article
C2 - 26992197
AN - SCOPUS:84961233881
SN - 0267-1379
VL - 32
SP - 182
EP - 188
JO - Current Opinion in Gastroenterology
JF - Current Opinion in Gastroenterology
IS - 3
ER -