1Department of Internal Medicine, Dongnam Institute of Radiological & Medical Sciences, Busan, Korea
2Department of Radiology, Dongnam Institute of Radiological & Medical Sciences, Busan, Korea
3Department of Radiation Oncology, Dongnam Institute of Radiological & Medical Sciences, Busan, Korea
4Department of Surgery, Dongnam Institute of Radiological & Medical Sciences, Busan, Korea
© 2024 The Korean Liver Cancer Association.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Conflicts of Interest
The authors have no conflicts to disclose.
Ethics Statement
This review article is fully based on articles which have already been published and did not involve additional patient participants. Therefore, IRB approval is not necessary.
Funding Statement
No specific grant was received from any funding agency in the public, commercial, or not-for-profit sectors.
Data Availability
Not applicable.
Author Contributions
Conception: SYH, HC, WJ, RGK
Manuscript preparation: SYH, HC, WJ, RGK
Critical revision: SYH, HC, WJ, RGK
All authors reviewed the paper and approved the final version.
UNOS downstaging criteria (with definitions of successful downstaging) |
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Inclusion criteria: HCC exceeding Milan criteria but meeting ONE of the following |
1. Single tumor size 5.1-8 cm |
2. 2 to 3 tumors, each ≤5 cm and sum of maximal tumor diameters ≤8 cm |
3. 3 to 4 tumors, each ≤3 cm and sum of maximal tumor diameters ≤8 cm |
AND absence of vascular invasion or extrahepatic disease on cross-section imaging |
Successful downstaging |
1. Posttreatment tumor size and number within Milan criteria |
2. Tumor burden must remain within Milan criteria for 6 months after downstaging to qualify for MELD exception points |
3. Only viable tumors are included in measurement, necrosis from LRTs is not |
4. If there are 2+ areas of enhancement in a tumor after treatment, the diameter of the entire lesion is counted toward the residual tumor burden |
Downstaging failure |
1. Tumor progression beyond eligibility criteria as defined above |
2. Tumor invasion of a major hepatic vessel on cross-sectional imaging |
3. Lymph node involvement or extrahepatic extension |
4. Infiltrative tumor growth |
5. AFP level >1,000 ng/mL (AFP must decreased to <500 ng/mL after LRT) |
UNOS, United Network for Organ Sharing; HCC, hepatocellular carcinoma; MELD, model for end-stage liver disease, LRT, locoregional therapy; AFP, alphafetoprotein.