Liver transplantation for hepatocellular carcinoma: A proposal of a prognostic scoring system

Background: The current staging system of hepatocellular carcinoma establis hed by the International Union Against Cancer and the American Joint Commit tee on Cancer does not necessarily predict the outcomes after hepatic resec tion or transplantation. Study Design: Various clinical and pathologic risk factors for tumor recurr ence were examined on 344 consecutive patients who received hepatic transpl antation in the presence of nonfibrolamellar hepatocellular carcinoma to es tablish a reliable risk scoring system. Results: Multivariate analysis identified three factors as independently si gnificant poor prognosticators: 1) bilobarly distributed tumors, 2) size of the greatest tumor (2 to 5 cm and > 5 cm), and 3) vascular invasion (micro scopic and macroscopic). Prognostic risk score (PRS) of each patient was ca lculated from the relative risks of multivariate analysis. The patients wer e grouped into five grades of tumor recurrence risk: grade 1: PRS=0 to <7.5 ; grade 2: PRS=7.5 to less than or equal to 11.0; grade 3: PRS > 11.0 to 15 .0; grade 4: PRS greater than or equal to 15.0; and grade 5: positive node, metastasis, or margin. The proposed PRS system correlated extremely well w ith tumor-free survival after liver transplantation (100%, 61%, 40%, 5%, an d 0%, from grades 1 to 5, respectively, at 5 years), but current pTNM stagi ng did not. Conclusions: 1) Patients with grades 1 and 2 are effectively treated with l iver transplantation, 2) patients with grades 4 and 5 are poor candidates f or liver transplantation, and 3) patients with grade 1 do not benefit from adjuvant chemotherapy. (J Am Coll Surg 2000; 131:389-334. (C) 2000 by the A merican College of Surgeons).