Survival differences between Milan criteria after down-staging and De novo Milan in living donor liver transplantation for hepatocellular carcinoma.

Background/aims: This study reports our experiences of adult living donor liver transplantation (LDLT) corresponding to downstaging.

Methodology: Between July 1992 and April 2008, we performed 553 adult LDLTs (35.1%, 553/1575) for HCC. Sixty-five patients was not treated before LDLT and belonged to Milan criteria, classified as De novo Milan group (De novo-M); 22 HCC patients did not meet Milan criteria initially, but subsequently met the criteria after downstaging, classified as artificial Milan group (Artificial-M). The evaluation of downstaging was based on preoperative CT scan and explanted liver biopsy, and excluded the patients having unclear treatment history on analysis.

Results: Artificial-M showed significantly less Child C patients (25%) than De novo-M (64.5%) (0.037). Artificial-M had greater tumor burden than De novo-M in maximal tumor size (2.5 +/- 1.2 versus 2.2 +/- 0.95 cm), sum of tumor diameter (3.4 +/- 1.4 versus 2.4 +/- 1.0 cm), number of nodules (1.8 +/- 0.9 versus 1.2 +/- 0.5), respectively. Five-year cumulative survival was not different between Artificial-M and De novo-M (83.9% versus 93.9%), but 5-year disease free survival were significantly different (71.1% versus 96.5%) (p = 0.0016).

Conclusions: Five year overall survival rates after LDLT were good in both groups. However, stricter follow-up is necessary in Artificial-M considering greater tumor burden and higher recurrence rate compared to De novo-M.