A Novel Model Measuring the Harm of Transplanting Hepatocellular Carcinoma Exceeding Milan Criteria

No empirical studies have defined the posttransplant survival that would justify expansion of the Milan cri-teria for liver transplantation of hepatocellular carci-noma. We created a Markov model comparing the survival benefit of transplantation for a patient with>Milan HCC, versus the harm caused to other patients on the waiting list. In the base-case analysis, the strategy of transplant-ing the patient with>Milan HCC resulted in a 44% increased risk of death and a utility loss of 3 quality-adjusted years of life across the pre- and posttrans-plant periods for a nationally representative cohort of patients on the waiting list. This harm outweighed the benefit of transplantation for a patient with>Milan HCC having a 5-year posttransplant survival of less than 61%. This survival threshold was most sensitive to geographic variations in organ shortage, with the threshold varying from 25 % (Region 3) to>72 % (Re-gions 1, 5, 7 and 9). In conclusion, expansion of the Milan criteria will re-quire demonstrating high survival rates for the newly eligible patients—approximately 61 % at 5 years af-ter transplantation. In regions with less severe organ shortage, a more aggressive approach to transplanting these patients may be justified