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

Abstract

<b><i>Introduction:</i></b> Current practice to only prioritize hepatocellular carcinoma (HCC) that fulfill the Milan criteria (IN_MC) is changing, since it causes the exclusion of patients who could benefit from liver transplantation. To select patients outside MC (OUT_MC) for transplantation, we implemented extended selection criteria without up-front morphometric restrictions containing surrogate parameters of tumor biology. <b><i>Methods:</i></b> OUT_MC patients were considered without restrictions of morphometrics and received locoregional treatment after interdisciplinary consultation. Our dynamic selection criteria for OUT_MC patients required (IN_MUC): (1) treatment response over (2) at least 6 months and (3) alpha-fetoprotein ≤400 ng/mL over the entire evaluation period. Patients with IN_MC tumors served as control and internal validation cohort. <b><i>Results:</i></b> 31 of 170 liver transplant candidates were OUT_MC. 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_MC compared to those OUT_MC IN_MUC (92.2% vs. 70.8%; <i>p</i> = 0.026) after 5 years of follow-up. Overall survival showed no significant difference (<i>p</i> = 0.552). With dynamic selection of transplant candidates, recurrence could also be predicted for the IN_MC patients as internal validation cohort (c-index: 0.896; CI 0.588–0.981, <i>p</i> = 0.005). <b><i>Conclusion:</i></b> Dynamic selection criteria for the stratification of patients with OUT_MC HCCs is feasible and allows for excellent long-term results and acceptable tumor recurrence rates comparable to IN_MC patients.