Published online Dec 27, 2020. doi: 10.4240/wjgs.v12.i12.520
Peer-review started: July 24, 2020
First decision: October 21, 2020
Revised: November 3, 2020
Accepted: November 13, 2020
Article in press: November 13, 2020
Published online: December 27, 2020
Processing time: 149 Days and 21 Hours
For many years, liver transplantation for hepatocellular carcinoma (HCC) has been performed according to the Milan criteria for patient selection, using a maximum dominant tumor diameter (MTD) of 5 cm and resulting in a 5-year survival of 75%.
It has recently become apparent, that an expansion of the Milan criteria may be possible for patients with a slightly larger MTD than 5 cm to be transplanted and achieve similar good survival. However, the extent by which MTD can be increased has not been clearly identified.
To identify subsets of HCC patients with larger tumors, who also have longer survival after liver transplant, despite having an MTD > 5 cm.
We retrospectively evaluated a prospectively accrued database of 50 patients who had HCCs > MTD of 5 cm and were treated by living donor liver transplantation.
We found that HCC patients with a MTD 6-10 cm could be stratified according to the presence of low or high levels of serum alpha-fetoprotein (AFP) or gamma glutamyl transpeptidase (GGT), or the 2 serum markers in combination. The results showed that patients with a combination of low AFP plus low GGT had excellent long-term survival. Patients who had either low AFP alone or low GGT alone had intermediate survival and patients with both high AFP plus high GGT had the worst survival.
Measurement of serum AFP and GGT levels permits the identification of HCC patients with tumors greater than the Milan criteria size who can have excellent post-liver transplant survival.
Future research should be directed towards the identification of new HCC biomarkers that will correlate with tumor biology and will help refine the selection of HCC patients with large tumors who can also benefit from treatment with liver transplantation. This will increase the number of HCC patients who can then benefit from increased survival following liver transplantation.