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DOI: 10.1055/a-2228-7496
Liver transplantation for HCC in cirrhosis: Are Milan criteria outdated?
Lebertransplantation bei HCC: Sind Milan-Kriterien überholt?
Abstract
In Germany, organ allocation is based on the MELD-system and lab-MELD is usually low in patients with hepatocellular carcinoma (HCC) in cirrhosis. Higher medical urgency can be achieved by standard exception for HCC (SE-HCC), if Milan criteria (MC) are met. Noteworthy, UNOS T2 reflects MC, but excludes singular lesions < 2 cm. Thus, SE-HCC is awarded to patients with one lesion between 2 and 5 cm or 2 to 3 lesions between 1 and 3 cm. These criteria are static and do not reflect biological properties of HCC.
We present a retrospective cohort of 111 patients, who underwent liver transplantation at UKSH, Campus Kiel between 2007 and 2017. No difference was found in overall survival for patient cohorts using Milan, UCSF, up-to-seven, and French-AFP criteria. However, there was a significantly reduced survival, if microvascular invasion was detected in the explanted organ and in patients with HCC-recurrence. The exclusive use of static selection criteria including MC appear to limit the access to liver transplantation.
Zusammenfassung
Die Organallokation zur Lebertransplantation in Deutschland basiert auf dem MELD-System. Patienten mit einem hepatozellulären Karzinom (HCC) in Zirrhose weisen meist einen niedrigen laborchemischen (lab-)MELD auf. Eine Priorisierung der Dringlichkeit auf der Warteliste kann durch eine Standard-Exception (SE-HCC) erfolgen, wenn die Milan-Kriterien (MC) erfüllt sind. Die Richtlinie verwendet UNOS T2, welche MC entsprechen aber singuläre Tumoren unter 2 cm ausschließen. Die Priorisierung erfolgt nach rein statischen Kriterien und berücksichtigt keine weiteren biologischen Tumoreigenschaften.
In einer retrospektiven Studie analysierten wir 111 Patienten, die zwischen 2007 und 2017 am UKSH, Campus Kiel, transplantiert wurden. Das Gesamt-Überleben der Patienten unterteilt nach Milan-, UCSF-, up-to-seven- sowie French-AFP-Kriterien zeigte keine signifikanten Unterschiede. Demgegenüber fand sich bei mikrovaskulärer Invasion im Explantat sowie in der Rezidiv-Situation ein signifikant schlechteres Gesamtüberleben.
Die ausschließliche Verwendung statischer Selektionskriterien einschließlich MC impliziert einen eingeschränkten Zugang zur Lebertransplantation.
Keywords
Liver transplantation - hepatocellular carcinoma - allocation - selection criteria - Milan criteriaSchlüsselwörter
Lebertransplantation - hepatozelluläres Karzinom - Allokation - Selektionskriterien - Milan KriterienPublikationsverlauf
Eingereicht: 08. September 2023
Angenommen nach Revision: 03. Dezember 2023
Artikel online veröffentlicht:
09. Januar 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
Georg Thieme Verlag KG
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Literatur
- 1 Sung H, Ferlay J, Siegel RL. et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA A Cancer J Clin 2021; 71 (03) 209-249
- 2 Siegel RL, Miller KD, Wagle NS. et al. Cancer statistics, 2023. CA A Cancer J Clinicians 2023; 73 (01) 17-48
- 3 Mazzaferro V, Regalia E, Doci R. et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996; 334 (11) 693-699
- 4 Gundlach JP, Linecker M, Dobbermann H. et al. Patients Benefit from Liver Transplantation for Hepatocellular Carcinoma beyond Milan Criteria without Harming the Health Care System. Cancers 2022; 14 (05) 1136
- 5 Lerut J, Foguenne M, Lai Q. Hepatocellular cancer selection systems and liver transplantation: from the tower of babel to an ideal comprehensive score. Updates Surg 2021; 73 (05) 1599-1614
- 6 Yao F. Liver transplantation for hepatocellular carcinoma: Expansion of the tumor size limits does not adversely impact survival. Hepatology 2001; 33 (06) 1394-1403
- 7 Mazzaferro V, Llovet JM, Miceli R. et al. Predicting survival after liver transplantation in patients with hepatocellular carcinoma beyond the Milan criteria: a retrospective, exploratory analysis. Lancet Oncol 2009; 10 (01) 35-43
- 8 Duvoux C, Roudot-Thoraval F, Decaens T. et al. Liver transplantation for hepatocellular carcinoma: a model including alpha-fetoprotein improves the performance of Milan criteria. Gastroenterology 2012; 143 (04) 986-994 e3
- 9 Organ Procurement and Transplantation Network. Guidance to Liver Transplant Programs and the National Liver Review Board for: Adult MELD Exceptions for Hepatocellular Carcinoma (HCC). 2023 https://optn.transplant.hrsa.gov/media/gqlnhrtn/20200804_nlrb_adult_hcc_guidance.pdf
- 10 Reig M, Forner A, Rimola J. et al. BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update. Journal of Hepatology 2022; 76 (03) 681-693
- 11 Llovet J, Brú C, Bruix J. Prognosis of Hepatocellular Carcinoma: The BCLC Staging Classification. Semin Liver Dis 1999; 19 (03) 329-338
- 12 Matsumoto MM, Mouli S, Saxena P. et al. Comparing Real World, Personalized, Multidisciplinary Tumor Board Recommendations with BCLC Algorithm: 321-Patient Analysis. Cardiovasc Intervent Radiol 2021; 44 (07) 1070-1080
- 13 Lai Q, Lesari S, Lerut JP. The impact of biological features for a better prediction of posttransplant hepatocellular cancer recurrence. Current Opinion in Organ Transplantation 2022; 27 (04) 305-311
- 14 Gundlach JP, Schmidt S, Bernsmeier A. et al. Indication of Liver Transplantation for Hepatocellular Carcinoma Should Be Reconsidered in Case of Microvascular Invasion and Multilocular Tumor Occurrence. J Clin Med 2021; 10 (06) 1155
- 15 Yao LQ, Chen ZL, Feng ZH. et al. Clinical Features of Recurrence After Hepatic Resection for Early-Stage Hepatocellular Carcinoma and Long-Term Survival Outcomes of Patients with Recurrence: A Multi-institutional Analysis. Ann Surg Oncol 2022; 29 (07) 4291-4303
- 16 Ferrer-Fàbrega J, Forner A, Liccioni A. et al. Prospective validation of ab initio liver transplantation in hepatocellular carcinoma upon detection of risk factors for recurrence after resection. Hepatology 2016; 63 (03) 839-849
- 17 Mehta N, Bhangui P, Yao FY. et al. Liver Transplantation for Hepatocellular Carcinoma. Working Group Report from the ILTS Transplant Oncology Consensus Conference. Transplantation 2020; 104 (06) 1136-1142
- 18 Sapisochin G, Castells L, Dopazo C. et al. Single HCC in cirrhotic patients: liver resection or liver transplantation? Long-term outcome according to an intention-to-treat basis. Ann Surg Oncol 2013; 20 (04) 1194-1202
- 19 Di Sandro S, Sposito C, Ravaioli M. et al. Surgical Treatment of Hepatocellular Carcinoma: Multicenter Competing-risk Analysis of Tumor-related Death Following Liver Resection and Transplantation Under an Intention-to-treat Perspective. Transplantation 2023; 107 (09) 1965-1975