Down-Staging Hepatocellular Carcinoma: A Survey of Clinical Practices and Attitudes

Hepatocellular carcinoma (HCC) can be cured with liver transplantation, if not exceeding Milan Criteria. “Down-staging” refers to the process of reducing HCC tumor burden, to allow transplant in a patient initially not satisfying these criteria. However, there is no consensus on how down-staging may best be achieved. We conducted an internet-based survey of medical and surgical directors of liver transplant centers nation-wide a series of questions regarding how they practice down-staging, and their attitudes towards these practices. We had a 21.5% response rate to our survey. Although most centers have some formal protocol defining candidacy for downstaging, only about half had a specific threshold in terms of number and size of tumors. The majority of centers did not use AFP levels to define candidacy for down-staging. A sizeable minority of centers did consider patients with portal vein tumor thrombus as candidates for down-staging. Variations in clinical practice of down-staging exist. In the absence of high-quality data on which to base more uniform down-staging protocols, such variation is likely inevitable. Such variation in practice may be beneficial, promoting exploration of the balance between accesses to transplant on one hand, while ensuring adequate post-transplant outcomes on the other hand.