The evidence base is poor overall because of the limitedsample sizes of most studies and the heterogeneouscohorts and variables, and few have well-plannedand statistically valid study designs. No studies haveaccounted for the effects of underlying liver diseaseseither before or after LT on overall outcomes, and onlya few studies have assessed the effects of adjuvanttreatments before transplantation. In the majority ofthe reports, the follow-up time is not sufficient forassessing 5-year survival rates. Many have used histologicalfindings from explanted livers to stagepatients, but this has little utility for preoperativestaging and selection for LT. The presence of vascularinvasion, the tumor number and size (also calculatedas the TTV), and the AFP level have most consistentlybeen associated with increased recurrence rates anddiminished survival after LT. Most studies havereported acceptable survival rates for patients meetingthe UCSF criteria; however, it is notable that there aredocumented survival rates for patients with HCCtumors beyond the UCSF criteria that would bemore than acceptable in any other surgicaloncology setting. It is the potential to affect candidateswithout HCC who are also competing for thelimited pool of donor organs that limits the criteria forselecting patients with HCC for LT, especially whenwe consider LT for patients with more advancedstages of HCC.
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