Systematic review of outcome of downstaging hepatocellular cancer before liver transplantation in patients outside the Milan criteria (Br J Surg 2011; 98: 1201–1208)

Sir We read the systematic review by Gordon-Weeks and colleagues on the outcome of patients with hepatocellular carcinoma (HCC) outside the Milan criteria who underwent downstaging before liver transplantation (LT). The process of selection of the eight articles identified by the review was based on: the outcome of at least ten patients with a HCC outside the Milan criteria who underwent downstaging before LT and had follow-up longer than 2 years. The authors concluded that the quality of the research needs improvement and there is no evidence to deny LT to a patient after effective downstaging. We agree with these conclusions, but we did not understand the exclusion of the prospective study performed at the University of Bologna1, which reported the results of a downstaging protocol for patients outside the Milan criteria. The survival analysis, using an intention-to-treat approach at a median follow-up of 2·5 years after LT, showed that 32 patients achieved a disease-free survival comparable to that of patients recruited during the same time period with the conventional criteria.