Liver transplantation for hepatocellular carcinoma in India: Are we ready for 2040?

Table 1 Various center-specific criteria for hepatocellular carcinoma used at the time of liver transplantation across India

No. of centers	Center-specific criteria
	Size/No. of tumor	Invasion	Extrahepatic	AFP/markers
4	Any size/any No.	No macrovascular	No	Any
2	Any size/any No.	No macrovascular	No	< 1000
1	Encapsulated, any size, < 10	No macrovascular	No	< 400
1	Within UCSF size/No.	Vp1-vp3 invasion	No	< 400
1	Any size/any No.	Vp1-vp2 invasion	No	Any

UCSF: University of California, San Francisco criteria; AFP: Alpha-fetoprotein.

Table 2 Indications of transarterial chemoembolization, transarterial radioembolization and stereotactic body radiotherapy in hepatocellular carcinoma–chronic liver disease patients awaiting liver transplantation

Modality	TACE	TARE	SBRT
Indications (No. Of centers preferred)	HCC patients on waitlist[12]	PVTT[12]	Vp1-3 PVTT[12]
	> Milan[4]	Large/multiple HCC[6]	Vp2 PVTT[2]
	> UCSF[2]	All affordable cases[3]	TACE/TARE not possible[4]
	Large tumor size[13]		Exophytic HCC[1]
	Awaiting donor fitness/logistical delay in transplant[2]		Diaphragm involved or local infiltration[1]
	High AFP[5]		Presence of shunt[1]
	Absence of PVTT[2]		Not preferred[3]
	TARE unaffordable/unavailable[4]

There is overlap among the respondents for the indications of either modalities. HCC: Hepatocellular carcinoma; PVTT: Portal vein tumor thrombosis; UCSF: University of California, San Francisco criteria; TACE: Trans-arterial chemo embolization; TARE: Trans-arterial radio embolization; SBRT: Stereotactic body radiotherapy; AFP: Alpha fetoprotein.

Table 3 Different criteria for liver transplantation in hepatocellular carcinoma patients

Criteria name (yr)	Size of tumor (cm)	No. of tumors	Additional criteria	Overall 5-year survival
Milan criteria (1996)	≤ 5; ≤ 3	1; 3	None	75%
UCSF criteria (2001)	6.5; ≤ 4.5 (total ≤ 8)	1; 3	None	75.2%
Up-to-7 criteria (2001)	Size (cm) + No. ≤ 7		None
Navarro criteria (2001)	≤ 6; ≤ 5	1; 3	None	79%
Tokyo criteria (2007)	≤ 5	≤ 5	None	75%
Asan criteria (2008)	≤ 5	≤ 6	None	82%
Hangzhou criteria (2008)	< 8 (total)	Any No.	AFP < 400 ng/mL	72%
Chang Gung criteria (2008)	≤ 6.5; ≤ 4.5	1; ≤ 3	None	90%
Hong Kong criteria (2008)	≤ 6.5; ≤ 4.5	1; ≤ 3	None	66%
Kyushu criteria (2009)	≤ 5	Any No.	PIVKA-II < 300 mAU/mL	83%
Kyoto criteria (2010)	≤ 5	≤ 10	PIVKA-II < 400 mAU/mL	87%
Toronto criteria (2011)	Any Size	Any No.	Poorly differentiated HCC excluded	72%
Japanese National Expanded criteria (2019)	≤ 5	≤ 5	AFP < 500 ng/mL	75.8%

All the criteria exclude any vascular invasion or any extra-hepatic spread[25-33]. HCC: Hepatocellular carcinoma.