title: Liver transplantation for hepatocellular carcinoma exceeding the Milan criteria: a single-center experience.
abstract: OBJECTIVE
  To establish a prognostic prediction system for patients with hepatocellular carcinoma (HCC) exceeding Milan criteria after liver transplantation (LT).
  
  
  METHODS
  A total of 130 patients undergoing LT for HCC exceeding Milan criteria were enrolled into the study. Independent predictors for relapse-free survival (RFS) were adopted to establish a grading system to predict the risk of post-LT tumor recurrence.
  
  
  RESULTS
  Multivariate Cox analysis revealed that tumor size >10 cm [vs. ≤ 5 cm: relative risk (RR) = 4.214, P < 0.001], preoperative alpha fetoprotein > 400 ng/ml (vs. ≤ 400 ng/ml: RR = 1.657, P < 0.001), extrahepatic invasion (RR = 2.407, P = 0.005) and vascular invasion (RR = 1.917, P = 0.013) were independent predictors for RFS. The risk index of each patient was defined as the sum of the RR obtained in the Cox analysis for RFS. The risk of tumor recurrence was classified into four grades: grade I-risk index equal to 0, grade II-risk index from 0 to 2, grade III-risk index from 2 to 6 and grade IV-risk index >6. RFS rates of patients with grade I-IV (n = 35, 46, 30 and 19) were 87.5, 57.8, 34.7 and 0 % in 1 year; and 74.4, 41.7, 14.4 and 0 % in 5 years. Both of overall survival (OS) and RFS correlated well with the risk index grade. Patients with grade I achieved comparable prognostic outcomes with the Milan group patients (n = 119) (5-year OS = 73.7 vs. 74.7 %, P = 0.748; 5-year RFS = 74.4 vs. 85.7 %, P = 0.148).
  
  
  CONCLUSIONS
  The new grading system was proved to be a promising system in predicting the patient prognosis after LT for HCC exceeding Milan criteria.
authors.affiliation: Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No.1630 Dongfang Road, Shanghai, 200127, China.
authors.forename: Ping
authors.initials: P
authors.lastname: Wan
authors.forename: Qiang
authors.initials: Q
authors.lastname: Xia
authors.forename: Jian-Jun
authors.initials: JJ
authors.lastname: Zhang
authors.forename: Qi-Gen
authors.initials: QG
authors.lastname: Li
authors.forename: Ning
authors.initials: N
authors.lastname: Xu
authors.forename: Ming
authors.initials: M
authors.lastname: Zhang
authors.forename: Xiao-Song
authors.initials: XS
authors.lastname: Chen
authors.forename: Long-Zhi
authors.initials: LZ
authors.lastname: Han
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000401:mortality* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality* / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011183:Postoperative Complications / Q000175:diagnosis*; D011379:Prognosis; D012307:Risk Factors; D015996:Survival Rate; D000509:alpha-Fetoproteins / Q000032:analysis
chemical_list: D000509:alpha-Fetoproteins