Liver transplantation in hepatocellular carcinoma - should we perform downstaging?

Aim To compare the long-term outcomes between liver transplant (LT) recipients with hepatocellular carcinoma (HCC) who were downstaged with transarterial-chemoem-bolization (TACE) to the Milan criteria (MC) and those ini-tially meeting the MC.Methods This retrospective study enrolled 198 patients with HCC: 38 were downstaged and 160 patients initially met the MC. Post-LT survival and HCC recurrence-free sur-vival were evaluated. We assessed the association of death and HCC recurrence with TACE, baseline (age, sex, disease etiology, Model of End-stage Liver Disease, tumor number and the sum of maximum tumor diameters, waiting time, alpha-fetoprotein level) and explant characteristics (tumor number and the sum of maximum tumor diameters, mi- cro-and macrovascular invasion).Results The recipient survival rates one, three, and five years after LT were 88.2%, 80.1%, and 75.9%, respectively. HCC recurrence-free probabilities were 92.3%, 87.9%, and 85%, respectively. The outcomes were comparable be-tween the groups. In multivariate analysis, the number of tumors on the explant, age, and tumor recurrence were independent risk factors for death. Only the sum of max-imum tumor diameters on the explant was an indepen-dent risk factor for HCC recurrence.Conclusions Patients successfully downstaged with TACE to the MC can achieve post-LT recipient and HCC recur-rence-free survival comparable with patients initially with-in the MC. Good response to TACE as a criterion for LT may be a method of selecting patients with favorable biological characteristics.