Yao FY et al. (2005) A prospective study on downstaging of hepatocellular carcinoma prior to liver transplantation. Liver Transpl 11: 1505–1514

The rising incidence of hepatocellular carcinoma (HCC), largely caused by the increasing prevalence of hepatitis C, has fed demand for orthotopic liver transplantation (OLT). Under the Model for End-Stage Liver Disease scheme in the US, only patients with stage T2 HCC are eligible for priority listing for OLT. Yao et al. have conducted a prospective study to assess the feasibility of downstaging HCC of stage >T2 to bring patients within accepted criteria for OLT.

Patients recruited to the study had one lesion >5 cm in diameter, two or three lesions of which one had to be >3 cm, or four or five nodules all ≤3 cm. In all cases the total tumor diameter was ≤8 cm. Depending on tumor size and location, the treatments employed were radiofrequency ablation, transarterial chemoembolization, percutaneous alcohol injection, or resection. Downstaging was successful in 21 of 30 patients. Seven patients dropped out because of tumor progression, and two others died of multiorgan failure shortly after treatment. OLT was later performed in 16 of 21 patients; another 4 were awaiting OLT and 1 was excluded for psychosocial reasons. By a median follow-up of 16 months after transplant, 15 patients were alive and 1 had died after 14 months because of poor graft function. The survival rates were 89.3% after 1 year and 81.8% after 2 years.

The authors conclude that, while the results are encouraging, expanded studies with extended follow-up are required for full feasibility assessment of downstaging as a means of qualifying patients for OLT.