title: Effect of Downstaging and Bridging of Hepatocellular Carcinoma on Survival Following Liver Transplant: A Single Center Experience.
abstract: OBJECTIVE
  Hepatocellular carcinoma is among the leading causes of cancer death. The Milan criteria are the first and most widely used criteria for selecting patients with hepatocellular carcinoma for a good transplant outcome. Studies have shown that patients with hepatocellular carcinoma outside the Milan criteria have good outcomes if they are successfully downstaged before transplant. We report our experience with locoregional therapy for hepatocellular carcinoma, either for bridging or for downstaging prior to transplant.
  
  
  METHODS
  We retrospectively reviewed the electronic charts and our institutional database for adult patients diagnosed with hepatocellular carcinoma between 2001 and 2016. We recorded patient demographics, the type of transplant (living donor or deceased donor), radiologic findings, the type of locoregional intervention, and overall survival.
  
  
  RESULTS
  A total of 642 adult liver transplants were performed during the study period (290 living donor and 352 deceased donor), of which 158 (24.6%) were conducted in patients with hepatocellular carcinoma (104 men and 54 women). Hepatocellular carcinoma was associated with hepatitis C in 80 patients (51%), hepatitis B in 44 (28%), and was cryptogenic in 13 (8%). Patients were grouped based on their radiologic staging (within Milan, within and beyond University of California, San Francisco), and subsequently described by whether they received locoregional therapy. Median survival and mortality were noted. Kaplan-Meier survival curves showed no statistically significant difference for patients within the Milan criteria, with or without locoregional therapy (P = .5). When patients within the Milan criteria were combined with patients within the University of California, San Francisco criteria, those who were downstaged from outside the latter criteria had similar survival.
  
  
  CONCLUSIONS
  We demonstrate that carefully selected patients beyond the Milan criteria and even beyond the University of California, San Francisco criteria can be bridged and downstaged successfully for liver transplant.
authors.affiliation: Department of Liver & Small Bowel Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
authors.forename: Mohammed I
authors.initials: MI
authors.lastname: Al Sebayel
authors.forename: Hussien
authors.initials: H
authors.lastname: Elsiesy
authors.forename: Waleed
authors.initials: W
authors.lastname: Al-Hamoudi
authors.forename: Saleh
authors.initials: S
authors.lastname: Alabbad
authors.forename: Yasser
authors.initials: Y
authors.lastname: ElSheikh
authors.forename: Hany
authors.initials: H
authors.lastname: Elbeshbeshy
authors.forename: Isam
authors.initials: I
authors.lastname: Salih
authors.forename: Sarra
authors.initials: S
authors.lastname: Yousif
authors.forename: Yahia
authors.initials: Y
authors.lastname: Saleh
authors.forename: Abdulmoneim
authors.initials: A
authors.lastname: Eldali
authors.forename: Faisal A
authors.initials: FA
authors.lastname: Abaalkhail
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D017115:Catheter Ablation / Q000009:adverse effects / Q000401:mortality; D016461:Chemoembolization, Therapeutic / Q000009:adverse effects / Q000401:mortality; D017024:Chemotherapy, Adjuvant; D016208:Databases, Factual; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality; D019520:Living Donors; D008297:Male; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D018579:Patient Selection; D012189:Retrospective Studies; D012307:Risk Factors; D012529:Saudi Arabia; D013997:Time Factors; D016896:Treatment Outcome