Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
    • Numerical inputs and outputsFormula
    • Med treatment and moreTreatment
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    Chief Complaint


    Organ System


    Patent Pending

    Metroticket Calculator for Hepatocellular Carcinoma (HCC) Survival

    Predicts survival for patients with HCC.
    When to Use
    Why Use
    • Derived in order to explore whether certain patients not fulfilling Milan Criteria could potentially benefit from liver transplant.
    • Similar survival as Milan criteria if criteria are expanded to Up-to-Seven(size of largest tumor in cm + number of tumors ≥7).
    • Not as widely used or validated as the original Milan criteria.
    • Tumor grade was not included as a prognostic factor, though it is known to correlate with survival. The authors cited a high number of patients missing data on tumor grade (28.5%) and used vascular invasion as an alternate pathologic parameter. 
    • Patients with HCC not fulfilling Milan Criteria but who may be considered for transplant with similar benefit.
    • Allows patients who don't fit the original Milan Criteria to be considered for transplantation with similar predicted survival benefit.
    • Offers potential curative option for patients who don't meet the Milan criteria.


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    Next Steps
    Creator Insights


    • For patients who fail to meet the Milan Criteria but fulfill the up-to-seven criteria, consider transplant evaluation.


    Complex matrix of values based on number of nodules and diameter of nodules.

    Facts & Figures

    For more information on the Metroticket calculators, visit the Metroticket Project website.

    Evidence Appraisal

    • The Metroticket calculator was derived by Mazzaferro and colleagues (who also developed the Milan criteria) in 2009 in order to more accurately characterize survival of patients failing to fulfill the Milan criteria.
    • Data from 1,556 patients at 36 centers were collected, 1,112 of whom exceeded (did not meet) the Milan criteria. Multivariable Cox regression models were used, with TNM staging specifications, to estimate survival based on the criteria, and an expanded version of the Milan criteria termed the Up-to-Seven criteria (size of largest tumor in cm + number of tumors ≥7) identified patients who did not meet the original Milan criteria but still had similar 5-year survival: 71.2% (95% CI 64.3-77.0) versus 73.3% (95% CI 68.2-77.7).
    • The data were collected via a web-based survey that could be filled out at the discretion of the investigators, thus potentially introducing bias.
    • The results have been validated in other populations including Chinese patients (Lei 2013) and patients undergoing transplant for Hepatitis B (Raj 2011).


    Dr. Vincenzo Mazzaferro

    About the Creator

    Vincenzo Mazzaferro, MD, is a professor of medicine and director of the Gastrointestinal and Hepato-Pancreatic Surgery and Liver Transplantation Unit at the Istituto Nazionale dei Tumori in Milan, Italy. He is an avid researcher of liver transplantation and studies treatment of metastatic cancers to the liver and novel treatments of tumors. Dr. Mazzaferro’s research group was responsible for the development of the Milan Criteria, which has been adopted as a transplant guideline in many countries.

    To view Dr. Vincenzo Mazzaferro's publications, visit PubMed

    About the Creator
    Dr. Vincenzo Mazzaferro