title: Low recurrence rate of hepatocellular carcinoma after liver transplantation: better patient selection or lower immunosuppression?
abstract: BACKGROUND
  Liver transplantation is currently offered to a limited number of patients with hepatocellular carcinoma (HCC) because of strict criteria introduced in the past to avoid recurrence. Immunosuppression represents a risk factor for tumor growth; the schedules of the immunosuppressant drugs have been modified through the years, aiming to reduce their dosage to the effective minimum.
  
  
  METHODS
  A series of 106 consecutive patients with HCC who underwent transplantation over a 15-year period at a single institution was retrospectively reviewed to ascertain whether tumor recurrence was influenced by the Milano criteria presently adopted in patient selection and whether the dosage of immunosuppressant agents administered was associated with tumor recurrence. Fifteen patients who died postoperatively and 9 with a follow-up of less than 1 year were excluded; presence of the Milano criteria, tumor-node-metastasis staging, and the cumulative dosage of the single immunosuppressants given at different intervals in the first postoperative year were analyzed in the remaining 82 patients. The influence of these variables on overall and recurrence-free survival was assessed statistically.
  
  
  RESULTS
  The Milano criteria did not influence recurrence-free survival, which was instead associated with the cumulative dosage of cyclosporine administered in the first postoperative year (93% 5-year recurrence-free survival for patients given low dosage vs. 76% for those given high dosage; P=0.01); T3 and T4 tumors did worse than T1 and T2 tumors.
  
  
  CONCLUSIONS
  Current limits to transplantation for HCC might be reassessed in view of modified patient management; immunosuppression should be minimized in these patients.
authors.affiliation: Department of Surgery and Transplantation, University of Bologna, Bologna, Italy. vivarelli@orsola-malpighi.med.unibo.it.
authors.forename: Marco
authors.initials: M
authors.lastname: Vivarelli
authors.forename: Roberto
authors.initials: R
authors.lastname: Bellusci
authors.forename: Alessandro
authors.initials: A
authors.lastname: Cucchetti
authors.forename: Giulia
authors.initials: G
authors.lastname: Cavrini
authors.forename: Nicola
authors.initials: N
authors.lastname: De Ruvo
authors.forename: Ardo Abdiueli
authors.initials: AA
authors.lastname: Aden
authors.forename: Giuliano
authors.initials: G
authors.lastname: La Barba
authors.forename: Stefano
authors.initials: S
authors.lastname: Brillanti
authors.forename: Antonino
authors.initials: A
authors.lastname: Cavallari
mesh_terms: D000328:Adult; D006528:Carcinoma, Hepatocellular / Q000276:immunology* / Q000401:mortality; D016572:Cyclosporine / Q000008:administration & dosage*; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage*; D008113:Liver Neoplasms / Q000276:immunology* / Q000401:mortality; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D018579:Patient Selection; D011183:Postoperative Complications / Q000276:immunology / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate
chemical_list: D007166:Immunosuppressive Agents; D016572:Cyclosporine