title: Hepatocellular carcinoma recurrence among liver transplant recipients within the Milan criteria.
abstract: BACKGROUND
  Orthotopic liver transplantation (OLT) is an excellent option for patients with unresectable hepatocellular carcinoma (HCC) within the Milan criteria. Recurrence of HCC has a severe impact on post-OLT survival. In this study, we performed an analysis of post-OLT recurrence pattern of HCC.
  
  
  METHODS
  The prospective cohort of OLT patients included those with unresectable HCC within the Milan criteria, and those beyond the Milan criteria who were downstaged with transcatheter arterial embolization until they achieved the Milan criteria.
  
  
  RESULTS
  Between May 2006 and May 2011, we performed 130 OLT for unresectable HCC within the Milan Criteria among whom 9 patients (6.9%) experienced tumor recurrence. Two (22.2%) had undergone preoperative downstaging. At the time of OLT, mean serum alpha-fetoprotein levels were 623.8 ± 682.9 ng/mL. The liver explants showed 7 (77.8%) subjects were within the Milan criteria, with an average 2.6 ± 2.2 tumors, most of which (89%) were moderately differentiated. Microvascular and macrovascular invasion were observed in 5 (55.6%) and 2 (22.2%) cases, respectively. Liver explants were beyond the Milan criteria in both patients who had undergone preoperative downstaging. Recurrence occurred 23.1 ± 14.3 months after OLT, having been detected in the liver (n = 3; 33.3%), lung (n = 3; 33.3%), brain, peritoneum, and adrenal gland (n = 1 each; 11.1% each). Mean survival after detection of recurrence was 137.4 ± 96.4 days.
  
  
  CONCLUSIONS
  Despite strict candidate selection criteria, HCC recurrence may occur after OLT, bearing a significant impact on posttransplant outcomes to optimize results requires refinements in candidate selection, as well as well-defined cost-effective post-OLT surveillance protocols.
authors.affiliation: Abdominal Organ Transplantation Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil.
authors.forename: G
authors.initials: G
authors.lastname: Felga
authors.forename: A S
authors.initials: AS
authors.lastname: Evangelista
authors.forename: P R
authors.initials: PR
authors.lastname: Salvalaggio
authors.forename: L A
authors.initials: LA
authors.lastname: Curvelo
authors.forename: B
authors.initials: B
authors.lastname: Della Guardia
authors.forename: M D
authors.initials: MD
authors.lastname: Almeida
authors.forename: R C
authors.initials: RC
authors.lastname: Afonso
authors.forename: B H
authors.initials: BH
authors.lastname: Ferraz-Neto
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D018579:Patient Selection; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome