Optimizing staging for hepatocellular carcinoma before liver transplantation: A retrospective analysis of the UNOS/OPTN database

Abstract

Assignment of liver allocation priority for hepatocellular carcinoma is predicated on accurate imaging staging. We analyzed radiographically defined stage (radiologic stage [RS]) at listing and most recent extension and pathologic stage (PS) data from 789 liver transplant recipients for whom no pretransplant ablative treatment was given. There were no predetermined imaging or pathological protocols in this retrospective analysis of wait list data. Seventy-two (9.1%), 690 (87.5%), and 27 (3.4%) were listed as stage 1, 2 and Ͼ2, respectively. Computed tomography (CT) scan alone (46.4%), magnetic resonance image scan alone (37.1%), ultrasound alone (1.3%), and multiple imaging studies (15.2%) were used with no difference in time to transplant for listing or most recent scan among the recipient groups. Overall accuracy (RS ϭ PS) was 44.1% and was not different if original listing RS or most recent RS was used for comparison with PS. No one type of imaging technique had superior accuracy (P ϭ 0.13); however, CT scan used alone or in combination compared to not being used at all, had higher odds of being accurate (odds ratio [OR] See Editorial on Page 1445Liver transplantation for early-stage hepatocellular carcinoma (HCC) is more likely to provide a potential cure and improve survival than other less radical techniques. 1 These excellent results for liver transplantation depend on selection of patients with early, favorable-stage disease. Mazzafero et al. indicated that patients with single tumors less than 5 cm in size or 3 or fewer tumors no larger than 3 cm in size have excellent long-term recurrence-free survival. 2 This staging was based on histologic criteria evaluated in the explanted native liver retrospectively. Although this report summarized relatively few cases, many subsequent reports have confirmed that these so-called Milan criteria consistently identify HCC disease with favorable prognosis after liver transplantation. 3,4 How-

Milan criteria in liver transplantation for hepatocellular carcinoma: An evidence-based analysis of 15 years of experience

“…According to the modified Model for End-Stage Liver Disease (MELD) score, cadaveric liver grafts are assigned with priority only to patients meeting the MC at the time of pretransplant staging 107 (ie, United Network for Organ Sharing category T2).…”

Diagnosis and staging of hepatocellular carcinoma prior to transplantation: Expertise or failure

“…Thus, several studies have pointed out which concepts or approaches should be abandoned or at least largely improved. The manuscripts by Kemmer et al 7 and by Freeman et al 8 published in this issue of Liver Transplantation are important additions in that regard.…”

Toward a standardized system for hepatocellular carcinoma diagnosis using computed tomography and MRI

“…The majority of such guidelines endorse ultrasound (US) for screening and surveillance. Contrastenhanced CT or contrast-enhanced MRI are recommended to more definitively evaluate US-detected lesions, detect HCC missed by US in at-risk patients [1][2][3], establish the noninvasive diagnosis of HCC [1][2][3][4], stage tumor extent [4,10,11], assess the severity of underlying liver disease and portal hypertension [12], inform treatment decisions for HCC [11], assess therapeutic response [9,10,13,14] and determine eligibility and priority for liver transplantation [9,13,[15][16][17][18]. In addition, in many North American centers, CT and MRI are used for screening and surveillance and not just for evaluation of patients with positive findings at US surveillance.…”

“…The imaging criteria in most of these guidelines focus only on HCC and hence, in effect, categorize lesions in cirrhotic livers in a binary fashion as either diagnostic of HCC or not diagnostic of HCC [5,9,10,15]. The criteria do not comprehensively address the full spectrum of lesions and pseudolesions, from benign to malignant, encountered in the cirrhotic liver at CT and MRI.…”