Proposal of new expanded selection criteria using total tumor size and¹⁸F-fluorodeoxyglucose - positron emission tomography/computed tomography for living donor liver transplantation in patients with hepatocellular carcinoma: The National Cancer Center Korea criteria

Abstract

AIM:To expand the living donor liver transplantation (LT) pool of eligible patients with hepatocellular carcinoma (HCC) using new morphological and biological criteria. METHODS: RESULTS:We enrolled a total of 280 patients who pathologically confirmed to have HCC and performed the PET/CT before transplantation. Among them, 164 (58.6%) patients fulfilled the NCCK criteria and 132 patients (47.1%) met the Milan criteria. Five-year overall and disease-free survival rates for patients who fulfilled the NCCK criteria showed 85.2% and 84.0%, respectively, and were significantly higher than those beyond the NCCK criteria (60.2% and 44.4%, respectively; P < 0.001). The correlation analysis between preoperative imaging tests and pathologic reports using Cohen's Kappa demonstrated the better results in the NCCK criteria than those in the Milan criteria (0.850 vs 0.583). The comparison of diseasefree analysis among the NCCK, Milan, and University of California, San Francisco (UCSF) criteria using the receiver operating characteristics curves revealed the similar area under the curve value criteria (NCCK vs Milan, P = 0.484; NCCK vs UCSF, P = 0.189 at 5-years). CONCLUSION:The NCCK criteria using hybrid concept of both morphological and biological parameters showed an excellent agreement between preoperative imaging and pathological results, and favorable survival outcomes. These new criteria might select the optimal patients with HCC waiting LDLT and expand the selection pool.

What Are the Optimal Liver Transplantation Criteria for Hepatocellular Carcinoma?

“…Another potential selection criterion for patients beyond Milan criteria, especially in LT centers with either short LT wait times or prior to live donor liver transplant (LDLT), is to use 18 F‐FDG‐PET scans, an excellent predictor of worse tumor differentiation and microvascular invasion. FDG‐negative patients beyond Milan criteria have satisfactory post‐LT outcome, whereas those with a tumor‐to‐nontumor ratio (TNR) greater than 2 tend to do poorly (Table ).…”

Advancements of liver transplantation for hepatocellular carcinoma in Korea

“…The NCCK criteria were defined as tumors with a total tumor size of 10 cm or less and negative PET status. In their study, the 5-year overall and disease-free survival rates of 164 patients within the NCCK criteria were 85.2% and 84.0%, respectively (36). The NCCK criteria increased the number of candidates suitable to LT by 24% compared with the Milan criteria, while the results of the NCCK were not inferior to those of the Milan criteria (36).…”

“…According to the NCCK criteria, the PET positivity was assessed by experienced nuclear medicine physicians who checked that the maximal standard uptake value of a tumor (T max ) was higher than that of surrounding noncancerous liver tissue (L max ) (T max /L max > 1.0) (36). On the other hand, Lee et al (38) reported that a T max /L max value >1.15 was the most effective predictor of HCC recurrence after LT.…”

The Evolution of Criteria for Liver Transplantation for Hepatocellular Carcinoma: From Milan to San Francisco and All Around the World!

“…In 2015, Lee et al 44 published a study including 280 patients who received LDLT at the National Cancer Center and reported that HCC patients exceeding the Milan criteria with a negative PET/CT and overall tumor size <10 cm demonstrated overall survival and recurrence-free survival rates similar to those meeting the Milan criteria. In 2016, they proposed the so-called National Cancer Center Korea (NCCK) criteria, according to which patients selected for LDLT should present with negative PET/ CT assessment and a total tumor size < 10 cm 45 .…”

“…Significantly, PET-positive findings were the only independent factor predictive of cancer-related patient drop-out from the waiting list. On this basis, Lee et al 45 proposed the aforementioned NCCK criteria.…”