Expanded criteria for hepatocellular carcinoma: Down-staging with a view to liver transplantation - Yes

In patients with hepatocellular carcinoma (HCC) exceeding conventional Milan criteria (one lesion <= 5 cm or two or three lesions <= 3 cm) for orthotopic liver transplantation (OLT), down-staging of the tumor before OLT presents an unique and intriguing perspective on tumor biology and expanded criteria for OLT. According to the University of California, San Francisco protocol, the eligibility criteria for down-staging included one lesion <= 8 cm, two or three lesions each <= 5 cm with total tumor diameter <= 8 cm, or four or five lesions each <= 3 cm with total tumor diameter <= 8 cm. In the majority of these patients, successful down-staging using well-defined endpoints could be achieved prior to OLT, without resulting in post-transplantation HCC recurrence. The promise of down-staging warrants consideration of a unified policy granting patients with HCC that has been successfully down-staged the same priority listing for OLT as those meeting conventional criteria.