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Expanded Milan criteria on pathological examination after liver transplantation: analysis of preoperative data
I F S F Boin1, E M Pracucho, M C Rique
1Unit of Liver Transplantation, Hospital de Clínicas, State University of Campinas, São Paulo, Brazil. ilkaboin@yahoo.com
Background:
We sought to evaluate the accuracy of imaging techniques related to the Milan criteria (MC) compared with the explant histology and the survival of these patients.
Methods:
Between 1997 and 2006, we selected 45 cirrhotic patients with hepatocellular carcinoma distributed into two groups according to explant histology: MC and Expanded Milan Criteria (EMC). Age, gender, preoperative imaging (ultrasound [US] and/or computed tomography [CT]), maximal tumor dimension, number of tumors, explanted histology, histology degree, alpha-fetoprotein (AFP) level and vascular invasion were compared among the patients to evaluate the value of these prognostic factors for survival after liver transplantation.
Results:
By histology 42.2% explants were identified as EMC. The mean AFP level was 204.5 ng/mL. Vascular invasion was detected in 31.5% of explants and 68.4% showed incidental tumors. The survival rates after 10 years were 47.4% whereas MC patients showed 57.77%. The mean AFP level among MC patients was 150.2 ng/mL with vascular invasion detected in 7.7% of explants, and 47.4% with incidental tumors. The overall sensitivity of the imaging techniques was 83.3% for CT and 75% for US. The specificity was 96% for CT and 80.1% for US.
Conclusion:
Scan examinations in the preoperative evaluation underestimated about 42.2% of tumors. Those patients had vascular invasion but the survival after 10 years was similar between the ECM and MC groups.
Insights
Imaging techniques often underestimate hepatocellular carcinoma (HCC) tumors, but survival after liver transplantation remains similar for patients meeting Milan Criteria (MC) and Expanded Milan Criteria (EMC). This highlights the importance of considering factors beyond initial imaging for HCC patient outcomes.
Area of Science:
- Hepatobiliary Surgery
- Transplant Surgery
- Oncology
Background:
- Hepatocellular carcinoma (HCC) management relies on accurate staging for liver transplantation eligibility.
- The Milan Criteria (MC) are widely used, but Expanded Milan Criteria (EMC) may include more patients.
- Evaluating preoperative imaging accuracy against explant histology is crucial for patient selection and outcomes.
Purpose of the Study:
- To assess the accuracy of imaging techniques (ultrasound and CT) in relation to the Milan Criteria (MC) and Expanded Milan Criteria (EMC).
- To compare explant histology with preoperative imaging findings for hepatocellular carcinoma (HCC).
- To analyze the impact of these criteria and imaging accuracy on patient survival after liver transplantation.
Main Methods:
- A retrospective analysis of 45 cirrhotic patients with HCC who underwent liver transplantation between 1997 and 2006.
- Patients were categorized into MC and EMC groups based on explant histology.
- Preoperative imaging (US/CT), tumor characteristics, alpha-fetoprotein (AFP) levels, and vascular invasion were compared to assess prognostic value for survival.
Main Results:
- 42.2% of explants met the Expanded Milan Criteria (EMC) but were not identified preoperatively.
- Imaging sensitivity was 83.3% for CT and 75% for US; specificity was 96% for CT and 80.1% for US.
- Ten-year survival rates were 57.77% for MC patients and 47.4% for EMC patients, with similar outcomes despite underestimated tumor burden in EMC group.
Conclusions:
- Preoperative imaging frequently underestimates tumor burden in HCC patients, with ~42.2% falling into EMC but not MC.
- Despite underestimation, patients meeting EMC criteria showed similar 10-year survival rates to those meeting MC criteria.
- These findings suggest that factors beyond strict adherence to MC imaging may support successful liver transplantation outcomes in HCC.
