Hcc: The San Francisco Criteria

Hepatocellular carcinoma (HCC) is one of the most common human malignancies and a leading cause of cancer-related mortality. The incidence of HCC has dramatically increased in recent decades. Cirrhosis is a major risk factor for HCC development, and because the diseased liver itself is a nidus for cancer formation, liver transplantation (LT) has emerged as a widely utilized therapy for patients with HCC.Because it was recognized early in the LT experience that patients with large and/or multicentric cancers fared poorly, criteria based on tumor size and number have emerged to govern which patients with HCC are eligible for LT. The most common criteria have been referred to as the "Milan criteria" and are associated with favorable outcomes after LT. But some groups have advocated expanding those criteria to include patients slightly outside of Milan criteria, whose tumor burden may become reduced back to within Milan criteria through a process known as "downstaging." In the United States one such downstaging pathway comprises what is known as the University of California San Francisco (UCSF) criteria.Herein we review the UCSF criteria. We describe the downstaging process, its rationale, and the outcomes associated with the expanded LT criteria. Concerns and controversies are acknowledged.