Liver transplantation for hepatocellular carcinoma in China

Abstract

In China, a large portion of liver transplant recipients were hepatocellular carcinoma (HCC) patients. Data from the China Liver Transplant Registry (CLTR) were analyzed to evaluate extended criteria developed and exercised in China in comparison with the Milan criteria to identify patients who may benefi t from liver transplantation. 11,457 patients who underwent liver transplantation in China from 1993 to 2007 were recorded in the Registry. Forty-fi ve percent (n=5159) of them were HCC patients. Male patients predominated (n=4641, 90%). The hospital mortality rate of the HCC recipients was 5.7%. The median follow-up duration was 15.8 months (range 0–111.6 months). The 1-, 3-, 5-year survival rates for all HCC recipients were 72.5%, 52.5% and 46.3%, respectively. Four selection criteria (Milan, UCSF, Fudan and Hangzhou) were evaluated based on the univariate analysis. All of them successfully predicted the post-transplant patient survival outcome (p<0.001). For patients with tumor status within the Milan, UCSF, Fudan and Hangzhou criteria, the estimated 5-year survival rates were 66%, 64.7%, 61.2% and 61%, respectively. For patients with tumors status beyond the Milan, UCSF, Fudan and Hangzhou criteria, the 5-year survival rates were 34.2%, 31%, 31.5%, and 24.8%, respectively. The survival rate of patients within the Milan criteria was higher than those of patient groups within the extended criteria but beyond the Milan criteria (p<0.05). Logistic regression analysis comparing patient groups beyond the Milan criteria with (n=1315, 75.4%) or without (n=430, 24.6%) HCC recurrences within 2 years of transplantation indicated that pre-operation alpha-fetoprotein level (>125ng/ml, p=0.004), vascular invasion (p<0.001), non-hepatitis B related liver disease (p=0.002), tumor size (one of nodule>=4cm while number of tumor nodule>1, p=0.004) and the number of tumor nodules (>5, p=0.001) were independent risk factors for disease recurrence. The information provided by this large cohort of HCC liver transplant recipients suggested that Milan criteria remains to be the most critical criteria but may dismiss 24.6% patients who may not have early tumor recurrence. A more sophisticated prediction model will be required to identify the HCC patients beyond the Milan criteria, yet have a potential to achieve satisfactory outcomes and benefi t from liver transplantation.