title: Total tumor volume and alpha-fetoprotein for selection of transplant candidates with hepatocellular carcinoma: A prospective validation.
abstract: The selection of liver transplantation (LT) candidates with hepatocellular carcinoma (HCC) is currently validated based on Milan criteria. The use of extended criteria has remained a matter of debate, mainly because of the absence of prospective validation. The present prospective study recruited patients according to the previously proposed total tumor volume (TTV; ≤115 cm(3) )/alpha-fetoprotein (AFP; ≤400 ng/mL) score. Patients with AFP >400 ng/mL were excluded, and, as such, the Milan group was modified to include only patients with AFP <400 ng/mL; these patients were compared to patients beyond Milan, but within TTV/AFP. From January 2007 to March 2013, 233 patients with HCC were listed for LT. Of them, 195 patients were within Milan and 38 beyond Milan, but within TTV/AFP. The average follow-up from listing was 33.9 ± 24.9 months. Risk of dropout was higher for patients beyond Milan, but within TTV/AFP (16 of 38; 42.1%), than for those within Milan (49 of 195 [25.1%]; P = 0.033). In parallel, intent-to-treat survival from listing was lower in patients beyond Milan (53.8% vs. 71.6% at 4 years; P < 0.001). After a median waiting time of 8 months, 166 patients were transplanted, 134 within Milan criteria, and 32 beyond Milan but within TTV/AFP. They demonstrated acceptable and similar recurrence rates (4.5% vs. 9.4%; P = 0.138) and post-transplant survivals (78.7% vs. 74.6% at 4 years; P = 0.932).
  
  
  CONCLUSIONS
  Based on the present prospective study, HCC LT candidate selection could be expanded to the TTV (≤115 cm(3) )/AFP (≤400 ng/mL) criteria in centers with at least 8-month waiting time. An increased risk of dropout on the waiting list can be expected, but with equivalent and satisfactory post-transplant survival.
authors.affiliation: Divisions of Transplant and Abdominal Surgery, Department of Surgery, University of Geneva Hospitals, Geneva, Switzerland.
authors.forename: Christian
authors.initials: C
authors.lastname: Toso
authors.affiliation: Division of Transplantation, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Glenda
authors.initials: G
authors.lastname: Meeberg
authors.affiliation: Multi-Organ Transplant Program, London Health Sciences Center, The University of Western Ontario, London, Ontario, Canada.
authors.forename: Roberto
authors.initials: R
authors.lastname: Hernandez-Alejandro
authors.affiliation: University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland.
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Dufour
authors.affiliation: Multi-Organ Transplant Program, London Health Sciences Center, The University of Western Ontario, London, Ontario, Canada.
authors.forename: Paul
authors.initials: P
authors.lastname: Marotta
authors.affiliation: Divisions of Transplant and Abdominal Surgery, Department of Surgery, University of Geneva Hospitals, Geneva, Switzerland.
authors.forename: Pietro
authors.initials: P
authors.lastname: Majno
authors.affiliation: Division of Transplantation, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Norman M
authors.initials: NM
authors.lastname: Kneteman
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000097:blood / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008099:Liver / Q000473:pathology*; D008113:Liver Neoplasms / Q000097:blood / Q000473:pathology / Q000601:surgery*; D016031:Liver Transplantation / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011446:Prospective Studies; D000509:alpha-Fetoproteins / Q000378:metabolism*
chemical_list: D000509:alpha-Fetoproteins