Metroticket 2.0 Calculator for Hepatocellular Carcinoma (HCC) Transplant Selection
Second generation of the Metroticket criteria for predicting post-liver-transplant HCC recurrence. Incorporates AFP levels and sum of tumour diameters to allow expanded transplant criteria beyond Milan.
Score interpretation
Within Milan criteria: 5-year post-transplant survival ~70-75%; standard listing recommended
→ List for liver transplantation; MELD exception points for HCC (UNOS policy: MELD + 22 points at listing, increase by 3 every 3 months up to 34); bridging therapy while awaiting transplant: TACE (transarterial chemoembolisation) for tumours > 3 cm or prolonged wait; ablation (RFA or microwave) for nodules <= 3 cm; re-staging imaging every 3 months; AFP monitoring every 6-8 weeks; if AFP rises > 100 ng/mL on waitlist: re-evaluate eligibility; transplant coordinator involvement; multidisciplinary liver tumour board discussion; post-transplant: everolimus or mTOR inhibitor (may reduce HCC recurrence -- SILVER trial); HBV prophylaxis if HBV-related; annual CT surveillance for 5 years post-transplant.
Outside Milan criteria -- evaluate against Metroticket 2.0 and UCSF/expanded criteria
→ Hepatobiliary MDT evaluation; if AFP <= 400 and sum diameters <= 7 cm (Metroticket 2.0 acceptable zone): consider listing with institutional approval or clinical trial enrolment; downstaging protocols: TACE/TARE/ablation to achieve Milan criteria (UNOS downstaging protocol: approved in US for outside Milan patients who achieve Milan on imaging post-treatment); if AFP > 400 ng/mL: transplant contraindicated (poor prognosis even with acceptable tumour morphology); if not transplant eligible: systemic therapy discussion (sorafenib first-line for advanced BCLC-C; lenvatinib alternative; atezolizumab + bevacizumab for selected patients -- IMbrave150 trial); SIRT (selective internal radiation therapy) / Y-90 for larger burden; clinical trial enrolment.
Interpretation bands for the Metroticket 2.0. Apply clinical judgement and local guidance.
References
- Mazzaferro V et al. Metroticket 2.0 model for analysis of competing risks of death after liver transplantation for hepatocellular carcinoma. Gastroenterology. 2018;154(1):128-139.
- EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol. 2018;69(1):182-236.
Related
Curated clinical cross-links plus same-class fallbacks.
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.