Evidence map›Paper›PMID 30048307›Full record

ArticleAnnals of surgery2018

Is it Time to Abandon the Milan Criteria?: Results of a Bicoastal US Collaboration to Redefine Hepatocellular Carcinoma Liver Transplantation Selection Policies.

Karim J Halazun, Parissa Tabrizian, Marc Najjar, Sander Florman, Myron Schwartz, Fabrizio Michelassi, Benjamin Samstein, Robert S Brown, Jean C Emond, Ronald W Busuttil and 1 more

Abstract readComparative StudyMulticenter Study
PubMed Publisher
In one paragraph

Article in Annals of surgery, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 51 papers, 1 of them a synthesis that pooled it.

0numbers the graph read from it
0cells of the map it votes in
51citing papers in PubMed, 1 pooled it
7.0field-weighted citation impact, top 2% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

51 citing papers in PubMed, 1 synthesis or guideline pooled it, 114 citations in OpenAlex.

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  15. Long-Term Prognostic Value of AFP and PIVKA-II in HCC After Living Donor Liver Transplantation: A Single-Center Retrospective Study.Transplant international : official journal of the European Society for Organ Transplantation · 2025
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4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

11 authors at 6 institutions in 1 country.

Karim J HalazunDivision of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY.
Parissa TabrizianDepartment of Transplantation, Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY.
Marc NajjarCenter for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY.
Sander FlormanDepartment of Transplantation, Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY.
Myron SchwartzDepartment of Transplantation, Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY.
Fabrizio MichelassiDivision of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY.
Benjamin SamsteinDivision of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY.
Robert S BrownDivision of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY.
Jean C EmondDivision of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY.
Ronald W BusuttilDivision of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
Vatche G AgopianDivision of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
Cornell University · USMount Sinai Hospital · USUniversity of California, Los Angeles · USColumbia University Irving Medical Center · USMount Sinai Medical Center · USPresbyterian Hospital · US

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

objectivesEuropean liver transplant (LT) centers have moved away from using the Milan Criteria (MC) for hepatocellular carcinoma (HCC) patient selection, turning to models including tumor biological indices, namely alpha-fetoprotein (AFP). We present the first US model to incorporate an AFP response (AFP-R), with comparisons to MC and French-AFP models (F-AFP).

methodsAFP-R was measured as differences between maximum and final pre-LT AFP in HCC patients undergoing LT at 3 US centers (2001 to 2013). Cox and competing risk-regression analyses identified predictors of recurrence-free survival (RFS).

resultsOf 1450 patients, 235 (16.2%) were outside MC. Tumor size, number, and AFP-R were independent predictors of RFS and were assigned weighted points based on Cox-regression analysis. An AFP-R consistently < 200 ng/mL predicted the best outcome. A 3-tiered competing-risk RFS model, the New York/California (NYCA) score, was developed, accurately discriminating between groups (P < 0.001), and correlating with overall survival (P < 0.001). Two hundred one of 235 patients outside MC (85.5%) would be recategorized into NYCA low/acceptable-risk groups. The c-statistic for our NYCA score is 0.731 compared with 0.613 for MC and 0.658 for F-AFP (P < 0.0001).

conclusionIncorporation of AFP-R into HCC selection criteria allows for MC expansion. As United Network for Organ Sharing considers adding AFP to selection algorithms, the NYCA score provides an objective, user-friendly tool for centers to appropriately risk-stratify patients.

Indexed as

Liver TransplantationPatient SelectionAgedalpha-FetoproteinsBiomarkers, TumorCarcinoma, HepatocellularFemaleHumansLiver NeoplasmsMaleOrganizational PolicyRisk AssessmentUnited Statesalpha-FetoproteinsBiomarkers, Tumor

Identifiers

PMID30048307
OpenAlexW2883179872

What OpenQuestion holds

Textmetadata
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.