title: Clinical profile and liver explant findings in patients with and without pretransplant downstaging for hepatocellular carcinoma.
abstract: BACKGROUND
  Since August 2010, The Brazilian National Transplantation System has allowed performance of liver transplantation (OLT) for patients with hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) who have been successfully treated with preoperative downstaging (DS). Herein we sought to compare the clinical profiles and liver explant findings among patients with versus without preoperative DS.
  
  
  METHODS
  Prospective cohort of patients with HCC within and beyond the MC undergoing OLT. Patients were considered for DS if they were beyond the MC without evidence of vascular invasion or extrahepatic disease. Transcatheter arterial chemoembolization was used for DS, which was considered to be successful if the MC were achieved at any moment during the follow-up.
  
  
  RESULTS
  Between May 2006 and May 2010, we performed 130 OLTs in HCC patients, among whom 10 received preoperative DS. Both groups were comparable for gender, age, viral etiology, serum levels of alpha fetoprotein, and Child-Pugh and Model for End-Stage Liver Disease (MELD) scores (P > .05). The liver explants were within the MC in 80% of patients with preoperative DS and 90% of those without preoperative DS. They were comparable for the number of HCC nodules, total tumor size, histologic grade, and presence of microvascular invasion. Patients with pretransplant DS showed larger HCC nodules (33.3 ± 9.65 vs 26.3 ± 9.62 mm; P .029) and more frequent macrovascular invasion (1 vs 1 patient, P = .024).
  
  
  CONCLUSIONS
  Preoperative DS for unresectable HCC may provide a curative treatment for patients who would otherwise be candidates for palliative therapy only. The baseline characteristics and liver explant findings were similar in both groups. We have yet to determine whether the differences observed regarding the size of the largest nodule and the higher frequency of macrovascular invasion have an impact on outcome.
authors.affiliation: Abdominal Organ Transplant 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; D001938:Brazil; D006528:Carcinoma, Hepatocellular / Q000097:blood / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D016461:Chemoembolization, Therapeutic; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000097:blood / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D060787:Neoplasm Grading; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D047368:Tumor Burden; D000509:alpha-Fetoproteins / Q000032:analysis
chemical_list: C097353:AFP protein, human; D000509:alpha-Fetoproteins