Extensive Liver Cancer Is No Bar to Successful Transplant

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Extensive Liver Cancer Is No Bar to Successful Transplant

By Gever, Senior Editor, MedPage Today

Published: December 03, 2008

Reviewed by Jasmer, MD; Associate Clinical Professor of Medicine,

University of California, San Francisco Earn CME/CE credit

for reading medical news

MILAN, Italy, Dec. 3 -- Current criteria for evaluating liver cancer patients

for possible transplantation may unnecessarily disqualify some who would benefit

from the procedure, researchers here said.

Action Points

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Explain to interested patients that the study found patients with liver cancer

extensive enough to disqualify them for transplant under current criteria can

nevertheless undergo successful transplants.

Explain that the study's methods for measuring the extent of liver cancer

differed from those used clinically for pre-transplant staging.

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Under so-called Milan criteria, the present international standard, patients

with single liver tumors less than 5 cm, or three or fewer tumors no more than 3

cm, receive the highest priority for available organs.

But among 1,556 patients studied retrospectively, there were clearly

identifiable subgroups of transplanted patients who exceeded these criteria yet

whose survival was as good as those meeting the Milan standard, reported

Vincenzo Mazzaferro, M.D., of the National Cancer Institute here, and colleagues

online in Lancet Oncology.

" This study shows that a group of patients with hepatocellular carcinoma with

excellent outcome exists outside the conventional Milan criteria, with upper

limits defined by the up-to-seven rule and in the absence of vascular invasion, "

the researchers wrote.

The " up-to-seven " rule refers to the sum of size (in cm) and number of tumors

for any given hepatocellular carcinoma. Patients with a score of seven or less

under this scheme would satisfy the rule.

Dr. Mazzaferro and colleagues conducted the study by inviting oncologists,

through a web-based survey, to provide information on liver cancer patients they

had treated.

The survey requested pre-transplant histopathologic and other data, as well as

post-transplant outcomes on individual patients.

The researchers obtained responses from 36 liver transplant centers, mainly in

Europe. Data for 444 patients meeting the standard Milan criteria and 1,112

patients outside those standards were included.

For patients meeting the Milan criteria, the five-year survival rate was 73.3%

(95% CI 68.2% to 77.7%).

Overall, five-year survival for those outside the Milan criteria was

substantially poorer -- 53.6% (95% CI 50.1% to 57.0%).

On the other hand, for 283 patients outside the Milan criteria but who satisfied

the up-to-seven rule and had no signs of microvascular invasion, the five-year

survival rate was 71.2% (95% CI 64.3% to 77.0%).

Under current procedures, that subpopulation, may be unnecessarily sent to the

back of the line for donor livers, the researchers suggested.

They noted that many transplant surgeons already consider the Milan criteria

excessively restrictive.

In fact, they recommended jettisoning rule-based systems for prioritizing

transplant candidates altogether, in favor of patient-specific predictions of

outcomes based on multiple factors.

" The advantages of an individualized forecast for patients with liver cancer who

are proposed for transplant candidacy are self-evident in the frame of graft

shortage and limited access to transplantation, " they said.

But they cautioned that additional research is needed before such a system could

be implemented.

" Further refinements of the model are desirable for other parameters that were

not included in the present study, " they said, listing tumor grade and etiology,

responses to previous treatments, and other factors already known to predict

liver cancer outcomes.

One limitation of the study, they noted, was the fact that information on tumor

characteristics came from post-transplant histopathology, which is more accurate

than the methods used pre-transplant to gauge tumor numbers and size.

No external funding was used for the study.

No potential conflicts of interest were reported./td>

Primary source: Lancet Oncology

Source reference:

Mazzaferro V, et al., " Predicting survival after liver transplantation in

patients with hepatocellular carcinoma beyond the Milan criteria: a

retrospective, exploratory analysis, " Lancet Oncology 2008;

DOI:10.1016/S1470-2045(08)70284-5.