ArticleSurgical endoscopy2026
Comparison of Milan versus up-to-seven criteria for liver resection in hepatocellular carcinoma: a multi-center study on risk factors and long-term outcomes.
Article in Surgical endoscopy, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
purposeThis multi-center study aimed to evaluate the clinical validity of the "up-to-seven" criteria (sum of tumor number and largest diameter ≤ 7) as an expanded threshold for curative liver resection in hepatocellular carcinoma (HCC), comparing its outcomes with the established Milan criteria and identifying independent prognostic factors.
methodsA retrospective analysis was conducted on 264 consecutive HCC patients who underwent R0 resection. Patients were stratified into up-to-seven compliant (n = 219) and non-compliant (n = 45) cohorts. The compliant group was further divided into Milan compliant (n = 167) and "Milan non-compliant" (beyond Milan but within up-to-seven, n = 52) subgroups for comparative survival analysis. Overall survival (OS) and recurrence-free survival (RFS) were compared using Kaplan-Meier analysis. Cox regression was used to identify independent prognostic factors within the up-to-seven compliant cohort.
resultsPatients within the up-to-seven criteria had significantly superior median OS (64.0 vs. 14.0 months, P = 0.020) and RFS (28.0 vs. 9.0 months, P = 0.023) compared to those beyond it. Critically, among up-to-seven compliant patients, there was no significant difference in OS (77.4 vs. 64.4 months, P = 0.648) or RFS (45.5 vs. 27.0 months, P = 0.883) between the Milan compliant and "Milan non-compliant" subgroups. Multivariate analysis identified age ≤ 60 years, open resection (vs. laparoscopic), and high histologic differentiation as independent prognostic factors for both OS and RFS. Recurrence analysis revealed distinct prognoses based on pattern: intrahepatic distant recurrence was associated with favorable median OS (81.2 months), while extrahepatic recurrence predicted poor outcomes (median OS: 28.0 months).
conclusionThe up-to-seven criteria can safely expand surgical eligibility for HCC resection, offering long-term survival comparable to the Milan criteria. Laparoscopic resection and high tumor differentiation are associated with significantly improved outcomes. These findings advocate for the adoption of the up-to-seven criteria as a pragmatic surgical threshold, complemented by tailored risk stratification based on patient age, surgical approach, and tumor biology.
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