Sa1023 Liver Transplantation for Hepatocellular Carcinoma Outside of Both Milan and UCSF Criteria: Does Etiology of Liver Disease Impact Outcomes?

Abstract

Background: Liver transplantation (LT) is the optimal treatment for selected patients with hepatocellular carcinoma (HCC). Survival of >80% at 4 years has been demonstrated for patients with HCC meeting Milan criteria. The UCSF group reported acceptable outcomes using a specific protocol for patients beyond Milan criteria. Proceeding with LT for HCC outside UCSF criteria is very controversial given the concern for recurrent HCC affecting longterm outcomes. Underlying viral disease may influence post-transplant immunosuppression. However, the impact of a viral etiology on patients with HCC at higher risk of recurrence is unknown. We sought to examine the impact of underlying etiology of liver disease on recurrence and outcomes in patients who had explants with HCC beyond Milan and UCSF criteria. Methods: We reviewed 87 patients after LT for HCC from 1998-2009 with explant tumor beyond Milan UCSF criteria. We compared outcomes of patients with cirrhosis due to chronic hepatitis B or C to those from non-viral etiology, with recurrence data up to 11/ 2012. Results: The viral hepatitis group (n=58) had a mean LT age of 56.7 years. Hepatitis C (HCV) was present in 86%, with eleven achieving SVR after transplant and one before. Mean biological MELD and mean alfa-fetoprotein (AFP) at LT were 14.4 and 537.9ng/mL, respectively. Pre-LT locoregional therapy with transarterial chemoembolization (TACE) or radiofrequency ablation (RFA) was given in 81% and 12%, respectively. At explant, mean tumor count (MTC) was 4.3, mean largest tumor size (mLTS) was 4.92cm, and 46.6% had vascular invasion. HCC recurrence occurred in 50%, with a mean patient survival time (PST) of 3.41 years. 10 of the 12 HCV patients with SVR had HCC recurrence. Patient survival at 1 year (1yPS) and 3 years (3yPS) was 81% and 48%, respectfully, both lower than the 2005-2010 Surgical Registry of Transplant Recipient (SRTR) national averages. The non-viral group (n=29) had a mean LT age of 61.3 years. Mean MELD and AFP were 17.3 and 1190.1ng/mL, respectively. Pre-LT TACE and RFA were performed in 85% and 7%, respectively. MTC was 4.7 and mLTS was 4.95cm. 65.5% had vascular invasion. HCC recurrence occurred in 55.2%, with a mean PST of 3.76 years. 1yPS and 3yPS was 79% and 48%, respectively, again lower than the national averages from the 2005-2010 SRTR. Conclusion: In our cohort of patients who had HCC outside of Milan and UCSF criteria that underwent LT, the cause of liver disease did not impact recurrence of HCC or patient survival. Both viral and non-viral groups had similar disease burden, AFP levels, and vascular invasion in the explant as well as cancer recurrence rates. HCV SVR did not appear to impact HCC recurrence. Longer term survival was less favorable for patients transplanted beyond Milan and UCSF criteria and was lower than the national average for the same time period.