1Department of Surgery, Washington University School of Medicine, St. Louis, MO. Electronic address: email@example.com.
2Department of Surgery, Washington University School of Medicine, St. Louis, MO.
3Department of Radiology, Washington University School of Medicine, St. Louis, MO.
4Department of Medical Oncology, Washington University School of Medicine, St. Louis, MO, (d)Department of Pathology, Washington University School of Medicine, St. Louis, MO.
The incidence of HCC continues to increase dramatically worldwide. Liver transplantation (LT) is now standard and optimal treatment for patients with HCC in the setting of cirrhosis, but only for tumors within Milan criteria (MC). In patients presenting beyond Milan, locoregional therapy (LRT) may downstage to within-Milan for consideration of LT. While controversial, the current study aims to evaluate the outcomes of LT in patients presenting with advanced stage HCC who underwent downstaging and compare to patients who meet Milan criteria at presentation.
Our protocol does not set a priori limitations, as long as HCC is confined to the liver. In this retrospective study, between 1/1/2002 and 12/31/2014, we reviewed outcomes associated with 284 patients presenting within Milan and patients who presented with more advanced stage tumor who were potential transplant candidates. The patients with advanced disease were further subdivided into those within or beyond UCSF criteria. Imaging, details of LRT, recurrence, and survival were compared between groups.
63/210 (30%) eligible patients were downstaged and transplanted; 14 additional downstaged and listed patients were withdrawn for the following: death while waiting (4), disease-progression (8), development of other malignancy (1), declined LT (1); 12 underwent resection following downstaging and did not require LT. Survival for patients downstaged was similar to those initially within Milan criteria. Recurrence of HCC at 5-years was similar between groups (10.9% vs 10.8%, p=0.84)
CONCLUSIONS: Patients with beyond-Milan HCC who are otherwise candidates for LT should undergo aggressive attempts at downstaging, without a priori exclusion. This highly selective approach allows for excellent long-term results, similar to patients presenting with earlier stage disease.