Predicting the probability of progression-free survival in patients with small hepatocellular carcinoma

Are MELD and MELDNa Still Reliable Tools to Predict Mortality on the Liver Transplant Waiting List?

Liver transplantation is the only curative treatment for end-stage liver disease. Unfortunately, the scarcity of donor organs and the increasing pool of potential recipients limit access to this life-saving procedure. Allocation should account for medical and ethical factors, ensuring equal access to transplantation regardless of recipient's gender, race, religion, or income. Based on their short-term prognosis prediction, model for end-stage liver disease (MELD) and MELD sodium (MELDNa) have been widely used to prioritize patients on the waiting list for liver transplantation resulting in a significant decrease in waiting list mortality/removal. Recent concern has been raised regarding the prognostic accuracy of MELD and MELDNa due, in part, to changes in recipients' profile such as body mass index, comorbidities, and general condition, including nutritional status and cause of liver disease, among others. This review aims to provide a comprehensive view of the current state of MELD and MELDNa advantages and limitations and promising alternatives. Finally, it will explore future options to increase the donor pool and improve donor-recipient matching.

Assessing the impact of COVID-19 on liver cancer management (CERO-19)

Background & Aims

The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges to healthcare systems and it may have heavily impacted patients with liver cancer (LC). Herein, we evaluated whether the schedule of LC screening or procedures has been interrupted or delayed because of the COVID-19 pandemic.

Methods

An international survey evaluated the impact of the COVID-19 pandemic on clinical practice and clinical trials from March 2020 to June 2020, as the first phase of a multicentre, international, and observational project. The focus was on patients with hepatocellular carcinoma or intrahepatic cholangiocarcinoma, cared for around the world during the first COVID-19 pandemic wave.

Results

Ninety-one centres expressed interest to participate and 76 were included in the analysis, from Europe, South America, North America, Asia, and Africa (73.7%, 17.1%, 5.3%, 2.6%, and 1.3% per continent, respectively). Eighty-seven percent of the centres modified their clinical practice: 40.8% the diagnostic procedures, 80.9% the screening programme, 50% cancelled curative and/or palliative treatments for LC, and 41.7% modified the liver transplantation programme. Forty-five out of 69 (65.2%) centres in which clinical trials were running modified their treatments in that setting, but 58.1% were able to recruit new patients. The phone call service was modified in 51.4% of centres which had this service before the COVID-19 pandemic (n = 19/37).

Conclusions

The first wave of the COVID-19 pandemic had a tremendous impact on the routine care of patients with liver cancer. Modifications in screening, diagnostic, and treatment algorithms may have significantly impaired the outcome of patients. Ongoing data collection and future analyses will report the benefits and disadvantages of the strategies implemented, aiding future decision-making.

Lay summary

The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges to healthcare systems globally. Herein, we assessed the impact of the first wave pandemic on patients with liver cancer and found that routine care for these patients has been majorly disrupted, which could have a significant impact on outcomes.

HEPATOCELLULAR CARCINOMA PATIENTS ARE ADVANTAGED IN THE CURRENT BRAZILIAN LIVER TRANSPLANT ALLOCATION SYSTEM. A COMPETING RISK ANALYSIS

BACKGROUND

In Brazil, the Model for End-Stage Liver Disease (MELD) score is used to prioritize patients for deceased donor liver transplantation (DDLT). Patients with hepatocellular carcinoma (HCC) receive standardized MELD exception points to account for their cancer risk of mortality, which is not reflected by their MELD score.

OBJECTIVE

To compare DDLT rates between patients with and without HCC in Rio Grande do Sul, the Southernmost state of Brazil.

METHODS

- We retrospectively studied 825 patients on the liver-transplant waiting list from January 1, 2007, to December 31, 2016, in a transplant center located in Porto Alegre, the capital of Rio Grande do Sul, to compare DDLT rates between those with and without HCC. The time-varying hazard of waiting list/DDLT was estimated, reporting the subhazard ratio (SHR) of waiting list/DDLT/dropout with 95% confidence intervals (CI). The final competing risk model was adjusted for age, MELD score, exception points, and ABO group.

RESULTS

Patients with HCC underwent a transplant almost three times faster than patients with a calculated MELD score (SHR 2.64; 95% CI 2.10-3.31; P<0.001). The DDLT rate per 100 person-months was 11.86 for HCC patients vs 3.38 for non-HCC patients. The median time on the waiting list was 5.6 months for patients with HCC and 25 months for patients without HCC.

CONCLUSION

Our results demonstrated that, in our center, patients on the waiting list with HCC have a clear advantage over candidates listed with a calculated MELD score.

Liver Allocation Policies in the USA: Past, Present, and the Future

Identifying the optimal allocation policy with regard to hepatocellular carcinoma has been a persistent and evolving challenge. The current criteria for LT for HCC endorsed by the United Network of Organ Sharing (UNOS) are based on the Milan Criteria: a solitary tumor < 5 cm, or maximum of three tumors ≤ 3 cm each, without vascular invasion or evidence of extrahepatic spread. Contraindications to HCC exception points include: stage 1 HCC, ruptured HCC, extrahepatic HCC, and main portal or hepatic vein HCC invasion. Based upon projected waitlist dropout rates due to tumor growth, patients with HCC are assigned MELD standardized exception points. In addition to tumor size and number, AFP levels are an important predictor of recurrence of HCC following liver transplantation. Standardized exception points for HCC patients are not awarded to patients with AFP levels > 1000 ng/mL that do not decrease to < 500 ng/mL with treatment. Appeals for MELD exception points for patients with HCC vary widely between UNOS regions, with success of nonstandardized exception point appeals varying from 3.1 to 21% between regions. In an effort to make prioritization for HCC more consistent, a national liver review board (NLRB)is being convened that will focus on developing a national guidance for assessing common requests and addressing exception points, including for HCC.

Surgical Treatment of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. In select patients, surgical treatment in the form of either resection or transplantation offers a curative option. The aims of this review are to (1) review the current American Association for the Study of Liver Diseases/European Association for the Study of the Liver guidelines on the surgical management of HCC and (2) review the proposed changes to these guidelines and analyze the strength of evidence underlying these proposals. Three authors identified the most relevant publications in the literature on liver resection and transplantation for HCC and analyzed the strength of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification. In the United States, the liver allocation system provides priority for liver transplantation to patients with HCC within the Milan criteria. Current evidence suggests that liver transplantation may also be indicated in certain patient groups beyond Milan criteria, such as pediatric patients with large tumor burden or adult patients who are successfully downstaged. Patients with no underlying liver disease may also benefit from liver transplantation if the HCC is unresectable. In patients with no or minimal (compensated) liver disease and solitary HCC ≥2 cm, liver resection is warranted. If liver transplantation is not available or contraindicated, liver resection can be offered to patients with multinodular HCC, provided that the underlying liver disease is not decompensated. Many patients may benefit from surgical strategies adapted to local resources and policies (hepatitis B prevalence, organ availability, etc). Although current low-quality evidence shows better overall survival with aggressive surgical strategies, this approach is limited to select patients. Larger and well-designed prospective studies are needed to better define the benefits and limits of such approach.

All-treatment array of hepatocellular carcinoma from initial diagnosis to death: observation of cumulative treatments

PURPOSE

In clinical practice, most patients with hepatocellular carcinoma require subsequent treatments for remaining, progressing, or recurring tumors. We investigated all-treatment array and outcomes in an HCC cohort from initial diagnosis to death.

METHODS

We enrolled 1687 consecutive patients with HCC who underwent initial diagnosis and treatment at the National Cancer Center, Korea, from January 2004 to December 2009.

RESULTS

In total, 1357 patients (80.4%) showed RPRTs during median 20.4-month follow-up. Initial transplantation resulted in the least rate (32.3%) of RPRTs. Median treatment frequency was 3.0 times (range 1-20) and 382 patients (27.3%) received treatments ≥6 times. The median treatment frequency was different based on four factors (p < 0.05): age, tumor stage, tumor type and initial treatment modality. Patients with Barcelona Clinic Liver Cancer stage 0 received less frequent treatments. As the stage progressed from 0 to B, the median treatment frequency increased. Radiofrequency ablation as initial treatment was associated with the longest median treatment interval at 19.0 weeks, followed by resection at 14.1 weeks. The median treatment interval was significantly shorter as the stage progressed (p < 0.01). TACE was most frequently performed for RPRTs; the median number of subsequent TACE was 3 (range 1-19). Subsequent treatment array was very heterogeneous, and no certain pattern was found.

CONCLUSIONS

Our findings suggest that the survival outcome of patients with HCC is based on the results of cumulative multiple treatments rather than an initial treatment. It is time to consider prospective studies evaluating sequential treatment array of 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.

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.

Liver transplantation for hepatocellular carcinoma: how far have we come and what is the future?

SUMMARY: 

Liver transplantation is the best treatment for hepatocellular carcinoma in the setting of chronic liver disease, completely removing malignancy and underlying diseased liver tissue. Technical aspects of liver transplantation have improved over the years, along with outcomes. But challenges continue in the areas of expanding existing indications for transplant with limited organ supply, calling for optimization of patient selection and the development of alternative or adjunctive treatment options. Expansion of existing transplant criteria will help identify patients most likely to have good outcomes. Locoregional and systemic treatments showing therapeutic promise are being investigated for use in achieving acceptable oncologic effect. Improvements in post-transplant treatment and continued attempts to enlarge the donor pool will continue to provide avenues for further improvements in outcomes.

HCC patients suffer less from geographic differences in organ availability

It has been suggested that the number of exception model for end-stage liver disease (MELD) points for hepatocellular carcinoma (HCC) overestimates mortality risk. Average MELD at transplant, a measure of organ availability, correlates with mortality on an intent-to-treat basis and varies by donation service area (DSA). We analyzed Scientific Registry of Transplant Recipients data from 2005 to 2010, comparing transplant and death parameters for patients transplanted with HCC exception points to patients without HCC diagnosis (non-HCC), to determine whether the two groups were impacted differentially by DSA organ availability. HCC candidates are transplanted at higher rates than non-HCC candidates and are less likely to die on the waitlist. Overall risk of death trends downward by 1% per MELD point (p = 0.65) for HCC, but increases by 7% for non-HCC patients (p < 0.0001). The difference in the change of mortality with MELD is statistically significant between HCC and non-HCC candidates p < 0.0001. Posttransplant risk of death trends downward by 2% per MELD point (p = 0.28) for HCC patients, but increases by 3% per MELD point in non-HCC patients (p = 0.027), with the difference being statistically significant with p < 0.005. In summary, increasing wait time impacts HCC candidates less than non-HCC candidates and under increased competition for donor organs, HCC candidates' advantage increases.

A decade of model for end-stage liver disease: lessons learned and need for re-evaluation of allocation policies

PURPOSE OF REVIEW

The model for end-stage liver disease (MELD) driven liver allocation system has been in place for 10 years now. Understanding what the driving forces were, what principles were developed and employed, and assessing how these have stood the test of time will help future policy makers further refine the system.

RECENT FINDINGS

Prior to development of the MELD system, policymakers had limited data and organ allocation policy development was rarely systematic or evidence-based and was not necessarily centered on the patient. The MELD process focused on patient-specific variables and validation of the risk prediction models to be sure the system would function reasonably well across the spectrum of potential candidates and that it did not impose artificial categorizations of patients. In addition, the transplant community focused on assessing the effects of this policy change which was also something new.

SUMMARY

Numerous publications since have reported outcomes for MELD-based liver allocation here in the United States and in many other areas around the world. Some of these reports have suggested changes to the MELD equation or other ways to adapt the system to more accurately reflect the need for transplant. The transparency that this type of system brings allows for much more rigorous assessment of results and for highlighting areas for improvement toward a more fair, equitable, and utilitarian system.

Effects of interferon therapy on development of hepatocellular carcinoma in patients with hepatitis C-related cirrhosis: A meta-analysis of randomized controlled trials

AIM

  The role of interferon (IFN) therapy on prevention of hepatocellular carcinoma (HCC) in patients with hepatitis C virus (HCV)-related cirrhosis remains controversial. This meta-analysis aimed to determine whether IFN therapy reduced the incidence of HCC in HCV-related cirrhotic patients.

METHODS

  We performed a meta-analysis including eight randomized controlled trials (RCT) (a total of 1505 patients) to assess the effect of IFN therapy on prevention of HCC in patients with HCV-related cirrhosis. The pooled odds ratios (OR) were calculated using a random or fixed effects model.

RESULTS

  Our results showed that IFN therapy significantly decreased the overall HCC incidence in HCV-related cirrhotic patients (OR, 0.29; 95% confidence interval [CI], 0.10-0.80; P = 0.02). HCC risk in patients who failed to achieve sustained virological response (SVR) in the initial IFN-based treatment was also reduced by maintenance IFN therapy (OR, 0.54; 95% CI, 0.32-0.90; P = 0.02). Subgroup analysis indicated that IFN therapy decreased HCC incidence in HCV-related cirrhotic patients during long-term follow up (>48 months) evidently (OR, 0.25; 95% CI, 0.09-0.67; P = 0.006). However, subgroup analysis of four RCT with short-term follow up (≤48 months) did not demonstrate the significant difference in HCC incidence between IFN-treated cirrhotic patients and controls (OR, 0.78; 95% CI, 0.39-1.55; P = 0.48).

CONCLUSION

  The present study suggested that IFN therapy could efficiently reduce HCC development in patients with HCV-related cirrhosis; this effect was more evident in the subgroup of patients with long-term follow up (>48 months). Patients who received maintenance IFN therapy had a lower risk of HCC than controls.

Which is more cost-effective under the MELD system: primary liver transplantation, or salvage transplantation after hepatic resection or after loco-regional therapy for hepatocellular carcinoma within Milan criteria?

OBJECTIVE

The optimal strategy for treating hepatocellular carcinoma (HCC), a disease with increasing incidence, in patients with Child-Pugh class A cirrhosis has long been debated. This study evaluated the cost-effectiveness of hepatic resection (HR) or locoregional therapy (LRT) followed by salvage orthotopic liver transplantation (SOLT) vs. that of primary orthotopic liver transplantation (POLT) for HCC within the Milan Criteria.

METHODS

A Markov-based decision analytic model simulated outcomes, expressed in costs and quality-adjusted life years (QALYs), for the three treatment strategies. Baseline parameters were determined from a literature review. Sensitivity analyses tested model strength and parameter variability.

RESULTS

Both HR and LRT followed by SOLT were associated with earlier recurrence, decreased survival, increased costs and decreased quality of life (QoL), whereas POLT resulted in decreased recurrence, increased survival, decreased costs and increased QoL. Specifically, HR/SOLT yielded 3.1 QALYs (at US$96 000/QALY) and LRT/SOLT yielded 3.9 QALYs (at US$74 000/QALY), whereas POLT yielded 5.5 QALYs (at US$52 000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities.

CONCLUSIONS

 Under the Model for End-stage Liver Disease (MELD) system, in patients with HCC within the Milan Criteria, POLT increases survival and QoL at decreased costs compared with HR or LRT followed by SOLT. Therefore, POLT is the most cost-effective strategy for the treatment of HCC.

Regional variability in symptom-based MELD exceptions: a response to organ shortage?

MELD (model for end-stage liver disease) exception awards affect the liver allocation process. Award rates of specific nonhepatocellular carcinoma exceptions, termed symptom-based exceptions (SBE), differ across UNOS regions. We aimed to characterize the regional variability in SBE awards and examine predictive factors for receiving a SBE in the MELD era. The OPTN liver transplant and waiting list dataset was analyzed for waiting list registrants during the MELD allocation on February 27, 2002, until November 22, 2006. Competing risks proportional hazards regression analysis was used to examine predictors for receiving a SBE in 39 169 registrants. The hazard ratios for receiving a SBE differed significantly across regions when adjusted for multiple variables including age, gender, ethnicity, physiologic MELD score, blood group, functional status, etiology of liver disease, insurer and education level. Utilization of SBE is highly significantly variable across UNOS regions, and does not correlate with organ availability as estimated by the regional mean physiologic MELD score at transplantation. Patients with Medicaid as their primary payer have a lower likelihood of receiving a SBE award, while patients with cryptogenic/NASH cirrhosis or cholestatic liver disease have a higher likelihood of receiving a SBE. Reasons for these regional and demographic disparities deserve further investigation.

The MELD score in patients awaiting liver transplant: strengths and weaknesses

Adoption of the Model for End-stage Liver Disease (MELD) to select and prioritize patients for liver transplantation represented a turning point in organ allocation. Prioritization of transplant recipients switched from time accrued on the waiting list to the principle of "sickest first". The MELD score incorporates three simple laboratory parameters (serum creatinine and bilirubin, and INR for prothrombin time) and stratifies patients according to their disease severity in an objective and continuous ranking scale. Concordance statistics have demonstrated its high accuracy in stratifying patients according to their risk of dying in the short-term (three months). Further validations of MELD as a predictor of survival at various temporal end-points have been obtained in independent patient cohorts with a broad spectrum of chronic liver disease. The MELD-based liver graft allocation policy has led to a reduction in waitlist new registrations and mortality, shorter waiting times, and an increase in transplants, without altering overall graft and patient survival rates after transplantation. MELD limitations are related either to the inter-laboratory variability of the parameters included in the score, or to the inability of the formula to predict mortality accurately in specific settings. For some conditions, such as hepatocellular carcinoma, widely accepted MELD corrections have been devised. For others, such as persistent ascites and hyponatremia, attempts to improve MELD's predicting power are currently underway, but await definite validation.

Maintenance peginterferon therapy and other factors associated with hepatocellular carcinoma in patients with advanced hepatitis C

BACKGROUND & AIMS

Interferon reportedly decreases the incidence of hepatocellular carcinoma (HCC) in patients with chronic hepatitis C. The Hepatitis C Antiviral Long-term Treatment against Cirrhosis (HALT-C) Trial showed that 4 years of maintenance therapy with pegylated interferon (peginterferon) does not reduce liver disease progression. We investigated whether peginterferon decreases the incidence of HCC in the HALT-C cohort over a longer posttreatment follow-up period.

METHODS

The study included 1048 patients with chronic hepatitis C (Ishak fibrosis scores ≥ 3) who did not have a sustained virologic response (SVR) to therapy. They were randomly assigned to groups given a half-dose of peginterferon or no treatment (controls) for 3.5 years and followed up for a median of 6.1 (maximum, 8.7) years.

RESULTS

Eighty-eight patients developed HCC (68 definite, 20 presumed): 37 of 515 who were given peginterferon (7.2%) and 51 of 533 controls (9.6%; P = .24). There was a significantly lower incidence of HCC among patients given peginterferon therapy who had cirrhosis, but not fibrosis, based on analysis of baseline biopsy samples. After 7 years, the cumulative incidences of HCC in treated and control patients with cirrhosis were 7.8% and 24.2%, respectively (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.24-0.83); in treated and control patients with fibrosis, incidences were 8.3% and 6.8%, respectively (HR, 1.44; 95% CI, 0.77-2.69). Treated patients with a ≥ 2-point decrease in the histologic activity index, based on a follow-up biopsy, had a lower incidence of HCC than those with unchanged or increased scores (2.9% vs 9.4%; P = .03).

CONCLUSIONS

Extended analysis of the HALT-C cohort showed that long-term peginterferon therapy does not reduce the incidence of HCC among patients with advanced hepatitis C who did not achieve SVRs. Patients with cirrhosis who received peginterferon treatment had a lower risk of HCC than controls.

The impact of the model for end-stage liver disease (MELD) on liver transplantation in one center in Brazil

CONTEXT: Presently the MELD score is used as the waiting list criterion for liver transplantation in Brazil. In this method more critical patients are considered priority to transplantation. OBJECTIVE: To compare the results of liver transplantation when the chronologic waiting list was the criterion for organ allocation (pre-MELD era) with MELD score period (MELD era) in one liver transplantation unit in Brazil. METHODS: The charts of the patients subjected to liver transplantation at the Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR, Brazil, were reviewed from January of 2001 to August of 2008. Patients were divided into two groups: pre-MELD era and MELD era. They were compared in relation to demographics of donors and receptors, etiology of cirrhosis, cold and warm ischemia time, presence of hepatocellular carcinoma, MELD score and Child-Pugh score and classification at the time of transplantation, units of red blood cells transfused during the transplantation, intensive care unit stay, total hospital stay and 3 month and 1 year survival. RESULTS: Initially, 205 liver transplantations were analyzed. Ninety four were excluded and 111 were included: 71 on the pre-MELD era and 40 on the MELD era. The two groups were comparable in relation to donors and receptors age and sex, etiology of cirrhosis and cold and warm ischemia time. The receptors of the MELD era had more hepatocellular carcinoma than those of the pre-MELD era (37.5% vs 16.9%). Patients with hepatocellular carcinoma had less advanced cirrhosis on both eras. The MELD score was the same on both eras. Excluding the cases of hepatocellular carcinoma, MELD era score was higher than pre-MELD score (18.2 vs 15.8). There were an increased number of transplants on Child-Pugh A and C and a decreased number on Child-Pugh B receptors on MELD era. Both eras had the same need of red blood cells transfusion, intensive care unit stay and hospital stay. Also, 3 month and 1 year survival were the same: 76% and 74.6% on pre-MELD era and 75% and 70.9% on MELD era. CONCLUSION: In our center, after the introduction of MELD score as the priority criterion for liver transplantation there were an increased number of transplants with hepatocellular carcinoma. Excluding these patients, the receptors were operated upon with more advanced cirrhosis. Nevertheless the patients had the same need for red blood cells transfusion, intensive care unit and hospital stay and 3 months and 1 year survival.

The challenges of liver transplantation for hepatocellular carcinoma on cirrhosis

Hepatocellular carcinoma (HCC) is a major cause of cancer mortality worldwide and liver transplantation (LT) has potentials to improve survival for patients with HCC. However, expansion of indications beyond Milan Criteria (MC) and use of bridging/downstaging procedures to convert intermediate-advanced stages of HCC within MC limits are counterbalanced by graft shortage and increasing use of marginal donors, partially limited by the use of donor-division protocols applied to the cadaveric and living-donor settings. Several challenges in technique, indications, pre-LT treatments and prioritization policies of patients on the waiting list have to be precised through prospective investigations that have to include individualization of prognosis, biological variables and pathology surrogates as stratification criteria. Also, liver resection has to be rejuvenated in the general algorithm of HCC treatment in the light of salvage transplantation strategies, while benefit of LT for HCC should be determined through newly designed composite scores that are able to capture both efficiency and equity endpoints. Innovative treatments such as radioembolization for HCC associated with portal vein thrombosis and molecular targeted compounds are likely to influence future strategies. Accepting this challenge has been part of the history of LT and will endure so also for the future.

Prediction of progression-free survival in patients presenting with hepatocellular carcinoma within the Milan criteria

Transplantation is the treatment of choice for hepatocellular carcinoma (HCC) meeting the Milan criteria. HCC and chronic liver diseases have distinct natural histories for which an equitable transplant policy must account. We enrolled and prospectively followed at a single center 206 consecutive HCC patients that presented within the Milan criteria. Patients were treated per the Barcelona Clinic Liver Cancer (BCLC) algorithm; 95% received resection, ablation, or transarterial chemoembolization. The median follow-up was 16 months. Progression occurred in 84 patients, and 8 patients died. Risk factors for the time to disease progression (death or progression beyond T2) were analyzed in 170 patients with a complete data set. Risk factors with the strongest relationship to progression included tumor diameter and tumor persistence/recurrence after local therapy (hazard ratios of 1.51 and 2.75, respectively, when transplanted patients were censored at the time of transplantation and hazard ratios of 1.53 and 3.66, respectively, when transplantation was counted as an event; P < or = 0.0001). To evaluate the current Model for End-Stage Liver Disease (MELD) exception, we compared the expected progression rate (PR) with our observed PR in 133 stage T2 patients. The current policy resulted in a large overestimation of the PR for T2 HCC and an unsatisfactory performance [Harrell's concordance index (C index) = 0.60, transplant censored; C index = 0.55, transplant as progression]. Risk factors for progression that were identified by univariate analysis were considered for multivariate analysis. With these risk factors and the patients' natural MELD scores, an adjusted model applicable to organ allocation was generated, and this decreased the discrepancy between the expected and observed PRs (C index = 0.66, transplant censored; C index = 0.69, transplant as progression). In conclusion, the current MELD exception largely overestimates progression in T2 patients treated according to the BCLC guidelines. The tumor response to resective or ablative treatment can predict tumor progression beyond the Milan criteria, and it should be taken into account in models designed to prioritize organ allocation.

[Prognostic scores of cirrhosis]

Prognostic models are useful to estimate disease severity, establish expected survival in a specific situation, and calculate the risk of certain medical interventions. Of all the scores described in liver cirrhosis, those with the widest clinical applicability are the Child-Pugh classification and the model for end-stage liver disease (MELD). Although the Child-Pugh classification was used for many years to stratify patients and select those that can safely undergo liver surgery, currently this classification has been substituted by the MELD. This model uses only three simple and objective variables and has consequently become the most widely used instrument, especially to fix priorities when allocating organs in liver transplantation. Nevertheless, this model has some limitations since some indications for liver transplantation (hepatocarcinoma, metabolic diseases, etc.) and certain comorbidities in patients with cirrhosis (hepatic encephalopathy, hyponatremia, refractory ascites) are not well represented in the MELD.

Recent advances in the natural history of hepatocellular carcinoma

Ongoing advances in liver disease management and basic research in recent years have changed our knowledge of the natural history of hepatocellular carcinoma (HCC). Indeed, the natural history of this tumor is fairly long and covers a preclinical and a clinical phase. Some of the biological steps involved in cell transformation and different carcinogenic pathways have been identified, disclosing potential novel markers for HCC. Following the progress in surveillance and early diagnosis, much more is now known about precancerous lesions and the process leading to overt HCC, including growth patterns, dedifferentiation and neoangiogenenesis. In particular, research has focused on clinical and biological factors predicting tumor aggressiveness and patients' prognosis. Lastly, clinical studies have described tumor presentation, evolution and causes of patients' death and how the new knowledge has influenced clinical management and patients' survival in recent years. By addressing 10 key questions, this review will summarize well-established and novel features of the natural history of HCC.

Development of a survival evaluation model for liver transplant recipients with hepatocellular carcinoma secondary to hepatitis B

AIM

To develop a model using easily obtainable, objective, verifiable preoperative parameters, to help evaluate post transplant survival probability for hepatocellular carcinoma (HCC) patients with hepatitis B.

METHODS

We retrospectively examined a cohort of 150 consecutive primary cadaveric liver transplants with HCC in our center over 6 years. Thirteen preoperative biochemical parameters and six tumor-related factors were analyzed to identify their correlation with post transplant survival using the Cox proportional-hazards regression model. The predictive power of a new model and the model for end stage liver disease was compared by the receiver operating characteristic curve.

RESULTS

In univariate analysis, the factors significantly associated with post transplant survival were serum concentrations of albumin, total bilirubin, alkaline phosphatase, alpha-fetoprotein, gamma-glutamyltransferase, aspartate aminotransferase, sodium, tumor diameter and the number of tumor nodules. Multivariate analysis showed alpha-fetoprotein, serum sodium, alkaline phosphatase and the number of tumor nodules were significantly associated with the post transplant outcome. Based on the four variables, we established a new model with a c-statistic of 0.72 which was significantly greater than 0.50 (P = 0.001), and the c-statistic of MELD was 0.59 (P = 0.146).

CONCLUSION

The new model based on four objective tumor-related parameters has the capacity to evaluate the risk of post transplant mortality for HCC patients with hepatitis B.

Allocation policy for hepatocellular carcinoma in the MELD era: room for improvement?

Currently, liver transplantation is the optimal cure for hepatocellular cancer (HCC) limited to the liver. The requisite use of a scarce resource and the effective "competition" between transplant candidates with and without HCC necessitates an allocation policy that defines the subset of HCC patients appropriate for transplantation and their equitable waiting-list prioritization relative to non-HCC patients. Under Model for End-Stage Liver Disease (MELD) allocation, HCC candidates must meet the Milan criteria (single tumor < or =5 cm in diameter or 2 or 3 tumors, each <3 cm in diameter) to qualify for exceptional HCC waiting-list consideration. Their waiting-list prioritization is based on estimating progression risk beyond the Milan criteria (termed dropout), an event for HCC patients considered equivalent to death for non-HCC patients. Although the Milan criteria may be too restrictive, thereby denying deserving patients access to transplantation, high rates of understaging by pretransplantation radiographic imaging and concern for erosion of recurrence-free survival rates have dampened enthusiasm for relaxation of tumor guidelines. The efficacy of pretransplantation locoregional therapies to reduce dropout, downstage patients, and/or decrease posttransplantation recurrence remains to be determined. Genomic, molecular, or clinical criteria to accurately differentiate HCC patients whose disease will recur from those whose disease will not recur would resolve much of the current controversy regarding appropriate criteria for HCC patients to qualify for transplantation.

A new priority policy for patients with hepatocellular carcinoma awaiting liver transplantation within the model for end-stage liver disease system

The best prioritization of patients with hepatocellular carcinoma (HCC) waiting for liver transplantation under the model for end-stage liver disease (MELD) allocation system is still being debated. We analyzed the impact of a MELD adjustment for HCC, which consisted of the addition of an extra score (based on the HCC stage and waiting time) to the native MELD score. The outcome was analyzed for 301 patients with chronic liver disease listed for liver transplantation between March 1, 2001 and February 28, 2003 [United Network for Organ Sharing (UNOS)-Child-Turcotte-Pugh (CTP) era, 163 patients, 28.8% with HCC] and between March 1, 2003 and February 28, 2004 (HCC-MELD era, 138 patients, 29.7% with HCC). In the HCC-MELD era, the cumulative dropout risk at 6 months was 17.6% for patients with HCC versus 22.3% for those patients without HCC (P = NS), similar to that in the UNOS-CTP era. The cumulative probability of transplantation at 6 months was 70.3% versus 39.0% (P = 0.005), being higher than that in the UNOS-CTP era for patients with HCC (P = 0.02). At the end of the HCC-MELD era, 12 patients with HCC (29.3%) versus 57 without HCC (58.8%) were still on the list (P = 0.001). Both native and adjusted MELD scores were higher (P < 0.05) and progressed more in patients with HCC who dropped out than in those who underwent transplantation or remained on the list (the initial-final native MELD scores were 17.3-23.1, 15.5-15.6, and 12.8-14.1, respectively). The patients without HCC remaining on the list showed stable MELD scores (initial-final: 15.1-15.4). In conclusion, the present data support the strategy of including the native MELD scores in the allocation system for HCC. This model allows the timely transplantation of patients with HCC without severely affecting the outcome of patients without HCC.

The model for end-stage liver disease comes of age

The care of patients who have chronic liver disease has evolved considerably since the Model for End-stage Liver Disease (MELD) was first described 6 years ago. This article traces the progress in liver allocation and clinical liver disease research that includes the MELD score and highlights the management of areas in which MELD and the principles underlying MELD enhance the clinician's ability to understand better the patient who has chronic liver disease.

Transplantation for hepatocellular carcinoma: The Milan criteria and beyond

1. Liver transplantation offers excellent results for selected candidates with hepatocellular carcinoma (HCC). 2. Selection strategies have evolved but are mainly based on size and number of tumors, which are surrogates for vascular invasion. Newer techniques show promise for identifying patients at high risk for recurrence and selecting those with low risk, even though they may exceed currently established tumor size criteria. 3. Evaluation of the effectiveness of liver transplantation for HCC requires an intent-to-treat approach that must include an accounting of the dropout rate of patients while waiting. 4. Locoregional pretransplantation adjuvant treatments may have some role for downstaging and/or reducing the dropout rate before transplantation, but their posttransplantation effect on outcome remains undetermined. 5. Liver allocation for HCC candidates in the context of increasing HCC prevalence requires better and evidence-based prioritization policies.

Optimizing staging for hepatocellular carcinoma before liver transplantation: A retrospective analysis of the UNOS/OPTN database

Assignment of liver allocation priority for hepatocellular carcinoma is predicated on accurate imaging staging. We analyzed radiographically defined stage (radiologic stage [RS]) at listing and most recent extension and pathologic stage (PS) data from 789 liver transplant recipients for whom no pretransplant ablative treatment was given. There were no predetermined imaging or pathological protocols in this retrospective analysis of wait list data. Seventy-two (9.1%), 690 (87.5%), and 27 (3.4%) were listed as stage 1, 2 and >2, respectively. Computed tomography (CT) scan alone (46.4%), magnetic resonance image scan alone (37.1%), ultrasound alone (1.3%), and multiple imaging studies (15.2%) were used with no difference in time to transplant for listing or most recent scan among the recipient groups. Overall accuracy (RS = PS) was 44.1% and was not different if original listing RS or most recent RS was used for comparison with PS. No one type of imaging technique had superior accuracy (P = 0.13); however, CT scan used alone or in combination compared to not being used at all, had higher odds of being accurate (odds ratio [OR] 1.38 [1.03-1.84], P = 0.031). In addition, imaging done less than 90 days before transplant had higher odds of being accurate (OR 1.49 [1.06-2.08], P = 0.019) as did RS = 2 or 3 (OR 5.56 [2.70-11.11], P < 0.0001). We observed considerable variation in RS accuracy among the United Network for Organ Sharing and Organ Procurement and Transplantation Network regions that is unexplained. In conclusion, current imaging requirements for RS prior to liver transplantation are unacceptably inaccurate. Future policy should require more accurate modalities or combinations of techniques.

Accuracy of staging as a predictor for recurrence after liver transplantation for hepatocellular carcinoma

BACKGROUND

Tumor number, size, and macrovascular invasion (MacroVI) are the most widely used predictors of survival after liver transplantation (LT) for hepatocellular carcinoma (HCC). We analyzed all patients undergoing LT for HCC at our center to establish the accuracy of preoperative clinical staging and to determine which patients have a higher probability of being understaged.

METHODS

In all, 118 patients with confirmed HCC after LT from April 1991 to October 2004 at our institution were reviewed. All patients were monitored with serial imaging every 3 months to ensure their eligibility for LT within Milan criteria. Understaging in the 118 patients was defined as evidence on explant pathology that Milan criteria (TNM stage pT1 or pT2) had been exceeded.

RESULTS

Five-year DFS was 78% with a recurrence rate of 15% after a median follow-up after LT of 30 months. On explant pathology, 43% (51/118) of patients exceeded Milan criteria and had a worse DFS (1 year, 95% vs. 87%; 3 year, 87% vs. 64%; P=0.03) compared to those who met LT criteria. Understaging was more likely in patients with imaging characteristics of > or = 2 tumor nodules (P=0.005) and tumor growth > 0.25 cm/month (P=0.02) and pathologic findings of vascular invasion (P=0.001) and bilobar tumors (P=0.002).

CONCLUSIONS

Preoperative imaging every 3 months while on the waiting list frequently understages HCC as assessed by explant pathology. Recurrence after LT often occurred in patients that were understaged. Improving the accuracy of clinical staging and inclusion parameters will ensure proper organ allocation and acceptable outcomes after LT.

A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplantation

The Model for End-Stage Liver Disease (MELD) score is now used for allocation in liver transplantation (LT) waiting lists, replacing the Child-Turcotte-Pugh (CTP) score. However, there is debate as whether it is superior to CTP score to predict mortality in patients with cirrhosis on the LT waiting list and after LT. We reviewed studies comparing the accuracy of MELD vs. CTP score in transplantation settings. We found that in studies of the LT waiting list (12,532 patients with cirrhosis), only 4 of 11 showed MELD to be superior to CTP in predicting short-term (3-month) mortality. In addition, 2 of 3 studies (n = 1,679) evaluating the changes in MELD score (DeltaMELD) showed that DeltaMELD had better prediction for mortality than the baseline MELD score. The impact of MELD on post-LT mortality was assessed in 15 studies (20,456 patients); only 6 (9,522 patients) evaluated the discriminative ability of MELD score using the concordance (c) statistic (the MELD score had always a c-statistic < 0.70). In 11 studies (19,311 patients), high MELD score indicated poor post-LT mortality for cutoff values of 24-40 points. In re-LT patients, 2 of 4 studies evaluated the discriminative ability of MELD score on post-LT mortality. Finally, several studies have shown that the predictive ability of MELD score increases by adding clinical variables (hepatic encephalopathy, ascites) or laboratory (sodium) parameters. On the basis of the current literature, MELD score does not perform better than the CTP score for patients with cirrhosis on the waiting list and cannot predict post-LT mortality.

Impact of model for end-stage liver disease (MELD) scoring system on pathological findings at and after liver transplantation

The Model for End-Stage Liver Disease (MELD) scoring system, a validated objective liver disease severity scale, was adopted in February 2002 to allocate cadaveric organs for liver transplantation (LT). To improve transplantability before succumbing to advanced disease, patients with low-stage hepatocellular carcinoma (HCC) are given extra points in this system commensurate with their predicted mortality. Our aims were to determine 1) any change in the pathological findings at LT following the implementation of this system and 2) the impact of scoring advantage given to early-stage HCC. Clinicopathologic findings were compared before (pre-MELD, n = 87) and after (MELD, n = 58) the introduction of the MELD system. The findings in the pre-MELD vs. MELD groups were as follows: HCC, 27.5% vs. 48.3% (P = 0.001); portal vein thrombosis (PVT), 13.7% vs. 25.9% (P = 0.08); cholestasis, 16.1% vs. 32.7% (P = 0.026); inflammation grade of 2 or more, 43.7% vs. 48.3% (P = not significant); hepatitis C (HCV), 45.9% vs. 51.7% (P = not significant); HCV with lymphoid aggregates, 25% vs. 60% (P = 0.003); HCV with hyperplastic hilar nodes, 15.0% vs. 36.6% (P = 0.001); and post-LT HCC recurrence, 4.1% vs. 3.4% (P = not significant). Non-HCC-related findings were further compared in the 2 subgroups of pre-MELD (n = 57) and MELD (n = 31) after exclusion of HCC and fulminant hepatic failure (FHF) cases, and only cholestasis was significantly increased in the subgroup MELD. In conclusion, increased incidence of native liver cholestasis in the MELD era may be the histologic correlate of clinically severe liver disease. The scoring advantage given to low-stage HCC did result in a significantly increased incidence of HCC in the MELD group, but it did not adversely affect the post-LT recurrence rate.

Waiting list removal rates among patients with chronic and malignant liver diseases

Equitable liver allocation should ensure that nonelective removal rates are fairly distributed among waiting candidates. We compared removal rates for adults entered with nonmalignant (NM) (N = 9379) and hepatocellular cancer (HCC) (N = 2052) diagnoses on the Organ Procurement and Transplantation Network (OPTN) list between April 30, 2003, and December 31, 2004. Unadjusted removal rates for NM vs. HCC diagnoses were 9.4% vs. 8.7%, 13.5% vs. 16.9% and 19.1% vs. 31.8% at 90, 180 and 365 days, respectively after listing. For NM candidates, model for end-stage liver disease (MELD) score (RR = 1.16), age (RR = 1.03) and metabolic disease diagnoses (RR = 1.66) had higher risks of removal; and PSC (RR = 0.62) and alcoholic cirrhosis (RR = 0.82) had lower risks of removal. For HCC candidates, MELD score at listing (RR = 1.09), AFP (RR = 1.02), maximum tumor size (RR = 1.16) and age at listing (RR = 1.02) had increased risks of removal. The equation 1 - 0.920 exp[0.09369 (MELD at listing - 12.48) + 0.00193 (AFP - 97.4) + 0.1505 (maximum tumor size - 2.59) defined the probability of dropout for HCC candidates within 90 days of listing. We conclude that factors associated with the risk of removal for HCC are different from NM candidates, although MELD score at listing remains the most predictive for both groups. Liver transplant candidates with HCC may be prioritized using a risk score analogous to the MELD score.

Liver allocation for hepatocellular carcinoma: a European Center policy in the pre-MELD era

BACKGROUND

Policies to decrease dropout during waiting time for liver transplantation (LT) are under debate.

METHODS

We evaluated the allocation system from 1996 to 2003, when recipients had priority related to Child-Pugh score and donors >60 years were mainly offered to recipients with hepatocellular carcinoma (HCC). The outcomes of 656 patients with chronic liver disease (142 HCC and 514 non-HCC) listed for LT were prospectively evaluated, considering recipient and donor features.

RESULTS

Transplantation and dropout rates were similar between HCC and non-HCC patients: 64.1% vs. 70.6% and 26% vs. 22.6%. Multivariate analysis showed the probability of being transplanted within 3 months was related to Child-Pugh score >10 and to HCC, whereas the probability of being removed from the list within 3 months was only related to Child-Pugh score >10. HCC patients had a lower median waiting time (97 vs. 197 days, P<0.001), a higher rate of donors > 60 years (50.5% vs. 33.5%, P<0.005) and with steatosis (31.6% vs. 14.3%, P<0.01), but a lower Child-Pugh score (9.1+/-2.1 vs. 9.6+/-1.7, P<0.05) than non-HCC patients. The 5-year patient survival was comparable since registration on the list and since LT: 56.9% and 77% in the HCC group vs. 61.4% and 79% in the non-HCC patients. Donors > 60 years affected outcome after LT in the non-HCC group, but not in the HCC patients.

CONCLUSION

By allocating donors >60 years mainly to HCC patients, we controlled dropout without affecting their survival and the outcome of non-HCC patients.

Liver transplantation for malignancy

Liver transplantation for hepatic malignancies has emerged from an exotic and desperate approach to a well-documented and proven treatment modality for these unfortunate patients. However, early unsatisfactory results emphasized that only a highly selected patient population would benefit from transplantation. Currently, <10% of all liver transplants performed are for hepatocellular cancer (HCC). There is no controversy that hepatoblastoma is an excellent indication in pediatric patients with unresectable tumors. Similarly, liver transplantation for HCC in the adult population yields good results for patients whose tumor masses do not exceed the Milan criteria. It remains to be determined whether patients with more extensive tumors can be reliably selected to benefit from the procedure. Adjunctive procedures like radiofrequency ablation, chemoembolization, or cryotherapy might be indicated to limit tumor progression for patients on waiting lists. Epitheloid hemangioendothelioma is also an appropriate indication for liver transplantation, unlike angiosarcoma. Metastatic liver disease is not an indication for liver transplantation, with the exception of cases in which the primary is a neuroendocrine tumor, for which liver transplantation can result in long-term survival and even cure in a number of patients. And finally, while gallbladder cancers are never an indication for liver transplantation, rare cases of cholangiocellular cancer might qualify if aggressive combination therapies, including chemotherapy and radiotherapy followed by OLT, are carried through. Survival in these selected patients can approach that for patients with cholestatic liver disease.

Liver transplant recipients mortality on the waiting list: long-term comparison to Child-Pugh classification and MELD

We sought to evaluate our experience concerning the high waiting list mortality rate for orthotopic liver transplantation (OLT) using the MELD (Model for End-Stage Liver Disease), which has been shown to predict short-term survival better than Child-Turcotte-Pugh (CTP) classification. The predominant end-stage disease was cirrhosis due to hepatitis C virus (67%), patient mean age was 36.8 years, and 72.1% were men. When the patients were included on a waiting list, the MELD score was stratified into W: 0 to 10; X: 11 to 20, and Y: 21 to 40 and the CPT as A: 5 to 6, B: 7 to 9, and C: 10 to 15. It was also observed that 77.8% of patients were on the waiting list, 16.4% underwent OLT and 5.8% had been removed. The estimated survival rate after 1 year was W = 85.4%; X = 83.3%, Y = 46.8%; A = 81.3%, B = 84.2%, C = 45.9%. Child median score was 8 +/- 1.5 (5 to 15) and the MELD was 14.7 +/- 5.1 (8 to 43). The mortality rate was 20.2%. Severe patients classified as Y or C showed greater mortality than the other groups (P <.001), but no significant difference between Y and C strata. The mortality rate was the same as in previous years.

Partial necrosis on hepatocellular carcinoma nodules facilitates tumor recurrence after liver transplantation

BACKGROUND

The presence of partial necrosis in hepatocellular carcinoma (HCC) nodules is a common histologic finding after liver transplantation, but its correlation with tumor recurrence has never been investigated.

METHODS

we retrospectively reviewed the outcome of 54 patients with a single histologically proven HCC after liver transplantation. All cases had a survival of more than 6 months, and patients treated preoperatively had a transarterial chemoembolization (TACE) procedure. Since 1996, our center has applied the Milan criteria. Correlations between tumor recurrences and clinicopathologic variables, including the presence of partial necrosis, were performed. Etiologic factors for HCC partial necrosis were also investigated.

RESULTS

Sixteen of 54 (29.6%) HCC nodules presented partial necrosis, and 4 (25%) of them developed HCC recurrence compared with 1 of 38 (2.6%) cases without this histologic finding (P<0.05). Partial necrosis was related to TACE procedure (P<0.05), patient age less than 50 years (P<0.05), and tumor diameter greater than 2 cm (P<0.05). Multivariate analysis showed only TACE as an independent variable. The other variables related to the five (9.3%) tumor recurrences were HCC diameter greater than 2 cm (P<0.05), year of liver transplantation before 1996 (P<0.05), and the presence of satellite nodules (P<0.05). The Cox regression analysis showed the presence of partial necrosis as an independent variable related to tumor recurrence. The analysis of the recurrence-free survival confirmed the results of the recurrence rate.

CONCLUSION

Partial necrosis was a risk factor for tumor recurrence after liver transplantation. Patients and procedures should be selected while also bearing in mind the side-effect of incomplete necrosis of the nodules.

Determination of the optimal model for end-stage liver disease score in patients with small hepatocellular carcinoma undergoing loco-regional therapy

The model for end-stage liver disease (MELD) has been a prevailing system to prioritize cirrhotic patients awaiting liver transplantation. An "exceptional" MELD score of 20 and 24 points is assigned for stage T1 and T2 patients with small hepatocellular carcinoma (HCC), respectively. However, this strategy is based on scarce data and the optimal score for these patients remains uncertain. We investigated 238 patients with small HCC who were candidates for liver transplantation and underwent arterial chemoembolization or percutaneous injection therapy using acetic acid or ethanol. Tumor stage (P = .001) and Child-Turcotte-Pugh (CTP) class (P < .001) were independent risk factors predicting tumor progression or death in survival analysis. The risk of disease progression in HCC patients stratified by tumor stage was mapped and equated with the risk of mortality of 456 cirrhotic patients without HCC. The 6- and 12-month rates of disease progression were 4% and 6%, respectively, for stage T1 HCC patients (n = 50; mean MELD: 9.5). These rates were close to and no higher than the mortality rate in MELD category 8-12 at the corresponding time period (7.1% and 11.3%, respectively; n = 141). For stage T2 patients (n = 188; mean MELD: 9.3), the corresponding rates were 5.3% and 13.8%, respectively, which were close to and no higher than the mortality rate in MELD category 10-14 (9.0% and 13.9%, respectively, n = 166). In conclusion, the risk of disease progression is quite low for selected HCC patients undergoing loco-regional therapy. A lower MELD score may be suggested to be equivalent to the risk of short- and mid-term mortality in the cirrhosis group.

Liver transplantation for hepatocellular cancer: the impact of the MELD allocation policy

Recent reports suggest that selected patients undergoing liver transplantation for stage 1-2 hepatocellular cancer (HCC) have an excellent long-term survival and a low incidence of recurrence. In the past, over 45% of HCC patients on the United Network for Organ Sharing/Organ Procurement Transplantation Network waiting list did not receive a donor organ for up to 2 years. This resulted in not only a high mortality rate but a high rate of being removed from the waiting list because of progression of HCC to advanced stages. The introduction of the Model for End-Stage Liver Disease (MELD) allocation policy has had a positive effect on HCC liver transplant candidates with the number of patients transplanted for HCC significantly increasing over the past several years. In addition, waiting time for HCC patients to receive a deceased donor has decreased significantly and the number of patients dropping out from the waiting list because of advanced stage disease has also decreased. An early assessment of the MELD allocation policy suggests that posttransplant survival for HCC patients comparing pre-MELD to post-MELD eras is similar. Using the data we have collected on the MELD allocation policy, we have already made modifications to the MELD allocation policy for HCC patients. It is hoped that through continued data collection and assessment, a consensus can be reached to further optimize the use of deceased donors in HCC recipients.

Liver transplantation for hepatocellular carcinoma validation of present selection criteria in predicting outcome

Appropriate patient selection is crucial in ensuring acceptable outcomes from orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC). The United Network for Organ Sharing (UNOS) has elected to prioritize HCC patients for OLT based on criteria of tumor burden. However, it is unclear whether these criteria correlate with outcome, or with the pathobiological features associated with tumor recurrence. Therefore, we analyzed 109 consecutive patients undergoing OLT for HCC at our center, to determine the utility of present selection criteria in predicting outcome. Pathologic tumor staging of the explanted liver was based on the American Tumor Study Group modified tumor node metastases (pTNM) classification system. Multifocality was defined as >4 tumor nodules on explant. Survival analysis was performed using Kaplan-Meier and Cox proportional hazards regression methods. At a median follow-up of 18.9 months, the overall mortality was 19% with 15 patients (14%) dying of recurrent HCC. Kaplan-Meier 1, 3 and 5-year survival rates were 89.5%, 68%, and 65%, respectively. Recurrence-free rates of 1, 3, and 5 years were 89%, 75%, and 65%, respectively. On univariate analysis, the factors found to be significantly associated with recurrence of HCC were explant features of macrovascular invasion, tumor size (per centimeter increase), pTNM stage (per 1-stage increase), and pre-transplant serum alphafetoprotein (AFP) >300 ng/mL. In defining a threshold level, we found that explant tumor diameter > or =3 cm, and those tumors classified as at least pT3 on pathological examination, were significantly associated with recurrence (P =.01 and.03, respectively). Tumor size on explant was found to be strongly correlated with multifocality (P =.017) and vascular invasion (P =.02). Patients exceeding pathological UNOS criteria were 3.1 times more likely to have recurrence of HCC (P =.03). In conclusion, we found that tumor size appears to be a surrogate marker for negative pathobiological predictors of outcome, i.e., vascular invasion and multifocality. Present UNOS selection criteria for HCC based on tumor burden appear to provide adequate discriminatory power in predicting outcome of OLT.

Improving liver allocation: MELD and PELD

On February 27, 2002, the liver allocation system changed from a status-based algorithm to one using a continuous MELD/PELD severity score to prioritize patients on the waiting list. Using data from the Scientific Registry of Transplant Recipients, we examine and discuss several aspects of the new allocation, including the development and evolution of MELD and PELD, the relationship between the two scoring systems, and the resulting effect on access to transplantation and waiting list mortality. Additional considerations, such as regional differences in MELD/PELD at transplantation and the predictive effects of rapidly changing MELD/PELD, are also addressed. Death or removal from the waiting list for being too sick for a transplant has decreased in the MELD/PELD era for both children and adults. Children younger than 2 years, however, still have a considerably higher rate of death on the waiting list than adults. A limited definition of ECD livers suggests that they are used more frequently for patients with lower MELD scores.