title: Expansion of the Milan criteria without any sacrifice: combination of the Hangzhou criteria with the pre-transplant platelet-to-lymphocyte ratio.
abstract: The Hangzhou criteria expand the Milan criteria safely and effectively in selecting hepatocellular carcinoma (HCC) candidates for liver transplantation (LT), but some patients exceeding the Milan but fulfilling the Hangzhou criteria still show poor outcomes due to early tumor recurrence. In this study, the platelet-to-lymphocyte ratio (PLR) was employed to differentiate high-risk tumor recurrence recipients, and a new method combining PLR and the Hangzhou criteria was established.
  
  
  
  The clinical data of 343 LT for HCC were retrospectively analyzed. Receiver operating characteristic (ROC) analysis was used to determine the PLR cut-off value to stratify patients exceeding the Milan but fulfilling the Hangzhou criteria. The recurrence-free survival (RFS) of recipients was compared after stratification. The Hangzhou criteria & PLR method was proposed and its feasibility was validated by ROC analysis.
  
  
  
  PLR 120 was the most significant cut-off value when comparing RFS of patients exceeding the Milan but fulfilling the Hangzhou criteria. After stratification, the 1-, 3-, and 5-year RFS of patients exceeding the Milan but fulfilling the Hangzhou criteria with PLR < 120 were 84.2%, 73.3%, and 73.3%, respectively, comparable with 85.7%, 73.9%, and 72.8%, respectively, in patients fulfilling the Milan criteria (P = 0.885). Patients exceeding the Milan but fulfilling the Hangzhou criteria with PLR ≥ 120 showed poor outcomes, which were similar in patients exceeding the Hangzhou criteria; 1-, 3-, and 5-year RFS were only 37.5%, 12.5%, and 12.5% vs. 32.3%, 17.6%, and 15.1%, respectively (P = 0.887). ROC analysis demonstrated that the ROC area of the Hangzhou criteria & PLR method was 0.768 for RFS. Multivariate analysis confirmed that PLR ≥ 120 was independently associated with RFS of patients exceeding the Milan but fulfilling the Hangzhou criteria.
  
  
  
  The Hangzhou criteria combined with the pre-transplant PLR can accurately exclude high-risk tumor recurrence recipients; this approach expands the Milan criteria effectively without any sacrifice.
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Weiliang
authors.initials: W
authors.lastname: Xia
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Qinghong
authors.initials: Q
authors.lastname: Ke
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Hua
authors.initials: H
authors.lastname: Guo
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Weilin
authors.initials: W
authors.lastname: Wang
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Min
authors.initials: M
authors.lastname: Zhang
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Yan
authors.initials: Y
authors.lastname: Shen
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Jian
authors.initials: J
authors.lastname: Wu
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Xiao
authors.initials: X
authors.lastname: Xu
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Sheng
authors.initials: S
authors.lastname: Yan
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Jun
authors.initials: J
authors.lastname: Yu
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China.
authors.forename: Mangli
authors.initials: M
authors.lastname: Zhang
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China. shusenzheng@zju.edu.cn.|Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou, 310003, China. shusenzheng@zju.edu.cn.
authors.forename: Shusen
authors.initials: S
authors.lastname: Zheng
mesh_terms: D000328:Adult; D000368:Aged; D019540:Area Under Curve; D014408:Biomarkers, Tumor / Q000097:blood*; D006528:Carcinoma, Hepatocellular / Q000097:blood / Q000473:pathology* / Q000601:surgery; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000097:blood / Q000473:pathology* / Q000601:surgery; D016031:Liver Transplantation; D018655:Lymphocyte Count; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000097:blood / Q000473:pathology; D018579:Patient Selection; D010976:Platelet Count; D012372:ROC Curve; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D014408:Biomarkers, Tumor
keywords: Hangzhou criteria; Hepatocellular carcinoma; Liver transplantation; Platelet-to-lymphocyte ratio