Liver Transplantation for Extended Criteria Hepatocellular Carcinoma Using Stable Response to Locoregional Therapy and Alpha-Fetoprotein as Selection Criteria

Introduction: Current practice to only prioritize hepatocellular carcinoma (HCC) that fulfill the Milan criteria (IN MC ) is changing, since it causes the exclusion of patients who could benefit from liver transplantation. To select patients outside MC (OUT MC ) for transplantation, we implemented extended selection criteria without up-front morphometric restrictions containing surrogate parameters of tumor biology. Methods: OUT MC patients were considered without restrictions of morphometrics and received locoregional treatment after interdisciplinary consultation. Our dynamic selection criteria for OUT MC patients required (IN MUC ): (1) treatment response over (2) at least 6 months and (3) alpha-fetoprotein ≤400 ng/mL over the entire evaluation period. Patients with IN MC tumors served as control and internal validation cohort. Results: 31 of 170 liver transplant candidates were OUT MC . Of these, 8 dropped out. The remaining 23 patients met the selection criteria and underwent transplantation. Recurrence-free survival was higher in patients transplanted IN MC compared to those OUT MC IN MUC (92.2% vs. 70.8%; p = 0.026) after 5 years of follow-up. Overall survival showed no significant difference (p = 0.552). With dynamic selection of transplant candidates, recurrence could also be predicted for the IN MC patients as internal validation cohort (c-index: 0.896; CI 0.588–0.981, p = 0.005). Conclusion: Dynamic selection criteria for the stratification of patients with OUT MC HCCs is feasible and allows for excellent long-term results and acceptable tumor recurrence rates comparable to IN MC patients.