Expanded selection criteria of living donor liver transplantation for hepatocellular carcinoma using total tumor size and 18F-FDG-PET/CT

Objectives: We proposed new expanded selection criteria using biological and morphological characteristics for living donor liver transplantation (LDLT) in patients with hepatocellular carcinoma (HCC). Background: Several expanded criteria based on morphological features have been proposed to identify appropriate candidates for liver transplantation (LT). However, the definitions are still complex, and the benefit of expanding the pool remains controversial. Methods: From March 2005 to May 2013, patients with HCC who underwent LDLT at the National Cancer Center, Korea (NCCK) were enrolled. Overall survival (OS) and disease-free survival (DFS) were investigated according to the NCCK criteria using 18F-fluorodeoxyglucose positron-emission tomography/computed tomography and total tumor size (cutoff 10 cm). Results: Of a total of 280 patients, 164 (58.6%) were pathologically confirmed to have HCC that fulfilled the NCCK criteria, compared with 132 patients (47.1%) within the Milan criteria. The five-year OS and DFS rates were greater for patients within the NCCK criteria (85.2% and 84.0%, respectively) than for patients beyond the NCCK criteria (60.2% and 44.4%, respectively; p<0.001). The NCCK criteria showed better correlation with preoperative imaging and explant pathological reports than the Milan criteria (Cohen's Kappa 0.850 vs. 0.583). The receiver operating characteristic curves for DFS using the NCCK criteria showed similar area under the curve values compared with the Milan and University of California, San Francisco criteria (NCCK vs. Milan, p = 0.484; NCCK vs. UCSF, p = 0.189 at five-years). Conclusions: The NCCK criteria showed an excellent agreement between preoperative imaging and pathological results, and favorable survival outcomes.