Potential indications for liver transplant in Child-Pugh A and Model for End-stage Liver Disease exception for hepatocellular carcinoma in Japan.
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AIM: In 2019, expanded criteria for hepatocellular carcinoma (HCC), known as 5-5-500 (size ≤5 cm, number ≤5, alpha-fetoprotein ≤500 ng/mL), as well as Model for End-stage Liver Disease (MELD) exception, were implemented in Japan. In the present study, we evaluated liver transplantation indications and the Japanese allocation policy for HCC. METHODS: Adults with HCC were evaluated between January 2013 and December 2017 in a multicenter study in Japan. The patients were aged ≤65 years, in line with the limits of Japanese transplant center limits. RESULTS: HCC patients (n = 289) were classified as Child-Pugh A (74%), B (18%), or C (8%). Of these, 178 (62%) and 185 (64%) met the Milan and 5-5-500 criteria, respectively. The respective 1- and 5-year overall survival rates of patients who met the criteria were 100% and 88.1% in Child-Pugh A, 91.7% and 30.6% in B, and 72.9% and 0% in C without access to liver transplantation. For Child-Pugh A patients, we developed a risk score using the Child-Pugh score, des-gamma-carboxy prothrombin, tumor-node-metastasis stage grade, as well as albumin-bilirubin and albumin-bilirubin tumor-node-metastasis stage , which predicted worse prognosis. Additionally, we showed the characteristics of patients who achieved MELD exception points high enough to receive an organ: survival at least 2 years after waitlist registration, relatively good liver functional reserve, and sufficient tumor control with multiple treatments. CONCLUSIONS: High-risk patients, identified by our scoring system and albumin-bilirubin tumor-node-metastasis stage ≥2 in Child-Pugh A, should be considered for liver transplantation eligibility. The allocation policy for HCC should be revised based on precise evaluations on a regular basis.