Liver Transplantation and Tacrolimus Monotherapy for Hepatocellular Carcinoma With Expanded Criteria A. Dalgic, H. Karakayali, G. Moray, R. Emiroglu, H. Sozen, A. Torgay, and M. Haberal ABSTRACT Liver transplantation is the only curative treatment option for patients with cirrhosis and unresectable hepatocellular carcinoma (HCC) without extrahepatic dissemination. Crite- ria for transplantation in HCC are controversial. In this study, we evaluate the early results of liver transplantation for unresectable HCC. Between 2003 and 2004, 10 patients (three woman, seven men; aged 1.1 to 64 years) with occult or incidental HCC underwent liver transplantation. The inclusion criteria (independent of tumor size and number of tumor nodules) were: no invasion of major vascular structures and no evidence of extrahepatic disease, including that based on hilar lymph node biopsy and cytopathological examination of intraperitoneal fluid. Eight patients (80%) received tacrolimus and two patients (20%) received rapamycin monotherapy with early withdrawal of the corticosteroid. Four patients had neoadjuvant chemoembolization before transplantation. None of the patients received adjuvant chemotherapy. Two patients with hepatitis B virus cirrhosis underwent antiviral prophylaxis with anti-HBs antibody and lamivudine. During follow-up (range, 8 to 19 months), all patients did well with excellent graft function. There was no evidence of tumor recurrence on imaging studies, and there were no elevations in alpha fetoprotein or carcinoembryonic antigen levels. Low-dose immunosuppression and expanded criteria for liver transplantation for HCC appear to have beneficial effects on disease recurrence and patient outcomes, especially in regard to living donation. P rimary hepatocellular carcinoma (HCC) is one of the most common causes of cancer-related death and the fifth most common cancer in the world. 1 The overall 3-year survival rate is less than 13%, and about 75% to 80% of tumors develop in patients with cirrhotic livers. The only curative therapy for HCC is complete resection of the tumor with a negative resection margin. 2,3 In Turkey, the majority of patients with HCC have accompanying hepatitis B virus (HBV)- or hepatitis C virus (HCV)-related cirrhosis. Many of the cases are unresect- able at the time of diagnosis. For patients with cirrhosis and unresectable HCC without extrahepatic dissemination, liver transplantation appears to be the only curative treatment option. Different criteria for liver transplantation in HCC have been reported. Despite many reports of consensus for the Milan criteria, many transplant centers use their own selection criteria (center-based evaluation) for patient se- lection for transplantation. Therefore, universal criteria remain controversial. 4,5 This study described expanded criteria for transplanta- tion in HCC and evaluated early results of liver transplan- tation for nonresectable HCC. METHODS Between 2003 and 2004, 10 patients (three women, seven men; aged 1.1 to 64 years) with HCC underwent liver transplantation, including seven recipients (70%) with incidental HCC, 2 (20%) with HCC, and 1 (10%) with primary HCC. Pathologic tumor staging was recorded based on the current staging system for HCC of the American Joint Committee on Cancer. 6 Six patients had accompanying cirrhosis (60%) at the time of transplantation. The remaining four patients (40%) did not de- velop cirrhosis despite chronic liver disease. The etiologies for cirrhosis were HCV in three patients (30%), HBV in two patients (20%), and cryptogenic cirrhosis in one patient (10%). Etiologies for chronic liver disease for the four patients (40%) without cirrhosis were tyrosinemia in two patients (20%), Byler’s disease in one patient (10%), and HBV seropositive chronic hepatitis in one patient (10%). The last patient with chronic HBV hepatitis also From the Departments of General Surgery (A.D., H.K., G.M., R.E., H.S., M.H.) and Anestesiology (A.T.), Baskent University Hospital, Ankara, Turkey. Address reprint requests to Mehmet Haberal, MD, FACS, Baskent University Hospital, 5. sok No. 48 Bahcelievler, 06490 Ankara, Turkey 06490. E-mail: rektorluk@baskent-ank.edu.tr 0041-1345/05/$–see front matter © 2005 by Elsevier Inc. All rights reserved. doi:10.1016/j.transproceed.2005.06.096 360 Park Avenue South, New York, NY 10010-1710 3154 Transplantation Proceedings, 37, 3154 –3156 (2005)