A Simple Measure of Hepatocellular Carcinoma Burden Predicts Tumor Recurrence after Liver Transplantation: The RH-IML Classification.

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Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society


Milan Criteria; Risk Model; liver cancer; locoregional therapy; prognostic model


Risk of post liver transplant (LT) recurrent HCC (rHCC) depends on pre-LT HCC burden, tumor behavior, and response to locoregional therapy (LRT). In December 2017, LT priority for HCC was expanded to select patients outside the Milan Criteria who respond to LRT.

AIMS: To 1) Develop a novel, objective measure of pre-LT HCC burden [model of Recurrent HCC - Initial, Maximum, Last; RH-IML], incorporating tumor behavior over time; and 2) Apply RH-IML to model post-LT rHCC.

METHODS: Using UNOS data from 2002-2014 (development) and 2015-2017 (validation), we identified adult LT recipients with HCC and assessed pre-LT HCC tumor behavior and post-LT rHCC. For each patient HCC burden was measured at three points on the waiting list: Initial (I), Maximum total tumor diameter (M), and Last exception petition (L). HCC burden at these 3 points were classified as (A): Milan to UCSF; (D): >UCSF, resulting in each patient having a three-letter RH-IML designation.

RESULTS: Of 16558 recipients with HCC, 1233 (7%) had any post-LT rHCC. rHCC rates were highest in RH-IML group CCC (15%) and DDD (18%). When Maximum and Last tumor burdens did not exceed Milan (class B or A), rHCC was low (≤10%) as in AAA, ABA, ABB, BBA, BBB. rHCC was also low (≤10%) with successful down-staging when Last was A (

CONCLUSIONS: The RH-IML classification system is a simple, summative measure of HCC burden that incorporates tumor behavior over time. RH-IML also estimates post-LT rHCC risk and is a useful tool for evaluating risk for rHCC post-LT. This article is protected by copyright. All rights reserved.

Clinical Institute


Clinical Institute

Digestive Health






Swedish Digestive Health Institute