title: Excellent outcome following down-staging of hepatocellular carcinoma prior to liver transplantation: an intention-to-treat analysis.
abstract: We previously reported encouraging results of down-staging of hepatocellular carcinoma (HCC) to meet conventional T2 criteria (one lesion 2-5 cm or two to three lesions <3 cm) for orthotopic liver transplantation (OLT) in 30 patients as a test of concept. In this ongoing prospective study, we analyzed longer-term outcome data on HCC down-staging in a larger cohort of 61 patients with tumor stage exceeding T2 criteria who were enrolled between June 2002 and January 2007. Eligibility criteria for down-staging included: (1) one lesion >5 cm and up to 8 cm; (2) two to three lesions with at least one lesion >3 cm and not exceeding 5 cm, with total tumor diameter up to 8 cm; or (3) four to five lesions with none >3 cm, with total tumor diameter up to 8 cm. A minimum observation period of 3 months after down-staging was required before OLT. Tumor down-staging was successful in 43 patients (70.5%). Thirty-five patients (57.4%) had received OLT, including two who had undergone live-donor liver transplantation. Treatment failure was observed in 18 patients (29.5%), primarily due to tumor progression. In the explant of 35 patients who underwent OLT, 13 had complete tumor necrosis, 17 met T2 criteria, and five exceeded T2 criteria. The Kaplan-Meier intention-to-treat survival at 1 and 4 years after down-staging were 87.5% and 69.3%, respectively. The 1-year and 4-year posttransplantation survival rates were 96.2% and 92.1%, respectively. No patient had HCC recurrence after a median posttransplantation follow-up of 25 months. The only factor predicting treatment failure was pretreatment alpha-fetoprotein >1,000 ng/mL.
  
  
  CONCLUSIONS
  Successful down-staging of HCC can be achieved in the majority of carefully selected patients and is associated with excellent posttransplantation outcome.
authors.affiliation: Department of Medicine, University of California, San Francisco, San Francisco, CA, USA. francis.yao@ucsf.edu
authors.forename: Francis Y
authors.initials: FY
authors.lastname: Yao
authors.forename: Robert K
authors.initials: RK
authors.lastname: Kerlan
authors.forename: Ryutaro
authors.initials: R
authors.lastname: Hirose
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Davern
authors.forename: Nathan M
authors.initials: NM
authors.lastname: Bass
authors.forename: Sandy
authors.initials: S
authors.lastname: Feng
authors.forename: Marion
authors.initials: M
authors.lastname: Peters
authors.forename: Norah
authors.initials: N
authors.lastname: Terrault
authors.forename: Chris E
authors.initials: CE
authors.lastname: Freise
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Ascher
authors.forename: John P
authors.initials: JP
authors.lastname: Roberts
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000473:pathology* / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D017408:Guidelines as Topic; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000473:pathology* / Q000601:surgery*; D016031:Liver Transplantation; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D016016:Proportional Hazards Models; D011446:Prospective Studies; D016896:Treatment Outcome; D014850:Waiting Lists