Liver Transplantation Guidelines and Studies

Aug 8, 2024

Behind the Knife - Liver Transplantation for Cirrhosis and Hepatocellular Carcinoma (HCC)

Introduction

  • Speaker: Kim Linden, General Surgery Resident, Cooper University Hospital
  • Topics: Guidelines for liver transplantation in patients with cirrhosis and hepatocellular carcinoma (HCC)

Transplantation Criteria for HCC

  • **Patients Considered for Transplantation: **
    • Patients with centrally located and unresectable HCC and cirrhosis
    • Patients with HCC and advanced cirrhotic disease preventing surgical resection
  • **UNOS Criteria: **
    • Single tumor < 5 cm in diameter
    • Up to 3 tumors, each up to 3 cm
    • No macrovascular involvement or extrahepatic disease

Key Studies Cited

  • **Milan Study (1996, New England Journal of Medicine)

    • **Study Design: ** 3-year prospective cohort study of 48 patients
    • **Participants: ** Patients with cirrhosis and resectable HCC
    • Criteria: T1 or T2 tumors on preoperative imaging
      • Solitary tumors up to 5 cm or 2-3 tumors up to 3 cm
    • **Findings: **
      • 8 out of 48 patients died post-transplant (2 cancer-related)
      • 4 had recurrence (3 had higher tumor stage pathologically than preoperatively identified)
      • Overall 4-year survival: 75%
      • Recurrence-free survival: 83%
      • Tumor size, stage, number of tumors, serum AFP, absence of capsule trended to higher recurrence rate but not statistically significant
    • Conclusion: Developed Milan criteria for transplant eligibility

  • **UCSF Study (2001, Journal of Hepatology)

    • Study Design: 12-year evaluation of consecutive patients
    • Participants: Patients with cirrhosis and HCC undergoing orthotopic liver transplant
    • Findings:
      • 70 out of 970 patients had cirrhosis with HCC
        • 23 were incidentally found with HCC
        • Tumor distribution: 11 (pathologic T1), 35 (T2), 18 (T3), 6 (T4)
        • Recurrence in 8 patients: 2 (T4), 3 (T3), 3 (T2)
      • Survival:
        • T2 or less: 1-year survival 91%, 5-year survival 72.4%
        • T3: 1-year survival 82.4%, 5-year survival 74%
        • T4 tumors were strongest predictor of mortality (HR = 8)
        • Poor survival predictors: Tumor diameter > 8 cm, poorly differentiated histology, age ≥ 55, AFP > 1000 ng/mL
    • Conclusion: Pathologic T3 tumors had similar survival rates to T2 or less, should be considered for transplant
    • Guidelines:
      • Tumor < 6.5 cm
      • 2-3 tumors, largest up to 4.5 cm, total diameter ≤ 8 cm

Preoperative Imaging Accuracy

  • **Imaging Modalities: ** Ultrasound, CT, MRI
    • Sensitivity for detecting main lesion:
      • Ultrasound: 79.4%
      • CT: 81.6%
      • MRI: 88.9%
    • Accuracy for lesion size within 1 cm:
      • Ultrasound: 62%
      • CT: 80%
      • MRI: 75.6%
    • Multiple nodules detection sensitivity:
      • Ultrasound: 34%
      • CT: 27.6%
      • MRI: 42.9%

Comparison of Milan and UCSF Criteria

  • **Milan Criteria: **
    • Solitary tumor ≤ 5 cm
    • 2-3 tumors, each ≤ 3 cm
  • **UCSF Criteria: **
    • Tumor ≤ 6.5 cm
    • 2-3 tumors, largest ≤ 4.5 cm, total diameter ≤ 8 cm
    • Higher cutoff for tumor sizes but same maximum number of tumors

Conclusion

  • Speaker: Kim Linden
  • Contact: Email or Twitter @ik_linden_md