Published online Mar 18, 2024. doi: 10.5500/wjt.v14.i1.88833
Peer-review started: October 11, 2023
First decision: November 21, 2023
Revised: December 21, 2023
Accepted: January 22, 2024
Article in press: January 22, 2024
Published online: March 18, 2024
Liver transplantation (LT) for hepatocellular carcinoma (HCC) has been widely researched and is well established worldwide. The cornerstone of this treatment lies in the various criteria formulated by expert consensus and experience. The variations among the criteria are staggering, and the short- and long-term out
To study the differences in the current practices of LT for HCC at different centers in India and discuss their clinical implications in the future.
We conducted a survey of major centers in India that performed LT in December 2022. A total of 23 responses were received. The centers were classified as high- and low-volume, and the current trend of care for patients und
Of the 23 centers, 35% were high volume center (> 500 Liver transplants) while 52% were high-volume centers that performed more than 50 transplants/year. Approximately 39% of centers had performed > 50 LT for HCC while the percent distribution for HCC in LT patients was 5%–15% in approximately 73% of the patients. Barring a few, most centers were divided equally between University of California, San Francisco (UCSF) and center-specific criteria when choosing patients with HCC for LT, and most (65%) did not have separate transplant criteria for deceased donor LT and living donor LT (LDLT). Most centers (56%) preferred surgical resection over LT for a Child A cirrhosis patient with a resectable 4 cm HCC lesion. Positron-emission tomography-computed tomography (CT) was the modality of choice for metastatic workup in the majority of centers (74%). Downstaging was the preferred option for over 90% of the centers and included transarterial chemoembolization, transarterial radioembolization, stereotactic body radiotherapy and atezolizumab/bevacizumab with varied indications. The alpha-fetoprotein (AFP) cut-off was used by 74% of centers to decide on transplantation as well as to downstage tumors, even if they met the criteria. The criteria for successful downstaging varied, but most centers conformed to the UCSF or their center-specific criteria for LT, along with the AFP cutoff values. The wait time for LT from down
The current predicted 5-year survival rate of HCC patients in India is less than 15%. The aim of transplantation is to achieve at least a 60% 5-year disease free survival rate, which will provide relief to the prediction of an HCC surge over the next 20 years. The current worldwide criteria (Milan/UCSF) may have a higher 5-year survival (> 70%); however, the majority of patients still do not fit these criteria and are dependent on other suboptimal modes of treatment, with much lower survival rates. To make predictions for 2040, we must prepare to arm ourselves with less stringent selection criteria to widen the pool of patients who may undergo transplantation and have a chance of a better outcome. With more advanced technology and better donor outcomes, LDLT will provide a cutting edge in the fight against liver cancer over the next two decades.
Core Tip: The current predicted 5-year survival rate of hepatocellular carcinoma (HCC) patients in India is less than 15%. The aim of transplantation is to achieve at least a 60% 5-year disease free survival which will truly provide a relief to the predictions of HCC surge over the next 20 years. The current worldwide criteria (Milan/University of California, San Francisco) may have a higher 5-year survival (> 70%) but the majority of patients still do not fit these criteria and are dependent on other sub-optimal modes of treatment with much lower survival rates. In order to face predictions for 2040, we must prepare to arm ourselves with less stringent selection criteria to widen the pool of patients who may avail transplant and have a chance at a better outcome.