Liver Transplantation for HCC Patients according to Milan's criteria

Abstract

Based on current data, general exclusion of patients with HCC beyond MC from LT is no longer justified. In fact, the implementation of the MC in 1996 had a tremendous impact on establishing HCC as major indication for LT. Patients with HCC meeting the MC may achieve 5-year recurrence-free survival rates of about 70%. In the last two decades, no other development in the field of visceral surgical oncology was able to provide comparable rates of cure. In recent years, however, huge advancements in radiographic and interventional tech-niques, surgical procedures, immunosuppressive treatments, and, not least, the understanding of tumor biology have been made. These proceedings opened up new perspectives “beyond” MC, where patients with advanced HCC may be identified to benefit from LT. Posttransplant 5-year survival probabilities above 50% in these patients have intensified the call for an extension of transplant selection criteria. It is a major problem in our days that frequency of organ donation is continuously decreasing and waiting times prior to LT are steadily increasing. Liver transplant candidates with HCC are, thereby, exposed to a significant risk of tumor-related drop-out from the waiting list or posttransplant HCC relapse. Against this background, implementing LT in patients with HCC beyond Milan criteria into clinical routine depicts a multisciplinary challenge. It is undoubted that adequate patients’ selection should be rather based on tumor biology than on static macromorphology of HCC. Histopathologic parameters of aggressive tumor behaviour, such as poor tumor grading or MVI, may be safely and reliably assessed only at explant analysis. Therefore, reliable clinical surrogate markers, such as AFP, should be incorporated into pretransplant decision process. Since biological tumor aggressiveness may change during prolonged waiting time, tumor biology should be reassessed in a dynamic way. This may be easily performed with already established tumor markers.