Editorial
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 14, 2017; 23(18): 3195-3204
Published online May 14, 2017. doi: 10.3748/wjg.v23.i18.3195
Liver transplantation for intermediate hepatocellular carcinoma: An adaptive approach
Marco Biolato, Giuseppe Marrone, Luca Miele, Antonio Gasbarrini, Antonio Grieco
Marco Biolato, Giuseppe Marrone, Luca Miele, Antonio Gasbarrini, Antonio Grieco, Liver Transplant Medicine, Gastroenterological Area, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario Gemelli, Universita’ Cattolica del Sacro Cuore, 00168 Roma, Italy
Author contributions: Biolato M, Marrone G and Miele L performed bibliographic research and wrote the paper; Gasbarrini A and Grieco A revised the paper for important intellectual contribution.
Conflict-of-interest statement: The authors declare no conflict of interest related to this publication.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Antonio Grieco, MD, Professor, Liver Transplant Medicine, Gastroenterological Area, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario Gemelli, Universita’ Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Roma, Italy. antonio.grieco@unicatt.it
Telephone: +39-6-30155451 Fax: +39-6-35502775
Received: January 28, 2017
Peer-review started: February 6, 2017
First decision: February 23, 2017
Revised: March 12, 2017
Accepted: April 12, 2017
Article in press: April 12, 2017
Published online: May 14, 2017
Processing time: 107 Days and 1.6 Hours
Abstract

Hepatocellular carcinoma is becoming an increasing indication for liver transplantation, but selection and allocation of patients are challenging because of organ shortages. Conventional Milan criteria are the reference for the selection of patients worldwide, but many expanded criteria, like University of California San Francisco criteria and up-to-7 criteria, have demonstrated that survival and recurrence results are lower than those for restricted indications. Correct staging is crucial and should include surrogate markers of biological aggressiveness (α-fetoprotein, response to loco-regional treatments). Successful down-staging can select between patients with tumor burden initially beyond transplantation criteria those with a more favorable biology, provided a 3-mo stability in meeting the transplantation criteria. Allocation rules are constantly adjusted to minimize the imbalance between the priorities of candidates with and without hepatocellular carcinoma, and take into account local donor rate and waitlist dynamics. Recently, Mazzaferro et al proposed a benefit-oriented “adaptive approach”, in which the selection and allocation of patients are based on their response to non-transplantation treatments: low priority for transplantation in case of complete response, high priority in case of partial response or recurrence, and no listing in case of progression beyond transplantation criteria.

Keywords: Milan criteria; α-fetoprotein; Down-staging; Allocation; Adaptive approach

Core tip: Hepatocellular carcinoma is an increasing indication for liver transplantation, but the selection of patients is challenging because of organ shortages. Conventional Milan criteria is the reference for the selection of patients worldwide, but many expanded criteria have also demonstrated satisfactory results. Correct staging should include surrogate markers of biological aggressiveness. Additionally, successful down-staging can help select patients with a more favorable biology. Allocation rules are adjusted to minimize the imbalance between the priorities of candidates with and without hepatocellular carcinoma. Recently, a benefit-oriented “adaptive approach” was proposed, in which the selection and allocation of patients are based on their response to treatments.