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ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

Print version ISSN 0102-6720On-line version ISSN 2317-6326

ABCD, arq. bras. cir. dig. vol.29 no.4 São Paulo Oct./Dec. 2016 

Original Article


Gustavo Pilotto D. SÁ1 

Fernando P. P. VICENTINE1  2 

Alcides A. SALZEDAS-NETTO1  2 

Carla Adriana Loureiro de MATOS2 

Luiz R. ROMERO2 

Dario F. P. TEJADA2 

Paulo Celso Bosco MASSAROLLO3 

Gaspar J. LOPES-FILHO1  2 

Adriano M. GONZALEZ1  2 

1Postgraduation Program in Interdisciplinary Surgical Science, Federal University of São Paulo, São Paulo, SP, Brazil

2; Sector of Liver Transplantation, Discipline of Surgical Gastroenterology, Federal University of São Paulo; São Paulo, SP, Brazil

3Sector of Liver Transplantation, Department of Surgery, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil



The criterion of Milan (CM) has been used as standard for indication of liver transplantation (LTx) for hepatocellular carcinoma (HCC) worldwide for nearly 20 years. Several centers have adopted criteria expanded in order to increase the number of patients eligible to liver transplantation, while maintaining good survival rates. In Brazil, since 2006, the criterion of Milan/Brazil (CMB), which disregards nodules <2 cm, is adopted, including patients with a higher number of small nodules.


To evaluate the outcome of liver transplantation within the CMB.


The medical records of patients with HCC undergoing liver transplantation in relation to recurrence and survival by comparing CM and CMB, were analyzed.


414 LTx for HCC, the survival at 1 and 5 years was 84.1 and 72.7%. Of these, 7% reached the CMB through downstaging, with survival at 1 and 5 years of 93.1 and 71.9%. The CMB patient group that exceeded the CM (8.6%) had a survival rate of 58.1% at five years. There was no statistical difference in survival between the groups CM, CMB and downstaging. Vascular invasion (p<0.001), higher nodule size (p=0.001) and number of nodules >2 cm (p=0.028) were associated with relapse. The age (p=0.001), female (p<0.001), real MELD (p<0.001), vascular invasion (p=0.045) and number of nodes >2 cm (p<0.014) were associated with worse survival.


CMB increased by 8.6% indications of liver transplantation, and showed survival rates similar to CM.

HEADINGS : Liver transplantation; Hepatocellular carcinoma; MELD.


The hepatocellular carcinoma (HCC) is the most common malignancy of the liver and the sixth leading cause of cancer mortality worldwide, with an incidence of 750,000 new cases per year. Liver transplantation (LTx) is currently considered the best treatment for the patient with liver cirrhosis and HCC2,11,16.

The MELD criteria for liver transplant waiting list, adopted in Brazil since 2006, does not cover some serious liver diseases that lead to loss of liver function, such as hepatocellular carcinoma. These cases were classified as special situation and have received extra points, reaching the top of the waiting list for liver transplantation5,12,15,23.

With the special situation, patients with HCC began to take the place of patients with the most deteriorated and worse overall condition liver function. The challenge in adopting an extra score is seeking criteria that reduce the chance of being prioritizing patients with advanced HCC, with high risk of recurrence, instead of patients with higher MELD score 6,22,24,29.

In 1996, Mazzaferro et al. introduced the Milan criteria (MC). Cirrhotic patients with single nodule up to 5 cm or up to three nodules being the largest up to 3 cm, with no macrovascular invasion or detectable metastasis had a survival rate of 75% in four years21. The concepts identified in this study have been widely adopted and reproduced in transplant centers in the world, including Brazil, where the good results of survival in this population was reproduced6,9,14,20,21,24. However, only a small portion of patients with HCC fit into the MC, stimulating the development of expanded criteria, with satisfactory results28.

Thus, other broader criteria began to emerge (Table 1) in order to offer more patients with hepatocellular carcinoma the possibility of liver transplantation, expanding the limits determined by the MC14,20,21,24.

TABLE 1 Expanded criteria for liver transplantation for HCC 

n Nodule Size (cm) Exams
Milan (16) 48 1 or 2 - 3 ≤ 5 or ≤ 3 (each) -
UCSF (19) 70 1 or 2 - 3 ≤ 6,5 ou ≤ 4,5 (sum ≤ 8) -
Navarro (20) 47 1 or 2 - 3 ≤ 6 ou ≤ 5 -
Kyoto (21) 125 ≤ 10 ≤ 5 (each) PIVKA-II< 400 (mU/mL)
Asan (22) 221 ≤ 6 ≤ 5 (each) -
Edmonton (23) 52 - Total volume ≤ 115 cm3 -
Valencia (24) 257 ≤ 3 ≤ 5 (sum ≤ 10) -
Hangzhou (25) 195 - Total ≤ 8 cm -
Total > 8cm AFP ≤ 400, degree I/II (BX)
Up - to - seven (26) 1556 ≤ 7 ≤ 7 (soma) -
Toronto (27) 294 Milan Milan -
- - pathological criteria
Milan/Brazil 414 1 or 2 - 3 ≤ 5 or ≤ 3 (each) -
(excluding nodules < 2cm)

Some comparative studies have demonstrated the safety of expanded the Milan criteria, to include more patients without increasing the HCC recurrence rate4,22. The implantation of MC in Brazil was followed by minor modifications. Nodules < 2 cm are not considered, making this a modified MC adopted exclusively in Brazil, called Milan/Brazil Criteria (MBC).

The objective of this study was to evaluate the results of liver transplantation with special situation for HCC using the MBC, after the implementation of MELD criteria.


This study is registered in Brazil Platform and approved as the CEP 81706 of 21/08/2013.

Data were analyzed retrospectively by reviewing the medical records stored in the São Paulo State Transplantation Center of 414 patients undergoing LTx for HCC, conducted between January 2007 and December 2011 in the city of São Paulo.

The groups determined by preoperative imaging (downstaging, MBC and MC) were compared with each other and with respect to the results of survival and recurrence rates. The groups determined by pathology of explanted liver (MBC, CM and Out of Criteria) were compared with each other in relation to survival and recurrence rates.

Statistical analysis

Data were analyzed descriptively. For categorical variables, absolute and relative frequencies were presented. The numerical variables were presented in summary measures (mean, quartiles, minimum, maximum and standard deviation). The tests included the Chi-Square, Student's t test, Mann-Whitney, Kruskal-Wallis, the Kappa coefficient and Kaplan-Meier survival curve. A p value <0.05 was considered statistically significant in all cases. Statistical analysis was carried out with SPSS 20.0 and STATA 12.


There was a predominance of Caucasian patients (80%), males (79.5%) with mean age of 56 years. In January 2015, three hundred patients were alive (72.5%). If extra points were not used for HCC, the MELD would be 12.6 on average at the time of transplant. In this study, the patients were on the waiting list for LTx for a year on average.

Patients were submitted to different imaging in the preoperative period. Was selected for the analysis the last imaging test performed before transplantation. Computed tomography (58.7%) was the test of choice in most cases, followed by magnetic resonance imaging (31.9%) and ultrasonography (9.4%). These tests were, on average, made four months before the LTx.

All 414 study patients met the BMC based on preoperative imaging. Of these, 54 (7%) passed before by downstaging (Table 2). Of these, 33 patients (8.6%) would be out of the MC; however, there is a high correlation between the two criteria according to the Kappa coefficient (k=0.6 - p<0.001).

TABLE 2 Distribution of patients by Milan criteria in accordance with Milan/Brazil criteria 

Milan/Brazil criteria Milan criteria Total
No Yes
n % n % n %
Total 62 15,0% 352 85,0% 414 100,0%
No 29 100,0% 0 0,0% 29 100,0%
Yes 33 8,6% 352 91,4% 385 100,0%

Kappa 0,6 - p<0,00

The explant were sent to examination and analyzed the size and real number of nodes present in the explanted livers. Regarding pathology of explanted livers, 11.3% of patients were out of both criteria and 10.4% were within the MBC but exceeded the MC (Table 3). There was no statistically significant difference regarding the variables mortality and vascular invasion in patients included in the CMB, Milan criteria, or those submitted to downstaging.

TABLE 3 Distribution of patients by Milan criteria and Milan/Brazil criteria 

Criteria n %
Criteria (imaging) 414 100,0
MBC 33 8,0
Downstaging 29 7,0
MC 352 85,0
MBC - (pathology) 414 100,0
No 47 11,3
Yes 367 88,7
MC - (pathology) 414 100,0
No 103 24,9
Yes 311 75,1

MBC=Milan/Brazil criteria; MC=Milan criteria

In Table 4, patients groups downstaging, Milan/Brazil Criteria and Milan Criteria, so classified by preoperative tests, were compared with the results of the pathology of explanted livers. Patients undergoing downstaging showed nodules larger than those previously classified by the Milan criteria. Patients classified as Criteria Milan/Brazil had higher total number of nodes compared to the other two groups.

TABLE 4 Comparison between the groups formed by preoperative imaging  

Criteria (imaging) Mean SD n p 1° Quartil Mediana n p
Size of the larger nodule* (pathology) 0,004 0,004
Downstaging 36,28A 18,82 29 23,00 35,00 29
MC 27,77B 13,34 352 20,00 25,00 352
MBC 24,72B 9,36 33 20,00 22,00 33
Nodules >2 cm (pathology) 0,118 0,118
Downstaging 1,21 0,68 29 1,00 1,00 29
MC 0,97 0,72 352 1,00 1,00 352
MBC 1,21 1,17 33 0,50 1,00 33
Nodule total number (pathology) <0,001 <0,001
Downstaging 2,38 1,52 29 1,00 2,00 29
MC 2,03B 1,52 352 1,00 1,00 352
MBC 3,48A 2,50 33 2,00 3,00 33

p=descriptive level of the Kruskal-Wallis test; (A) and (B) show separate averages from Bonferroni-Dunn multiple comparisons; SD=standard deviation; *milimeters

To evaluate the effect of each of the numerical data variables, patient survival were adjusted to a simple Cox regression model (Table 5). There was a correlation between patient age (p=0.001), real MELD (p<0.001), number of nodules >2 cm in pathology (p=0.014) and survival time. Thus, every increase of one year in the age of the patient there is an increase of 4.4% in the risk of death and every 1-point increase in the real MELD, there is a 5% increase in the risk of death. Since every increase of 1 nodule >2 cm in pathology, there is an increase of 29.2% in the risk of death.

TABLE 5 Model results of simple Cox regression with patient data, imaging and pathology in relation to survival 

Risk ratio (IC95%) p n
Age 1,044 (1,019 - 1,069) 0,001 414
Real MELD 1,050 (1,023 - 1,078) <0,001 414
Size of larger nodule (imaging) 1,003 (0,983 - 1,024) 0,744 379
Number of nodule >2 cm (imaging) 1,052 (0,657 - 1,687) 0,832 332
Number of nodule <2 cm (imaging) 0,944 (0,775 - 1,150) 0,567 413
Nodule total number (imaging) 1,019 (0,841 - 1,235) 0,848 331
Size of larger nodule (pathology) 1,006 (0,994 - 1,018) 0,326 413
Number of nodule >2 cm (pathology) 1,292 (1,052 - 1,586) 0,014 414
Number of nodule <2 cm (pathology) 1,035 (0,922 - 1,161) 0,562 413
Nodule total number (pathology) 1,086 (0,981 - 1,203) 0,113 413

The survival analysis Kaplan-Meier showed significance in relation to gender. Male patients had higher survival than female (p<0.001). The association of increased survival in patients without vascular invasion identified by histopathologic study was demonstrated as well (p=0.045). The other analyzed factors have shown no difference in survival at 1, 3 and 5 years (Figure 1, Table 6).

FIGURE 1 Results of the Kaplan-Meier survival analysis by patient characteristics, imaging and pathology 

TABLE 6 Kaplan-Meier survival analysis for patient data, imaging and pathology 

% Survival (years) p
1 3 5
Gender <0,001
Female 70,6 ± 4,9 60,0 ± 5,3 54,4 ± 5,7
Male 87,2 ± 1,8 79,8 ± 2,2 75,9 ± 2,5
Vascular Invasion 0,045
No 85,1 ± 2,0 78,0 ± 2,4 74,3 ± 2,7
Yes 80,7 ± 3,8 69,7 ± 4,4 64,1 ± 4,7
Downstaging 0,961
No 83,1 ± 1,9 76,1 ± 2,2 71,5 ± 2,4
Yes 93,1 ± 4,7 71,9 ± 8,5 71,9 ± 8,5
Criteria (imaging) 0,381
MBC 72,7 ± 7,8 69,6 ± 8,0 58,1 ± 10,1
Downstaging 93,1 ± 4,7 71,9 ± 8,5 71,9 ± 8,5
MC 84,1 ± 1,9 76,7 ± 2,3 72,7 ± 2,5
Criteria (pathology) 0,279
Out of Criteria 80,9 ± 5,7 66,0 ± 6,9 63,3 ± 7,1
MBC 83,7 ± 5,6 74,4 ± 6,7 67,9 ± 7,5
MC 84,3 ± 2,0 77,4 ± 2,3 73,2 ± 2,6

Estimate the probability of survival±SE; p=descriptive level of Log Rank test (Mantel-Cox)

During the study period, were observed (7.2%) thirty recurrence of HCC and there was an association only between recurrence and vascular invasion (p<0.001). Thus, it was noted a higher rate of recurrence in patients with vascular invasion (16.5%) compared to those without this condition (4.0%). For the other variables, there were no associations (Table 7).

TABLE 7 Distribution of patients for recurrence and Odds Ratio 

Recurrence Total p Odds Ratio
No Yes
N % N % N %
Gender 384 92,8% 30 7,2% 414 100,0% 0,071
Female 75 88,2% 10 11,8% 85 100,0% 2,06
Male 309 93,9% 20 6,1% 329 100,0% 1,00
Vascular Invasion 381 92,7% 30 7,3% 411 100,0% <0,001
No 290 96,0% 12 4,0% 302 100,0% 1,00
Yes 91 83,5% 18 16,5% 109 100,0% 4,78
Criteria (imaging) 384 92,8% 30 7,2% 414 100,0% 0,107a
Downstaging 24 82,8% 5 17,2% 29 100,0% 2,98
MC 329 93,5% 23 6,5% 352 100,0% 1,00
MBC 31 93,9% 2 6,1% 33 100,0% 0,92
Criteria (pathology) 384 92,8% 30 7,2% 414 100,0% 0,139a
Out of criteria 40 85,1% 7 14,9% 47 100,0% 2,53
MC 303 93,5% 21 6,5% 324 100,0% 1,00
MBC 41 95,3% 2 4,7% 43 100,0% 0,70

p=descriptive level of chi-square test or Fisher's exact testa

There were significant differences in the variables: larger nodule size (p=0.005), number of nodules <2 cm (p=0.026), number of nodes >2 cm (p=0.028) and size of the largest nodule (p=0.001) in relation to recurrence rate. Thus, on average, patients with recurrences had higher values in these variables than those without recurrence. Moreover, the average number of lower nodes 2 cm was lower than in-group of patients with recurrence in the patients without recurrence (Table 8).

TABLE 8 Summary of variable by recurrence occurrence 

HCC Recurrence Mean SD n p
Age (years) 56,39 8,72 414 0,052
No 56,16 8,84 384
Yes 59,37 6,40 30
Real MELD 12,64 5,75 414 0,448
No 12,56 5,60 384
Yes 13,63 7,47 30
Number of nodule >2 cm (imaging) 1,13 0,40 332 0,487a
No 1,12 0,39 306
Yes 1,19 0,49 26
Size of larger nodule* (imaging) 27,91 9,39 379 0,005a
No 27,60 9,47 353
Yes 32,04 7,19 26
Number of nodule <2 cm (imaging) 0,63 0,97 413 0,026
No 0,65 0,99 383
Yes 0,37 0,61 30
Nodule, total number (imaging) 1,69 1,03 331 0,784a
No 1,69 1,05 305
Yes 1,62 0,75 26
Number of nodule >2 cm (pathology) 1,00 0,77 414 0,028
No 0,98 0,77 384
Yes 1,30 0,70 30
Size of larger nodule* (pathology) 28,13 13,71 413 0,001
No 27,53 13,22 383
Yes 35,83 17,29 30
Number of nodule <2 cm (pathology) 1,17 1,53 413 0,324
No 1,19 1,55 384
Yes 0,90 1,32 29
Nodule, total number (pathology) 2,17 1,66 413 0,992
No 2,17 1,69 384
Yes 2,17 1,34 29

*=measured in millimeters; p=descriptive level of the Student t test or Mann-Whitney


Most patients were men (79.5%), white (80%), middle-aged (mean age 56 years), mildly overweight (BMI=26.5) and low value of MELD (average 12.7). Females in the sample showed a lower survival in Kaplan-Meier curve for 1, 3 and 5 years (p<0.001) when compared to males (Table 6). This result contradicts what is reported in the medical literature. Duffy et al. demonstrated relative risk of mortality of 2.43 for men (p<0.023); however, this variable was not significant in the multivariate analysis24. There is little data available in the literature relating gender as a prognostic factor, but few studies have reported female gender as a protective factor for recurrence and mortality, determining improved survival rate8,18,19.

The patient's age is presented as a factor associated with survival (p=0.001). For each increase of one year of age, there is an increase of 4.4% in the risk of death (Table 5). Other studies have identified age as a prognostic factor of mortality. Adler et al. in the European study for liver transplantation survival, in 226 patients, identified the age of 50 years as a risk factor for increased mortality1.

A few studies have linked real MELD with survival of the transplanted patient, since this value has no influence on the waiting list due to the extra marks for HCC12,26. Todo et al. in Japan, presented a study in patients with HCC underwent living donor liver transplantation demonstrating that the real MELD influenced survival26. The results of this study validate the association of real MELD with survival time with p<0.001. For each 1-point increase in the real MELD, there is an increase of 5% in the risk of death (Table 5).

The waiting time for LTx for HCC patients is crucial for a better prognosis since the progression of the disease can exclude it from the queue for transplantation if nodules size or number exceed the MC. This rate ranges from 7-11% in 6 months and approaches 40% at one year30.

Some authors, however, suggest that the delay in the waiting list can provide a better selection of candidates for LTx. Patients with aggressive tumor behavior, and increased risk of recurrence present a greater risk of drop out due to faster progression of neoplasia and would not be transplanted25. Recent studies have shown increased survival after liver transplantation for HCC in patients who waited longer in the awaiting list14,25.

Apparently, patients with HCC have an advantage in the current organ allocation system, when compared with patients without tumor, raising the question of including biological factors of poor prognosis, such as alpha-fetoprotein, and tumor growth rate4. Currently, the proportion of transplantation for HCC in São Paulo is around 33% of total LTx. This scenario is worrying because it coincides with increased mortality in the awaiting list 6,12,22,29.

This analysis shows no association of time on the waiting list and survival. The mean time for the liver transplantation was 11.5 months in patients alive and 13 months in patients who died (p>0.1).

Comparing the CM, CMB and downstaging groups, no difference was detected regarding the occurrence of vascular invasion (p= 0.501). In accordance with what is widely reported in the literature, vascular invasion showed association with decreased survival. There was a significant difference (p 0.045), with 5-year survival of 74.3% for the group without vascular invasion and 64.1% for the group with vascular invasion. Similarly, the HCC recurrence rate is significantly associated with the presence of vascular invasion detected on pathology (p<0.001).

Following the release of the MC by Mazzaferro et al. in 1996, transplantation in HCC began to show better results, since patients with HCC to respect the limits of one nodule ≤5 cm or even 3 cm nodules ≤321. Most expanded criteria shows increasing the size and number of nodules in a controlled manner would result a recurrence risk and survival rate comparable to the MC7,9,14,20,21,24,27.

MBC disregards the counting of nodules smaller than 2 cm and thus offers the possibility of liver transplantation to patients with higher number of small nodules, which would exceed most of the criteria cited above. Table 3 shows the distribution of patients according to MBC, MC and downstaging.

Note that only a small proportion of patients selected for liver transplantation, the CMB has exceeded CM (8.6%), there is a strong correlation between the two criteria.

Analyzing the groups, the hypothesis that the MBC group has a higher number of nodules on biopsy compared to the MC is confirmed. This significant difference can be explained by the presence of nodules smaller than 2 cm, which are not accounted for at the time of indication for liver transplantation, but are identified on pathology of the explanted liver.

Applying the MBC and MB to results from the pathology of explanted livers, the formation of other three groups can be observed, adding to the first two groups the Out of Criteria group (OC, Table 3). This group corresponds to 47 patients (11.3% of the sample) who did not fulfill neither of the two allocation criteria and therefore configure the failure rate in the Brazilian allocation system. Other studies showed a failure rate that ranged from 18-40%1,4,10.

There was no difference in patient survival between the MBC and MC groups. Patients transplanted in the MBC had a survival rate of 72.6% at five years, comparable to the most important services in the world14. Considering only those patients who exceeded the MC, the survival rate drops to 58.1%, but without statistical significance. The decrease in survival is probably associated with higher number of identified nodules in the MBC group. Several studies of risk factors for post-LTx mortality from HCC indicate to multiple nodules as a criterion of poor prognosis2,16,10.

There was no statistical difference in vascular invasion and survival when compared both groups, submitted or not to downstaging, respectively, 71.9% and 71.5% survival at five years (Figure 1). This result confirms the data widely available in the literature3,7,13,17.

The recurrence was associated with the size of the largest nodule, both measured by imaging preoperative (p=0.005) as the pathology of the explanted liver (p<0.001). Patients with larger nodules showed a higher recurrence rate. The number of nodules larger than 2 cm identified in pathology also been associated with the recurrence of HCC after liver transplantation (p<0.028).


The CMB increased by 8.6% indications of liver transplantation, and showed survival rates similar to CM.


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Financial source: none

Received: May 12, 2016; Accepted: August 16, 2016

Correspondence: Adriano Miziara Gonzales E-mail:

Conflicts of interest:


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