Hepatocellular carcinoma patients are advantaged in the current liver transplant allocation system

Transarterial chemoembolization with drug-eluting beads is effective for the maintenance of the Milan-in status in patients with a small hepatocellular carcinoma

Transarterial chemoembolization (TACE) is the standard of care for the treatment of patients with an intermediate (Barcelona Clinic Liver Cancer [BCLC] B) hepatocellular carcinoma and to bridge patients with an early cancer to liver transplantation (LT). We explored the efficacy of TACE with drug-eluting beads (DEB) in BCLC A patients. Included are all BCLC A patients unsuitable for resection or locoregional ablation who underwent a DEB TACE between 2006 and 2012. Treatment was carried out "a la demande" until complete tumor devascularization or progression beyond Milan criteria. In patients with a complete response (CR), a contrast computed tomography (CT) scan was repeated at 3-month intervals during the first 2 years and then every 6 months alternating with abdominal ultrasound in the subsequent 3 years. Fifty-five patients had 79 tumor nodules ranging 7 to 50 mm; 32 (58%) achieved a CR that was maintained up to 4 and 7 months in 21 (38%) and 17 (31%) patients, respectively. The 24- and 36-month tumor-free survivals were 21% and 9%, respectively. The overall cumulative progression beyond Milan criteria at 3, 6, 12, and 24 months was 2%, 5%, 30%, and 54%. LT eligibility was maintained for a median of 19 months (range, 2-63 months). CR to first TACE was the strongest independent predictor of Milan-in maintenance. In conclusion, DEB TACE may effectively bridge patients with an early cancer to LT, and a CR to the first procedure may guide patient prioritization during the waiting list.

The Use of Donation After Cardiac Death Allografts Does Not Increase Recurrence of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) recurrence in patients undergoing liver transplantation (LT) with donation after brain death (DBD) and donation after cardiac death (DCD) allografts has not previously been investigated. Rates and patterns of HCC recurrences were investigated in patients undergoing DBD (N = 1633) and DCD (N = 243) LT between 2003 and 2012. LT for HCC was identified in 397 patients (340 DBD and 57 DCD). No difference in tumor number (p = 0.26), tumor volume (p = 0.34) and serum alphafetoprotein (AFP) (p = 0.47) was seen between the groups. HCC recurrence was identified in 41 (12.1%) patients in the DBD group and 7 (12.3%) patients in the DCD group. There was no difference in recurrence-free survival (p = 0.29) or cumulative incidence of HCC recurrence (p = 0.91) between the groups. Liver allograft was the first site of recurrence in 22 (65%) patients in the DBD group and two (37%) patients in the DCD group (p = 0.39). LT for HCC with DBD and DCD allografts demonstrate no difference in the rate of HCC recurrence. Previously published differences in survival demonstrated between recipients with HCC receiving DBD and DCD allografts despite statistical adjustment can likely be explained by practice patterns not captured by variables contained in the SRTR database.

Comparison of Liver Transplant-Related Survival Benefit in Patients With Versus Without Hepatocellular Carcinoma in the United States

BACKGROUND & AIMS

Patients with T2 hepatocellular carcinoma (HCC) can obtain an exception that allows them to undergo liver transplantation with much lower actual Model for End-Stage Liver Disease (MELD) scores than patients without HCC. We compared patients who received liver transplants, with and without HCC, with regard to transplantation-related survival benefit.

METHODS

We modeled the post-transplantation survival of adult, first-time liver transplant recipients with HCC (n = 9135) or without (n = 25,890) from 2002 through 2013 using Cox proportional hazards regression. We modeled waitlist survival of patients listed for transplantation with HCC (n = 15,605) or without (n = 85,229) using competing risks analysis and combined outcomes of death or liver failure (defined as MELD score ≥30). We used these survival models to calculate monthly transition probabilities and 5-year life expectancies. Survival benefit was calculated as the difference between post-transplantation and waitlist life expectancy.

RESULTS

The 5-year survival benefit increased with actual MELD score for patients with and without HCC, ranging from just a few months in patients with low MELD scores (ie, 6-8) to 4 years in patients with the highest MELD scores (ie, 36-40). The survival benefit of patients with HCC was similar to that of patients without HCC who had the same actual MELD score, irrespective of tumor burden or serum level of α-fetoprotein. However, because patients with HCC received liver transplants when they had a lower mean MELD score (13.3 ± 6.2) than patients without HCC (21.8 ± 8.0), a much lower mean 5-year survival benefit was achieved by providing liver transplants to patients with HCC (0.12 years/patient) than patients without HCC (1.47 years/patient).

CONCLUSIONS

The HCC MELD exception policy has unintentionally resulted in a large reduction in transplantation-related survival benefit.

Liver transplantation in the context of organ shortage: toward extension and restriction of indications considering recent clinical data and ethical framework

PURPOSE OF REVIEW

The scarcity of liver grafts requires to optimize the results of transplantation. Extensions and alternatives of liver transplantation have to be regularly evaluated.

RECENT FINDINGS

Acute-on-chronic liver failure and severe alcoholic hepatitis may represent potential extensions of transplant indications. In these diseases, selected patients could obtain a significant benefit from liver transplantation, whereas long-term outcomes and global impact on waiting lists remain to be evaluated prospectively. Alternatives to transplantation may be represented by recent progress in the management of hepatitis C and the treatment of hepatocellular carcinoma. In hepatitis C, new drug combinations may improve the disease control, reducing the progression to cirrhosis and also the risk of post-transplant reinfection allowing to anticipate a future decrease in the indications for transplantation and retransplantation in these patients. In hepatocellular carcinoma, thanks to improvements in operative techniques and better identification of prognostic factors of cancer recurrency, surgical resection or radiofrequency destruction could appear now as true alternatives to transplant in highly selected patients.

SUMMARY

Before implementation of these potential changes into decisional algorithms for listing and organ allocation, their consequences, either for patient's individual benefit or for global transplant outcomes, should be closely evaluated using objective long-term end points and taking into account the ethical recommendations for organ transplantation.

Model for end-stage liver disease score and MELD exceptions: 15 years later

The model for end-stage liver disease (MELD) score has been used as an objective scale of disease severity for management of patients with end-stage liver disease; it currently serves as the basis of an urgency-based organ-allocation policy in several countries. Implementation of the MELD score led to a reduction in waiting-list registration and waiting-list mortality and an increase in the number of deceased-donor transplants without adversely affecting long-term outcomes after liver transplantation (LT). The MELD score has been used for management of non-transplant patients with chronic liver disease. MELD exceptions serve as a mechanism to advance the needs of subsets of patients with liver disease not adequately addressed by MELD-based organ allocation. Several models have been proposed to refine and improve the MELD score as the environment within which it operates continues to evolve toward transplantation for sicker patients. The MELD score continues to serve and be used as a template to improve upon as an objective gauge of disease severity and as a metric enabling optimization of allocation of scarce donor organs for LT.

Delayed hepatocellular carcinoma model for end-stage liver disease exception score improves disparity in access to liver transplant in the United States

The current system granting liver transplant candidates with hepatocellular carcinoma (HCC) additional Model for End-Stage Liver Disease (MELD) points is controversial due to geographic disparity and uncertainty regarding optimal prioritization of candidates. The current national policy assigns a MELD exception score of 22 immediately upon listing of eligible patients with HCC. The aim of this study was to evaluate the potential effects of delays in granting these exception points on transplant rates for HCC and non-HCC patients. We used Scientific Registry of Transplant Recipients data and liver simulated allocation modeling software and modeled (1) a 3-month delay before granting a MELD exception score of 25, (2) a 6-month delay before granting a score of 28, and (3) a 9-month delay before granting a score of 29. Of all candidates waitlisted between January 1 and December 31, 2010 (n = 28,053), 2773 (9.9%) had an HCC MELD exception. For HCC candidates, transplant rates would be 108.7, 65.0, 44.2, and 33.6 per 100 person-years for the current policy and for 3-, 6-, and 9-month delays, respectively. Corresponding rates would be 30.1, 32.5, 33.9, and 34.8 for non-HCC candidates.

CONCLUSION

A delay of 6-9 months would eliminate the geographic variability in the discrepancy between HCC and non-HCC transplant rates under current policy and may allow for more equal access to transplant for all candidates.

Management of hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC), a common cause for cancer-related death, is increasing worldwide. Over the past decade, survival and quality of life of HCC patients have significantly improved due to better prevention strategies, early diagnosis, and improved treatment options. We performed this narrative review to synthesize current status on the HCC management.

METHODS

Literature search for publications especially over the last decade, which has changed the paradigm on the management of HCC.

RESULTS

Hepatitis B vaccination and treatment of chronic hepatitis B and C are important measures for HCC prevention. Screening and surveillance for HCC using ultrasonogram and alpha-fetoprotein estimation are directed toward cirrhotics and hepatitis B patients at high risk of HCC. If detected at an early stage, curative treatments for HCC can be used such as tumor resection, ablation and liver transplantation. HCC patients without curative options are managed by loco-regional therapies and systemic chemotherapy. Loco-regional treatments include trans-arterial chemoembolization, radioembolization and combinations of loco-regional plus systemic therapies. Currently, sorafenib is the only FDA-approved systemic therapy and newer better chemotherapeutic agents are being investigated. Palliative care for terminally ill patients with metastatic disease and/or poor functional status focusses on comfort care and symptom control.

CONCLUSIONS

In spite of significant advancement in HCC management, its incidence continues to rise. There remains an urgent need to continue refining understanding of HCC and develop strategies to increase utilization of the available preventive measures and curative treatment modalities for HCC.

MELDEQ : An alternative Model for End-Stage Liver Disease score for patients with hepatocellular carcinoma

Multiple studies have demonstrated an advantage for hepatocellular carcinoma (HCC) patients under the current liver allocation system, such that the United Network for Organ Sharing (UNOS) recently voted in support of a proposal to delay granting Model for End-Stage Liver Disease (MELD) exception points to all HCC patients for 6 months, independently of a candidate's native MELD score or alpha-fetoprotein (AFP) level. We obtained UNOS data on adult patients who were added to the wait list between January 22, 2005 and September 30, 2009, and we explored the relationship between HCC, MELD, AFP, and other factors that contribute to not only dropout on the wait list but posttransplant survival as well. The aim was to establish an equivalent Model for End-Stage Liver Disease (MELDEQ ) score for HCC patients that would reduce the disparity in access to transplantation between HCC and non-HCC patients. We determined risk groups for HCC patients with dropout hazards equivalent to those of non-HCC patients, and we evaluated projections for HCC wait-list dropout/transplantation probabilities on the basis of the MELDEQ prioritization scheme. Projections indicate that lower risk HCC patients (MELDEQ  ≤ 18) would have dropout probabilities similar to those of non-HCC patients in the same MELD score range, whereas dropout probabilities for higher risk HCC patients would actually be improved. The posttransplant survival of all HCC risk groups is lower than that of their non-HCC counterparts, with 1-year survival of 0.77 (95% CI, 0.70-0.85) for MELDEQ scores ≥ 31. These results suggest that HCC patients with a combination of a low biochemical MELD score and a low AFP level (MELDEQ  ≤ 15) would receive a marked advantage in comparison with patients with chemical MELD scores in a similar range and that a delay of 6 months for listing may be appropriate. In contrast, patients with MELDEQ scores > 15 would likely be adversely affected by a universal 6-month delay in listing.

Current strategies for preventing the recurrence of hepatocellular carcinoma after liver transplantation

BACKGROUND

Liver transplantation is the optimal treatment for a selected group of patients with moderate to severe cirrhosis and hepatocellular carcinoma (HCC). Despite the strict selection of candidates, post-transplant recurrence often occurs and markedly reduces the long-term survival of patients with HCC. The present review focuses on the current strategies on preventing the recurrence of HCC after liver transplantation.

DATA SOURCES

Relevant articles were identified by extensive searching of PubMed using the keywords "hepatocellular carcinoma", "recurrence" and "liver transplantation" between January 1996 and January 2014. Additional papers were searched manually from the references in key articles.

RESULTS

The current theories of HCC recurrence after liver transplantation are: (i) the growth of pre-transplant occult metastases; (ii) the engraftment of circulating tumor cells released at the time of transplantation. Pre-transplant treatment aims to control local tumor by radiofrequency ablation, transarterial embolization and transarterial chemoembolization. The main objective during the operation is to prevent tumor cell dissemination. Post-transplant treatment includes systemic anticancer therapy, antiviral therapy, and most recently, immunotherapy. These strategies concentrate on the control of the tumor when the patients are waiting for transplant, to reduce the release of HCC cells during surgical procedures and to clear the occult HCC cells after transplantation.

CONCLUSIONS

Much can be done to prevent HCC recurrence after liver transplantation. In future, effort is likely to be directed towards combining multidisciplinary approaches and various treatment modalities.

List and liver transplant survival according to waiting time in patients with hepatocellular carcinoma

The time that patients with hepatocellular carcinoma (HCC) can safely remain on the waiting list for liver transplantation (LT) is unknown. We investigated whether waiting time on the list impacts transplant survival of HCC candidates and transplant recipients. This is a single-center retrospective study of 283 adults with HCC. Patients were divided in groups according to waiting-list time. The main endpoint was survival. The median waiting time for LT was 4.9 months. The dropout rates at 3-, 6-, and 12-months were 6.4%, 12.4%, and 17.7%, respectively. Mortality on the list was 4.8%, but varied depending of the time on the list. Patients who waited less than 3-months had an inferior overall survival when compared to the other groups (p = 0.027). Prolonged time on the list significantly reduced mortality in this analysis (p = 0.02, HR = 0.28). Model for End Stage Liver Disease (MELD) score at transplantation did also independently impact overall survival (p = 0.03, HR = 1.06). MELD was the only factor that independently impacted posttransplant survival (p = 0.048, HR = 1.05). We conclude that waiting time had no relation with posttransplant survival. It is beneficial to prolong the waiting list time for HCC candidates without having a negative impact in posttransplant survival.

Early changes in liver distribution following implementation of Share 35

In June 2013, a change to the liver waitlist priority algorithm was implemented. Under Share 35, regional candidates with MELD ≥ 35 receive higher priority than local candidates with MELD < 35. We compared liver distribution and mortality in the first 12 months of Share 35 to an equivalent time period before. Under Share 35, new listings with MELD ≥ 35 increased slightly from 752 (9.2% of listings) to 820 (9.7%, p = 0.3), but the proportion of deceased-donor liver transplants (DDLTs) allocated to recipients with MELD ≥ 35 increased from 23.1% to 30.1% (p < 0.001). The proportion of regional shares increased from 18.9% to 30.4% (p < 0.001). Sharing of exports was less clustered among a handful of centers (Gini coefficient decreased from 0.49 to 0.34), but there was no evidence of change in CIT (p = 0.8). Total adult DDLT volume increased from 4133 to 4369, and adjusted odds of discard decreased by 14% (p = 0.03). Waitlist mortality decreased by 30% among patients with baseline MELD > 30 (SHR = 0.70, p < 0.001) with no change for patients with lower baseline MELD (p = 0.9). Posttransplant length-of-stay (p = 0.2) and posttransplant mortality (p = 0.9) remained unchanged. In the first 12 months, Share 35 was associated with more transplants, fewer discards, and lower waitlist mortality, but not at the expense of CIT or early posttransplant outcomes.

Impact of multiple transarterial chemoembolization treatments on hepatocellular carcinoma for patients awaiting liver transplantation

Transarterial chemoembolization (TACE) is a common treatment for patients with hepatocellular carcinoma (HCC) who are awaiting liver transplantation (LT). The aim of this study was to assess the impact of multiple TACE treatments on tumor necrosis, tumor recurrence, and survival in these patients. A retrospective analysis was performed for 104 consecutive patients undergoing LT for HCC from January 2002 to December 2009 who were treated with TACE before LT. The number of TACE treatments was not associated with tumor necrosis in the explant. After a median follow-up of 69 months (range = 0-123 months), 14 of the 104 patients (13%) developed recurrent HCC after LT. Recurrence had a significant relationship with a short interval between the diagnosis of HCC and LT (≤6 months) in univariate and multivariate analyses [P = 0.029, odds ratio (OR) = 19.2]. Patients subjected to a single TACE treatment were more likely to experience recurrence, although this finding was not confirmed in the multivariate analysis. No significant relationship was observed between tumor necrosis in the explant and recurrence. The mean overall survival was 102.8 months (95% confidence interval = 94.9-110.8 months) with 1-, 3-, and 5-year survival rates of 91%, 89%, and 84% respectively. In the univariate survival analysis, the presence of ascites before TACE, a waiting time ≤ 9 months, and tumor characteristics at the pathological examination were statistically associated with shorter survival. In the multivariate analysis, only vascular invasion (P < 0.001, OR = 7.99) remained independently associated with shorter survival. The number of TACE treatments was not associated with survival. In conclusion, multiple TACE treatments were not associated with a higher risk of recurrence or shorter survival. Continued use of TACE should be considered as indicated if the patient and lesions are suitable for retreatment. A shorter waiting time before LT is related to an increased risk of recurrence and decreased survival after LT for HCC. These data could reflect the presence of more aggressive tumor biology and may be useful for guiding organ allocation policy to consider a minimum observation period before LT for regions with shorter wait times.

Potential role of the donor in hepatocellular carcinoma recurrence after liver transplantation

A subset of liver transplantation (LT) recipients who undergo transplantation for hepatocellular carcinoma (HCC) will develop postoperative recurrence. There has yet to be a thorough investigation of donor factors influencing recurrence. Data regarding adult, primary LT recipients with HCC (n = 5002) who underwent transplantation between January 1, 2006 and September 30, 2010 were extracted from the United Network for Organ Sharing database, and the cumulative incidence of post-LT recurrence by donor factors was subsequently estimated. Among the HCC LT recipients, 324 (6.5%) developed recurrence. An analysis of donor characteristics demonstrated a higher cumulative incidence of recurrence within 4 years of transplantation among recipients with donors ≥ 60 years old (11.8% versus 7.3% with donors < 60 years old, P < 0.001) and with donors from a nonlocal share distribution (10.6% versus 7.4% with donors with a local share distribution, P = 0.004). The latter 2 findings held true in a multivariate analysis: the risk of HCC recurrence increased by 70% for recipients of livers from donors ≥ 60 years old [subhazard ratio (SHR) = 1.70, 95% confidence interval (CI) = 1.31-2.20, P < 0.001] and by 42% for recipients of nonlocal share distribution livers (SHR = 1.42, 95% CI = 1.09-1.84, P = 0.009) after adjustments for clinical characteristics. In conclusion, the consideration of certain donor factors may reduce the cumulative incidence of posttransplant HCC recurrence and thus improve long-term survival after LT.

The race to liver transplantation: a comparison of patients with and without hepatocellular carcinoma from listing to post-transplantation

BACKGROUND

There are geographic and disease-specific inequities in liver allograft distribution. We examined differences between hepatocellular carcinoma (HCC) and non-HCC liver transplantation (LT) candidates from listing through LT in a region with prolonged wait times.

STUDY DESIGN

We performed a single-center retrospective study, from 2005 to 2013, of adult, primary, nonstatus 1 candidates who were listed and subsequently underwent LT (n=270), or were removed because of death or clinical deterioration (n=277).

RESULTS

Of the HCC candidates removed from the waitlist (n=184), 5.5% died waiting, 25.5% deteriorated clinically, and 69% had LT. Of the non-HCC candidates (n=363), 38.8% died waiting, 21.8% clinically deteriorated, and 39.4% had LT. Of the LT recipients, 127 (47%) had HCC. When compared with non-HCC transplant recipients, HCC recipients spent more time on the waitlist (435±475 vs 301±604 days, p=0.045) and from listing until LT had higher total pre-transplant hospital admissions per patient (1.1±1.2 vs 0.8±1.8, p<0.001). These admissions were more often planned (0.65±0.88 vs 0.17±0.52 planned admissions per patient, p<0.001) and of shorter duration (2.7±2.8 vs 5.2±4.6 days, p<0.001). The HCC and non-HCC recipients demonstrated similar overall post-transplant survival (5 year 80% vs. 83%, respectively; p=0.84).

CONCLUSIONS

Despite a shorter wait to have LT, non-HCC candidates at our center have inferior waitlist outcomes. National reprioritization of liver allocation to improve access for non-HCC candidates may lead to increased wait time and resource use for the HCC population; however, a mortality benefit may exist for the non-HCC candidate lacking the benefit of time.

Growing Up: Not an Easy Transition-Perspectives of Patients and Parents regarding Transfer from a Pediatric Liver Transplant Center to Adult Care

The transition from pediatric to adult care is a critical time when children with chronic illness sustain high morbidity and mortality. Transition services need to be focused on the adolescents' needs, which may differ from those perceived by healthcare providers. In this study, a survey of 31 patients with chronic liver disease and/or liver transplant who were "transferred" to adult services within the last 3 years was conducted. Patients were asked about their current health status and their perceptions of the overall transfer process. The mean age at transfer was 19.81 (18-21) years. Almost half the patients (47%) were not seen at the adult facility until 2-6 months after leaving the Children's hospital and 20% were not seen until 6-12 months. About 20% had their first contact with adult services through an emergency room visit. About 19% reported being out of medication during transition. Of the transplanted patients, 19% were being evaluated for a retransplant. The majority (82%) felt that an increased emphasis on promoting independence and "letting go" both by parents and by pediatric care providers was critical in their transition to independence and adult care services. This study provides thought-provoking insights, which are critical in designing the ideal transition program for children with chronic diseases.

Evaluating the validity of model for end-stage liver disease exception points for hepatocellular carcinoma patients with multiple nodules <2 cm

Liver transplant allocation policy does not give model for end-stage liver disease (MELD) exception points for patients with a single hepatocellular carcinoma (HCC) <2 cm in size, but does give points to patients with multiple small nodules. Because standard-of-care imaging for HCC struggles to differentiate HCC from other nodules, it is possible that a subset of patients receiving liver transplant for multiple nodules <2 cm in size does not have HCC. We evaluate risk of post-transplant HCC recurrence and wait-list dropout for patients with multiple small nodules using competing risks regression based on the Fine and Gray model. We identified 5002 adult HCC patients in the OPTN/UNOS dataset diagnosed and transplanted between January 2006 and September 2010. Compared to patients with >1 tumor <2 cm, risk of developing recurrence was significantly higher in patients with one or more tumors with only one tumor ≥2 cm (SHR 1.63, p = 0.009), as well as in patients with 2-3 tumors ≥2 cm (SHR 1.84, p = 0.02). Dropout risk was not significantly different among size categories. HCC recurrence risk was significantly lower in patients with multiple nodules <2 cm in size than in those with larger tumors, supporting the possibility that some patients received unnecessary transplants. The priority given to these patients must be re-examined.

Excess mortality on the liver transplant waiting list: unintended policy consequences and Model for End-Stage Liver Disease (MELD) inflation

The Model for End-Stage Liver Disease (MELD) allocation system for liver transplantation provides "exceptions" for diseases such as hepatocellular carcinoma (HCC). It was the aim of this study to assess equipoise between exception candidates and nonexception candidates on the waiting list and to assess if the exception system contributes to steadily increasing regional MELD at transplant. In all, 78,595 adult liver transplant candidates between January 2005 and December 2012 were analyzed. Yearly trends in waiting list characteristics and transplantation rates were analyzed for statistical association with MELD exceptions. Regional variations in these associations and the effect of exceptions on regional MELD scores at transplant were also analyzed. 27.29% of the waiting list was occupied by candidates with exceptions. Candidates with exceptions fared much better on the waiting list compared to those without exceptions in mean days waiting (HCC 237 versus non-HCC 426), transplantation rates (HCC 79.05% versus non-HCC 40.60%), and waiting list death rates (HCC 4.49% versus non-HCC 24.63%). Strong regional variation in exception use occurred but exceptions were highly correlated with waiting list death rates, transplantation rates, and MELD score at removal in all regions. In a multivariate model predicting MELD score at transplant within regions, the percentage of HCC MELD exceptions was the strongest independent predictor of regional MELD score at transplant.

CONCLUSION

Liver transplant candidates with MELD exceptions have superior outcomes compared to nonexception candidates and the current MELD exception system is largely responsible for steadily increasing MELD scores at transplant independent of geography.

Female gender in the setting of liver transplantation

The evolution of liver diseases to end-stage liver disease or to acute hepatic failure, the evaluation process for liver transplantation, the organ allocation decision-making, as well as the post-transplant outcomes are different between female and male genders. Women’s access to liver transplantation is hampered by the use of model for end-stage liver disease (MELD) score, in which creatinine values exert a systematic bias against women due to their lower values even in the presence of variable degrees of renal dysfunction. Furthermore, even when correcting MELD score for gender-appropriate creatinine determination, a quantifiable uneven access to transplant prevails, demonstrating that other factors are also involved. While some of the differences can be explained from the epidemiological point of view, hormonal status plays an important role. Moreover, the pre-menopausal and post-menopausal stages imply profound differences in a woman’s physiology, including not only the passage from the fertile age to the non-fertile stage, but also the loss of estrogens and their potentially protective role in delaying liver fibrosis progression, amongst others. With menopause, the tendency to gain weight may contribute to the development of or worsening of pre-existing metabolic syndrome. As an increasing number of patients are transplanted for non-alcoholic steatohepatitis, and as the average age at transplant increases, clinicians must be prepared for the management of this particular condition, especially in post-menopausal women, who are at particular risk of developing metabolic complications after menopause.

Standardizing MELD Exceptions: Current Challenges and Future Directions

Since MELD-based allocation was implemented in 2002, a system of exception points has been in place in order to award increased waitlist priority to those patients whose severity of illness or risk of complications are not captured by the MELD score. These exceptions, categorized as standardized and non-standardized, have been used with increasing frequency over time. Several challenges to the exception point system have emerged, including lack of standardization in the criteria used to approve such exceptions, geographic variability in the use and approval of such exceptions, and limited evidence base to support certain exceptions. Herein, we summarize the current implementation of exception points, the challenges facing the transplant community, and suggestions for improving and standardizing the current exception point system.

Standing the test of time: outcomes of a decade of prioritizing patients with hepatocellular carcinoma, results of the UNOS natural geographic experiment

Priority is given to patients with hepatocellular carcinoma (HCC) to receive liver transplants, potentially causing significant regional disparities in organ access and possibly outcomes in this population. Our aim was to assess these disparities by comparing outcomes in long waiting time regions (LWTR, regions 5 and 9) and short waiting time regions (SWTR regions 3 and 10) by analyzing the United Network for Organ Sharing (UNOS) database. We analyzed 6,160 HCC patients who received exception points in regions 3, 5, 9, and 10 from 2002 to 2012. Data from regions 5 and 9 were combined and compared to data from regions 3 and 10. Survival was studied in three patient cohorts: an intent-to-treat cohort, a posttransplant cohort, and a cohort examining overall survival in transplanted patients only (survival from listing to last posttransplant follow-up). Multivariate analysis and log-rank testing were used to analyze the data. Median time on the list in the LWTR was 7.6 months compared to 1.6 months for SWTR, with a significantly higher incidence of death on the waiting list in LWTR than in SWTR (8.4% versus 1.6%, P < 0.0001). Patients in the LWTR were more likely to receive loco-regional therapy, to have T3 tumors at listing, and to receive expanded-criteria donor (ECD) or donation after cardiac death (DCD) grafts than patients in the SWTR (P < 0.0001 for all). Survival was significantly better in the LWTR compared to the SWTR in all three cohorts (P < 0.0001 for all three survival points). Being listed/transplanted in an SWTR was an independent predictor of poor patient survival on multivariate analysis (P < 0.0001, hazard ratio = 1.545, 95% confidence interval 1.375-1.736).

CONCLUSION

This study provides evidence that expediting patients with HCC to transplant at too fast a rate may adversely affect patient outcomes.

Management of “very early” hepatocellular carcinoma on cirrhotic patients

Due to the advances in screening of cirrhotic patients, hepatocellular carcinoma (HCC) is being diagnosed in earlier stages. For this reason the number of patients diagnosed of very early HCC (single tumors ≤ 2 cm) is continuously increasing. Once a patient has been diagnosed with this condition, treatment strategies include liver resection, local therapies or liver transplantation. The decision on which therapy should the patient undergo depends on the general patients performance status and liver disease. Anyway, even in patients with similar conditions, the best treatment offer is debatable. In this review we analyze the state of the art on the management of very early HCC on cirrhotic patients to address the best treatment strategy for this patient population.

Survival benefit of repeat liver transplantation in the United States: a serial MELD analysis by hepatitis C status and donor risk index

Survival benefit (SB) for first liver transplantation (LT) is favorable at Model for End-Stage Liver Disease (MELD)≥15. Herein, we identify the MELD threshold for SB from repeat liver transplantation (ReLT) by recipient hepatitis C virus (HCV) status and donor risk index (DRI). We analyzed lab MELD scores in new United Network for Organ Sharing registrants for ReLT from March 2002 to January 2010. Risk of ReLT graft failure≤1 year versus waitlist mortality was calculated using Cox regression, adjusting for recipient characteristics. Of 3057 ReLT candidates, 54% had HCV and 606 died while listed. There were 1985 ReLT recipients, 52% had HCV and 567 ReLT graft failures by 1 year. Unadjusted waitlist mortality and post-ReLT graft failure rates were 416 (95% confidence interval [CI] 384-450) and 375 (95% CI 345-407) per 1000 patient-years, respectively. Waitlist mortality was higher with increasing waitlist MELD (p<0.001). The MELD for SB from ReLT overall was 21 (21 in non-HCV and 24 in HCV patients). MELD for SB varied by DRI in HCV patients (MELD 21, 24 and 27 for low, medium and high DRI, respectively) but did not vary for non-HCV patients. Compared to first LT, ReLT requires a higher MELD threshold to achieve an SB resulting in a narrower therapeutic window to optimize the utility of scarce liver grafts.

Reframing the impact of combined heart-liver allocation on liver transplant wait-list candidates

Simultaneous heart-liver (H-L) transplantation, although rare, has become more common in the United States. When the primary organ is a heart or liver, patients receiving an offer for the primary organ automatically receive the second, nonprimary organ from that donor. This policy raises issues of equity, such as whether liver transplantation alone candidates bypassed by H-L recipients are disadvantaged. No prior published analyses have addressed this issue, and few methods have been developed as means of measuring the impact of such allocation policies. We analyzed Organ Procurement and Transplantation Network match run data from 2007 to 2013 to determine whether this combined organ allocation policy disadvantages bypassed liver transplant wait-list candidates in a clinically meaningful way. Among 65 H-L recipients since May 2007, 42 had substantially higher priority for the heart versus the liver, and these 42 bypassed 268 liver-alone candidates ranked 1 to 10 on these match runs. Bypassed patients had a lower risk of wait-list removal for death or clinical deterioration in comparison with controls selected by the match Model for End-Stage Liver Disease (MELD) score [hazard ratio (HR) = 0.56, 95% confidence interval (CI) = 0.40-0.79] and a risk similar to that of controls selected by the laboratory MELD score (HR = 0.91, 95% CI = 0.63-1.33) or on match runs of similar graft quality (HR = 0.97, 95% CI = 0.73-1.37). The waiting time from bypass to subsequent transplantation was significantly longer among bypassed candidates versus controls on match runs of similar graft quality [median: 87 days (interquartile range = 27-192 days) versus 24 days (interquartile range = 5-79 days), P < 0.001]. Although transplantation was delayed, liver transplant wait-list candidates bypassed by H-L recipients did not have excess mortality in comparison with 3 sets of matched controls. These analytic methods serve as a starting point for considering other potential approaches to evaluating the impact of multiorgan transplant allocation policies.

Toward a better liver graft allocation that accounts for candidates with and without hepatocellular carcinoma

In some countries where the Model for End-Stage Liver Disease (MELD) score is used for graft allocation, selected patients with hepatocellular carcinoma (HCC) receive a fixed number of exception points at listing, and increasing priority on the list by accruing additional exception points at regular time intervals. This system originally aimed at balancing the risks of HCC patients of developing contraindications and of non-HCC patients of dying before transplantation, is not ideal because it appears to offer an advantage to HCC patients, regardless of tumor characteristics and response to loco-regional treatment. Scores modulated by HCC characteristics have been proposed. They are based on a more refined estimate of the risk of pretransplant drop-out or of the posttransplant transplant benefit expressed as the life-years gained for each graft. This review describes the newly proposed systems, and discusses their advantages and drawbacks. We believe that the current exception points allocation should be revised and that drop-out-equivalent or transplant benefit-equivalent models should be studied further. As with all policy changes, these should be done under close monitoring that allows subsequent revisions.

Review article: liver transplantation for hepatocellular carcinoma - a critical appraisal of the current worldwide listing criteria

BACKGROUND

Liver transplantation (LT) plays an important role in the management of patients with hepatocellular carcinoma (HCC). Although early results following LT for HCC were poor, since the introduction of the Milan criteria in 1996 morphological criteria have since been well established. Thereafter, various expansions of the Milan criteria were introduced worldwide. Listing criteria for LT for HCC in the United Kingdom (UK) initially conformed to the Milan criteria but were re-defined in 2009 by expansion of the Milan criteria.

AIMS

To look at the evidence in literature on listing criteria and management of HCC worldwide in comparison with the UK. Secondly, we aim to review worldwide vs. UK literature on prioritisation models, loco-regional therapy protocols and role of alpha-fetoprotein (AFP) in LT for HCC.

METHODS

An electronic literature search with Medline was carried out to identify articles related to LT for HCC.

RESULTS

Although various expansions of the Milan criteria have been described, they remain the gold standard against which other criteria are measured. The UK criteria are an expansion of the Milan criteria that go beyond Milan and University of California, San Francisco (UCSF) criteria. The current UK listing criteria for LT for HCC when compared to the worldwide criteria have a worse survival benefit (projected 5-year survival between 35-50%) when plotted on the metroticket calculator.

CONCLUSIONS

In keeping with most transplant centres worldwide, the UK have adopted expansions to Milan to allow more patients to benefit from LT. However, currently, as it stands the UK criteria when plotted in the modification of the Metroticket model project worse survival that would seem unjustified.

Waiting time predicts survival after liver transplantation for hepatocellular carcinoma: a cohort study using the United Network for Organ Sharing registry

Recipients of liver transplantation (LT) for hepatocellular carcinoma (HCC) have an 8% to 20% risk of HCC recurrence. Single-center studies suggest that a period of waiting after HCC therapy may facilitate the selection of patients at low risk for post-LT HCC recurrence and mortality. We evaluated whether a longer waiting time after Model for End-Stage Liver Disease (MELD) prioritization for HCC predicts longer post-LT survival. From the United Network for Organ Sharing registry, we selected 2 groups registered for LT between March 2005 and March 2009: (1) HCC patients receiving MELD prioritization and (2) non-HCC patients. Patients were stratified by their MELD status at LT (a marker of time on the wait list after HCC MELD prioritization) and were followed from LT until death or censoring through October 2012. By comparing post-LT survival to intention-to-treat (ITT) survival from registration, we assessed predictors of post-LT survival and estimated the benefit of LT. The median MELD scores at LT were 22 (HCC) and 24 (non-HCC). A higher MELD score at LT was independently associated with lower post-LT mortality in the HCC group [hazard ratio (HR) = 0.84, 95% confidence interval (CI) = 0.73-0.98] and higher post-LT mortality in the non-HCC group (HR = 1.20, 95% CI = 1.15-1.25). Compared with the HCC group, the non-HCC group had lower post-LT mortality [relative risk (RR) = 0.85, log-rank P < 0.01] but higher ITT mortality (RR = 1.25, log-rank P < 0.01) because of a 33 percentage point lower probability of undergoing LT. In conclusion, a longer waiting time before LT for HCC predicted longer post-LT survival in a national transplant registry. Delaying LT for HCC may reduce disparities in ITT survival and access to LT among different indications and thereby improve system utility and organ allocation equity for the overall pool of LT candidates.

Challenges in living donor liver transplantation

Living donor liver transplantation is a procedure that has waned in its application over the past decade but remains a beneficial procedure for properly selected candidates. This review discusses some of the newer, relevant studies in the field, focusing on outcomes with hepatocellular carcinoma, ABO-incompatible transplant, and issues in donor complications and safety.

Time to transplantation as a predictor of hepatocellular carcinoma recurrence after liver transplantation

In the United States, there are significant geographic disparities in the time to transplantation for patients with hepatocellular carcinoma (HCC); it is possible that rapid transplantation contributes to higher rates of posttransplant HCC recurrence because there is insufficient time for the tumor biology to manifest. In this study, we compared HCC recurrence in rapid transplant patients and their slower transplant counterparts. We identified adult liver transplantation (LT) candidates in the Organ Procurement and Transplantation Network/United Network for Organ Sharing (UNOS) data set who were granted an initial exception for an HCC diagnosis between January 1, 2006 and September 30, 2010 and underwent transplantation in the same time window. Patients were followed until HCC recurrence, non-HCC-related death, or last follow-up. The cumulative incidence of HCC recurrence was compared for patients waiting ≤ 120 days and patients waiting >120 days from an HCC exception to LT. The association between the risk of posttransplant recurrence and the wait time was further evaluated via competing risks regression with the Fine and Gray model. For 5002 LT recipients with HCC, the median wait time from an exception to LT was 77 days, and it varied from 30 to 169 days by UNOS region. The cumulative incidence of posttransplant HCC recurrence was 3.3% [95% confidence interval (CI) = 2.8%-3.8%] and 5.6% (95% CI = 5.0%-6.3%) within 1 and 2 years, respectively. The rate of observed recurrence within 1 year of transplantation was significantly lower for patients waiting >120 days versus patients waiting ≤ 120 days (2.2% versus 3.9%, P = 0.002); however, the difference did not persist at 2 years (5.0% versus 5.9%, P = 0.09). After we accounted for clinical factors, the HCC recurrence risk was reduced by 40% for patients waiting >120 days (subhazard ratio = 0.6, P = 0.005). In conclusion, the risk of HCC recurrence within the first year after transplantation may be lessened by the institution of a mandatory waiting time after an exception is granted.

Waiting time and explant pathology in transplant recipients with hepatocellular carcinoma: a novel study using national data

Risk factors for hepatocellular carcinoma (HCC) recurrence after liver transplantation have been well described. It has been surmised that longer time on the waitlist may select for tumors with a lower-risk of recurrence posttransplant, as patients with unfavorable tumor characteristics would be delisted due to tumor progression. Utilizing national explant pathology records from transplant recipients waitlisted with T2 HCC exception points, this study explored the correlation between waiting time and the development of pathologic HCC features associated with increased risk of tumor recurrence. Of 1976 explant pathology reports submitted nationally between April 8, 2012 and June 30, 2013, 1453 (73.5%) were from recipients with automatic T2 HCC exception points. There was no association between pretransplant waiting time and the proportion of HCC explants with either: (i) a poorly differentiated tumor; (ii) macrovascular invasion; (iii) HCC beyond Milan or University of California San Francisco criteria; (iv) HCC beyond the "up-to-seven" criteria; or (v) extra-hepatic or lymph node involvement. Though there was a statistically significant increase in microvascular invasion in recipients with pretransplant waiting 6-12 months, this association was not seen when adjusted for United Network for Organ Sharing region. These findings suggest that waiting time alone may not select for tumors with more favorable characteristics.

Section 2. Small-for-size liver graft and hepatocellular carcinoma recurrence

Liver transplantation (LT) is the most effective treatment for small and unresectable hepatocellular carcinomas (HCCs). With scarcity of deceased donor livers, living donor LT (LDLT) is the alternative to deceased donor LT (DDLT). Animal studies have suggested that regeneration of the partial liver graft encourages HCC recurrence. Increased recurrence was observed in a few studies. Thus, there is the belief that the use of small-for-size graft carries the potential risk of disease recurrence. Nevertheless, those studies were retrospective, with sample sizes not large enough for conclusions.Living donor LT can be performed when a suitable donor is available. The fast tracking of patients for transplantation without a period of observation is an issue. Meta-analyses, however, showed no significant increase in HCC recurrence after LDLT. Patients listed for DDLT and without suitable living donors have to endure a long wait, during which the aggressiveness of their HCC is observed. Such observation almost guarantees slow disease progression when they get transplanted. Nevertheless, a long wait has the disadvantage of transplanting patients with more advanced tumors, although still within standard criteria. Judicious use of deceased donor grafts is the responsibility of the transplant community.Living donor LT for HCC should only be performed after careful assessment of the recipient and tumor status. Although tumor size and number are references widely adopted in tumor staging, biological staging of tumors using positron emission tomography could provide additional information of tumor behavior. A high level of serum α-fetoprotein also warns against LT because it is predictive of a high HCC recurrence rate.

Is resectable hepatocellular carcinoma a contraindication to liver transplantation? A novel decision model based on "number of patients needed to transplant" as measure of transplant benefit

BACKGROUND & AIMS

Number-needed-to-treat is used in assessing the effectiveness of a health-care intervention, and reports the number of patients who need to be treated to prevent one additional bad outcome. Although largely used in medical literature, there are no studies measuring the benefit of liver transplantation (LT) over hepatic resection (HR) for hepatocellular carcinoma (HCC) in terms of "Number of patients needed to transplant (NTT)."

EXCLUSION CRITERIA

Child-Turcotte-Pugh (CTP) Classes B-C, very large (>10 cm) and multi-nodular (>2 nodules) tumours, macroscopic vascular invasion and extra-hepatic metastases.

STUDY POPULATION

1028 HCC cirrhotic patients from one Eastern (n=441) and two Western (n=587) surgical units. Patient survival observed after HR by proportional hazard regression model was compared to that predicted after LT by the Metroticket calculator. The benefit obtainable from LT compared to resection was analysed in relationship with number of nodules (modelled as ordinal variable: single vs. oligonodular), size of largest nodule (modelled as a continuous variable), presence of microscopic vascular invasion (MVI), and time horizon from surgery (5-year vs. 10-year).

RESULTS

330 patients were beyond the Milan criteria (32%) and 597 (58%) had MVI. The prevalence of MVI was 52% in patients within Milan criteria and 71% in those beyond (p<0.0001). In the 5-year transplant benefit analysis, nodule size and HCC number were positive predictors of transplant benefit, while MVI had a strong negative impact on NTT. Transplantation performed as an effective therapy (NTT <5) only in oligonodular HCC with largest diameter >3cm (beyond conventional LT criteria) when MVI was absent. The 10-year scenario increased drastically the transplant benefit in all subgroups of resectable patients, and LT became an effective therapy (NTT <5) for all patients without MVI whenever tumor extension and for oligonodular HCC with MVI within conventional LT criteria.

CONCLUSIONS

Based on NTT analysis, the adopted time horizon (5-year vs. 10-year scenario) is the main factor influencing the benefit of LT in patients with resectable HCC and Child A cirrhosis.

Validation of a dropout assessment model of candidates with/without hepatocellular carcinoma on a common liver transplant waiting list

The model of end-stage liver disease (MELD) score is often used for liver graft allocation, and patients with hepatocellular carcinoma (HCC) receive exception points (22 in the US). A better model is desirable for patients with HCC as they tend to have a privileged access to transplantation, without taking HCC characteristics into account. A new simpler model designed from a training set of US patients (n = 49 026) was tested on two validation sets (US and UK patient cohorts with, respectively, n = 20 475 and n = 1781). The risk of dropout was between 3.2 and 7.8% at 3 months in patients with HCC, and was captured into a score, including HCC size, HCC number, AFP, and MELD (-37.8 +1.9*MELD+5.9 if HCC Nb ≥ 2 + 5.9 if AFP > 400 + 21.2 if HCC size > 1 cm). This new model could be validated on external US and UK liver candidate cohorts. It provides a dynamic and more accurate assessment of dropout than the use of exception MELD (C-indices of 66.2-73.7% vs. 52.7-56.6%). In addition, the model shows a similar distribution as MELD for patients with non-HCC, and both scores could be used in parallel for the management of waiting-list patients with and without HCC.

A method for establishing allocation equity among patients with and without hepatocellular carcinoma on a common liver transplant waiting list

BACKGROUND & AIMS

The current organ allocation system for liver transplantation (LT) creates an imbalance between patients with and without hepatocellular carcinoma (HCC). We describe a model designed to re-establish allocation equity among patient groups using transplant benefit as the common endpoint.

METHODS

We enrolled consecutive adult patients entering the waiting list (WL group, n=2697) and undergoing LT (LT group, n=1702) during the period 2004-2009 in the North Italy Transplant program area. Independent multivariable regressions (WL and LT models) were created for patients without HCC and for those with stage T2 HCC. Monte Carlo simulation was used to create distributions of transplant benefit, and covariates such as Model for End-stage Liver Disease (MELD) and alpha-fetoprotein (AFP) were combined in regression equations. These equations were then calibrated to create an "MELD equivalent" which matches HCC patients to non-HCC patients having the same numerical MELD score.

RESULTS

Median 5 year transplant benefit was 15.12 months (8.75-25.35) for the non-HCC patients, and 28.18 months (15.11-36.38) for the T2-HCC patients (p<0.001). Independent predictors of transplant benefit were MELD score (estimate=0.89, p<0.001) among non-HCC patients, and MELD (estimate=1.14, p<0.001) and logAFP (estimate=-0.46, p<0.001) among HCC patients. The equation "HCC-MELD"=1.27∗MELD - 0.51∗logAFP+4.59 calculates a numerical score for HCC patients, whereby their transplant benefit is equal to that of non-HCC patients with the same numerical value for MELD.

CONCLUSIONS

We describe a method for calibrating HCC and non-HCC patients according to survival benefit, and propose that this method has the potential, if externally validated, to restore equity to the organ allocation system.

Wait and transplant for stage 2 hepatocellular carcinoma with deceased-donor liver grafts

BACKGROUND

As a new scheme at our center, a Model for End-stage Liver Disease score of 18 points is assigned to candidates of deceased-donor liver transplantation (DDLT) who have hepatocellular carcinoma (HCC) remaining at stage 2 six months after their disease has been confirmed stage 2 HCC. Two points are added every 3 months if their disease remains at stage 2 or below. This study evaluated patient and tumor characteristics as well as surgical and short-term outcomes of DDLT in these patients.

METHODS

Comparison of survival was made among three groups of patients who underwent liver transplantation (LT) in the same period. Group 1 consisted of 22 HCC patients who received DDLT under the new scheme. Group 2 consisted of 18 HCC patients who underwent living-donor LT. Group 3 consisted of 52 patients who underwent DDLT because of liver failure, among whom 6 had HCC but were not included in the new scheme.

RESULTS

Group 1 had a median follow-up period of 17.9 months, and the 1-, 3-, and 5-year overall survival rates were 100%, 100%, and 80%, respectively. Group 2 had the corresponding rates at 100%, 100%, and 100% with a median follow-up of 19.6 months. Group 3 had the corresponding rates at 96.1%, 96.1%, and 96.1% with a median follow-up of 19.4 months.

CONCLUSIONS

The policy of a 6-month wait has benefited the HCC patients who practically had no chance of undergoing living-donor LT. Their survival outcomes will be excellent as long as they can stand the test of time.

Donor factors similarly impact survival outcome after liver transplantation in hepatocellular carcinoma and non-hepatocellular carcinoma patients

BACKGROUND

Many have advocated the preferential use of high risk allografts for hepatocellular carcinoma patients undergoing liver transplantation. Hepatocellular carcinoma (HCC) patients tend to have relatively preserved liver function, and their outcome is felt to be driven largely by tumor-related factors.

AIM

The aim of this study was to compare the relative importance of donor versus recipient factors on post-orthotopic liver transplantation survival among HCC and non-HCC recipients.

METHODS

The study group included Scientific Registry of Transplant Recipients data on adult recipients of deceased donor liver transplants from February 2002 through December 2008. Recipients were classified as HCC based on MELD exception applications and were compared to all other recipients. Predictors of post-LT survival were identified by Cox regression. To test whether donor factors have less impact on survival in HCC patients, interaction terms were created between HCC diagnosis and donor factors.

RESULTS

Of the 40,212 DDLTs during the study period, 29,020 (72 %) met study criteria. A total of 7,786 (27 %)were transplanted with a diagnosis of HCC. The mean donor risk index was 1.5 in both cohorts. The 1-/5-year survival was 88 %/68 % and 87 %/74 % among HCC and non-HCC recipients, respectively (p\0.0001). On multivariate analysis, there was no statistically significant interaction between HCC diagnosis and DRI (HR 0.94,p = 0.317). Likewise, no interaction was seen between HCC diagnosis and individual donor factors. In both groups, donor and recipient factors carried similar weight in determining post-LT survival.

CONCLUSIONS

Contrary to previous assumptions, donor factors play a similar role in determining survival post-LT among HCC patients and non-HCC patients.

Meeting report of the 19th Annual International Congress of the International Liver Transplantation Society (Sydney Convention and Exhibition Centre, Sydney, Australia, June 12-15, 2013)

The International Liver Transplantation Society held its annual meeting from June 12 to 15 in Sydney, Australia. More than 800 registrants attended the congress, which opened with a conference celebrating 50 years of liver transplantation (LT). The program included series of featured symposia, focused topic sessions, and oral and poster presentations. This report is by no means all-inclusive and focuses on specific abstracts on key topics in LT. Similarly to previous reports, this one presents data in the context of the published literature and highlights the current direction of LT.

Transplant benefit for patients with hepatocellular carcinoma

Although liver transplantation is theoretically the best treatment for hepatocellular carcinoma (HCC), it is limited by the realities of perioperative complications, and the shortage of donor organs. Furthermore, in many cases there are available alternative treatments such as resection or locoregional therapy. Deciding upon the best option for a patient with HCC is complicated, involving numerous ethical principles including: urgency, utility, intention-to-treat survival, transplant benefit, harm to candidates on waiting list, and harm to living donors. The potential contrast between different principles is particularly relevant for patients with HCC for several reasons: (1) HCC candidates to liver transplantation are increasing; (2) the great prognostic heterogeneity within the HCC population; (3) in HCC patients tumor progression before liver transplantation may significantly impair post transplant outcome; and (4) effective alternative therapies are often available for HCC candidates to liver transplantation. In this paper we suggest that allocating organs by transplant benefit could help balance these competing principles, and also introduce equity between patients with HCC and nonmalignant liver disease. We also propose a triangular equipoise model to help decide between deceased donor liver transplantation, living donor liver transplantation, or alternative therapies.

Wait and transplant for stage 2 hepatocellular carcinoma with deceased-donor liver grafts

BACKGROUND

As a new scheme at our center, a Model for End-stage Liver Disease score of 18 points is assigned to candidates of deceased-donor liver transplantation (DDLT) who have hepatocellular carcinoma (HCC) remaining at stage 2 six months after their disease has been confirmed stage 2 HCC. Two points are added every 3 months if their disease remains at stage 2 or below. This study evaluated patient and tumor characteristics as well as surgical and short-term outcomes of DDLT in these patients.

METHODS

Comparison of survival was made among three groups of patients who underwent liver transplantation (LT) in the same period. Group 1 consisted of 22 HCC patients who received DDLT under the new scheme. Group 2 consisted of 18 HCC patients who underwent living-donor LT. Group 3 consisted of 52 patients who underwent DDLT because of liver failure, among whom 6 had HCC but were not included in the new scheme.

RESULTS

Group 1 had a median follow-up period of 17.9 months, and the 1-, 3-, and 5-year overall survival rates were 100%, 100%, and 80%, respectively. Group 2 had the corresponding rates at 100%, 100%, and 100% with a median follow-up of 19.6 months. Group 3 had the corresponding rates at 96.1%, 96.1%, and 96.1% with a median follow-up of 19.4 months.

CONCLUSIONS

The policy of a 6-month wait has benefited the HCC patients who practically had no chance of undergoing living-donor LT. Their survival outcomes will be excellent as long as they can stand the test of time.

The MELD system and liver transplant waiting-list mortality in developing countries: lessons learned from São Paulo, Brazil

OBJECTIVE

The MELD system has not yet been tested as an allocation tool for liver transplantation in the developing countries. In 2006, MELD (Model for End-stage Liver Disease) was launched as a new liver allocation system in São Paulo, Brazil. This study was designed to assess the results of the new allocation policy on waiting list mortality.

METHODS

The State of São Paulo liver transplant database was retrospectively reviewed from July 2003 through July 2009. Patients were divided into those who were transplanted before (Pre-MELD Group) and those who were transplanted after (post-MELD Group) the implementation of the MELD system. Only adult liver transplant candidates were included. Waiting list mortality was the primary endpoint.

RESULTS

The unadjusted death rate in waiting list decreased significantly after the implementation of the MELD system (from 91.2 to 33.5/1,000 patients per year; p<0.0001). Multivariate analysis showed a significant drop in risk of waiting list death for post-MELD patients (HR 0.34; p<0.0001). Currently, 48% of patients are transplanted within 1-year of listing (versus 23% in the pre-MELD era; p<0.0001). Patient and graft survival did not change with MELD implementation.

CONCLUSION

There was a reduction in waiting time and list mortality after implementation of the MELD system in São Paulo. Patients listed in the post-MELD era had a significant reduction in risk for the waiting list mortality. There were no changes in post-transplant outcomes. MELD can be successfully utilized for liver transplant allocation in developing countries.

Identification of liver transplant candidates with hepatocellular carcinoma and a very low dropout risk: implications for the current organ allocation policy

It has been shown that patients with hepatocellular carcinoma (HCC) meeting the United Network for Organ Sharing T2 (Milan) criteria have an advantage in comparison with patients without HCC under the current organ allocation system for liver transplantation (LT). We hypothesized that within the T2 HCC group, there is a subgroup with a low risk of wait-list dropout that should not receive the same listing priority. This study evaluated 398 consecutive patients with T2 HCC listed for LT with a Model for End-Stage Liver Disease exception from March 2005 to January 2011 at our center. Competing risk (CR) regression was used to determine predictors of dropout. The probabilities of dropout due to tumor progression or death without LT according to the CR analysis were 9.4% at 6 months and 19.6% at 12 months. The median time from listing to LT was 8.8 months, and the median time from listing to dropout or death without LT was 7.2 months. Significant predictors of dropout or death without LT according to a multivariate CR regression included 1 tumor of 3.1 to 5 cm (versus 1 tumor of 3 cm or less), 2 or 3 tumors, a lack of a complete response to the first locoregional therapy (LRT), and a high alpha-fetoprotein (AFP) level after the first LRT. A subgroup (19.9%) that met certain criteria (1 tumor of 2 to 3 cm, a complete response after the first LRT, and an AFP level ≤ 20 ng/mL after the first LRT) had 1- and 2-year probabilities of dropout of 1.3% and 1.6%, respectively, whereas the probabilities were 21.6% and 26.5% for all other patients (P = 0.004). In conclusion, a combination of tumor characteristics and a complete response to the first LRT define a subgroup of patients with a very low risk of wait-list dropout who do not require the same listing priority. Our results may have important implications for the organ allocation policy for HCC.