title: Benefit of downsizing hepatocellular carcinoma in a liver transplant population.
abstract: BACKGROUND
  Long-term results after downstaging hepatocellular carcinoma (HCC) prior to liver transplantation (LT) remain unknown.
  
  
  OBJECTIVE
  To investigate dropouts and post-transplant outcome among patients with downstaged HCC by transarterial chemo-lipiodolization (TACL).
  
  
  METHODS
  Between 2000 and 2007, 386 patients with HCC initially exceeding Milan criteria underwent TACL for tumour downstaging and were consecutively enrolled.
  
  
  RESULTS
  Overall, 160 (41.5%) patients achieved successful downstaging of HCC to within Milan criteria. During the follow-up, 82 eventually dropped off the waiting list for LT, with estimated dropout rates at 1, 2 and 5 years of 46.7%, 70.2%, and 87.2%, respectively. The overall post-transplant survival rates at 1, 2 and 5 years were 89.2%, 70.3% and 54.6% and the corresponding rates for recurrence-free survival were 74.7%, 71.8% and 66.3% respectively. Multivariate analysis indentified alpha-fetoprotein (AFP) levels > or = 100 ng/mL at LT (P = 0.003), maximum tumour size > or = 7 cm (P = 0.002) and the lack of complete necrosis by TACL (P = 0.048) as independent predictors of HCC recurrence after LT. Patients with none of these risk factors had an excellent post-transplant outcome, with an 87.5% probability of recurrence-free survival up to 6 years.
  
  
  CONCLUSIONS
  These long-term results may contribute to the database for optimizing management of LT candidates with downstaged HCC. Based on our data, patients with a maximum tumour size <7 cm who achieve complete necrosis together with AFP levels <100 ng/mL at LT may be the best candidates for LT following downstaging using TACL.
authors.affiliation: Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 137-040, Korea. garden@catholic.ac.kr
authors.forename: J W
authors.initials: JW
authors.lastname: Jang
authors.forename: C R
authors.initials: CR
authors.lastname: You
authors.forename: C W
authors.initials: CW
authors.lastname: Kim
authors.forename: S H
authors.initials: SH
authors.lastname: Bae
authors.forename: S K
authors.initials: SK
authors.lastname: Yoon
authors.forename: Y K
authors.initials: YK
authors.lastname: Yoo
authors.forename: D G
authors.initials: DG
authors.lastname: Kim
authors.forename: J Y
authors.initials: JY
authors.lastname: Choi
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000379:methods*; D018579:Patient Selection; D011300:Preoperative Care / Q000379:methods*; D015996:Survival Rate; D014850:Waiting Lists