Recurrent HCC
Initial Max Last

Tumor Burden

Recurrent HCC Risk:
1 yr:2 yr:3 yr:
IML Code: Ablate / Wait / AFP:

Recurrent HCC
Initial Max Last


Unlike current allocation policy that only uses HCC burden at one time point, the RH-IML calculator uses a summative measure of pre-liver transplant HCC burden that incorporates tumor behavior and treatment response to predict the risk of post-liver transplant recurrent HCC.


Vutien P, Dodge J, Bambha KM, Nordstrom EM, Gralla J, Campbell K, Levek C, Nydam T, Fix O, Ioannou G, Biggins SW. A simple measure of hepatocellular carcinoma burden predicts tumor recurrence after liver transplantation: The RH-IML classification. Accepted for publication in Liver Transplantation.

the data

Using UNOS data from 2002-2014, 16,558 liver transplant recipients with HCC (any stage) were assessed for HCC size (total diameter), pre-liver transplant treatment and post-liver transplant recurrent HCC.

HCC was measured at 3 dates on the waitlist: (I) Initial, (M) Max, (L) Last. Tumor burden at each date was classified as:

  1. < Milan
  2. Milan
  3. > Milan to ≤ UCSF
  4. > UCSF

milan and ucsf criteria

Milan criteria

  • single tumor ≤ 5 cm, or
  • 2 or 3 tumors, each ≤ 3 cm

UCSF criteria

  • single tumor ≤ 6.5 cm, or
  • 2 or 3 tumors, each ≤ 4.5 cm
  • total tumor diameter ≤ 8 cm

statistical analysis

Chi-Square tests assessed associations of IML coordinates with post-liver transplant recurrent HCC. Confounders (age, sex, race, MELD, wait-time, pre-liver transplant HCC treatment, AFP, DRI) were assessed.

insufficient data

Of the 64 potential combinations of IML, only 30 make clinical sense as max can not be less than initial or last. Of those 30 clinically viable combinations, 10 did not have sufficient power and 3 combinations did not occur in the available data, leaving 17 IML combinations with sufficient power to predict post-liver transplant recurrent HCC.

app development team

Scott W. Biggins, MD, MAS:

Dr. Biggins is a transplant hepatologist and the Chief of Hepatology at the University of Washington in Seattle, WA. Dr. Biggins and his research team from the University of Washington, University of Colorado and the University of California San Francisco developed the RH-IML calculator.

Research Team:

Scott W. Biggins, Philip Vutien, Jennifer L. Dodge, Kiran M. Bambha, Eric M. Nordstrom, Jane Gralla, Kristen Campbell, Clair Levek, Trevor L. Nydam, Oren K. Fix, George Ioannou

Oren Fix, MD, MSc:

Dr. Fix is the Medical Director of Liver Transplantation and a Lead Informatics Physician at the University of North Carolina at Chapel Hill