Comparison of Wait‐List Mortality Between Cholangiocarcinoma and Hepatocellular Carcinoma Liver Transplant Candidates

Abstract

Despite the divergent disease biology of cholangiocarcinoma (CCA) and hepatocellular carcinoma (HCC), wait‐list prioritization is identical for both diagnoses. We compared wait‐list and posttransplant outcomes between CCA and HCC liver transplantation patients with Model for End‐Stage Liver Disease exceptions using Scientific Registry of Transplant Recipients data. The 408 CCA candidates listed between 2003 and mid‐2017 were matched to 2 HCC cohorts by listing date (±2 months, n = 816) and by Organ Procurement and Transplantation Network (OPTN) region and date (±6 months, n = 408). Cumulative incidence competing risk regression examined the effects of diagnosis, OPTN region, and center‐level CCA listing volume on wait‐list removal due to death/being too ill (dropout). Cox models evaluated the effects of diagnosis, OPTN region, center‐level CCA volume, and waiting time on graft failure among deceased donor liver transplantation (DDLT) recipients. After adjusting for OPTN region and CCA listing volume (all P ≥ 0.07), both HCC cohorts had a reduced likelihood of wait‐list dropout compared with CCA candidates (HCC with period matching only: subdistribution hazard ratio [SHR] = 0.63; 95% CI, 0.43‐0.93; P = 0.02 and HCC with OPTN region and period matching: SHR = 0.60; 95% CI, 0.41‐0.87; P = 0.007). The cumulative incidence rates of wait‐list dropout at 6 and 12 months were 13.2% (95% CI, 10.0%‐17.0%) and 23.9% (95% CI, 20.0%‐29.0%) for CCA candidates, 7.3% (95% CI, 5.0%‐10.0%) and 12.7% (95% CI, 10.0%‐17.0%) for HCC candidates with region and listing date matching, and 7.1% (95% CI, 5.0%‐9.0%) and 12.6% (95% CI, 10.0%‐15.0%) for HCC candidates with listing date matching only. Additionally, HCC DDLT recipients had a 57% reduced risk of graft failure compared with CCA recipients (P < 0.001). Waiting time was unrelated to graft failure (P = 0.57), and there was no waiting time by diagnosis cohort interaction effect (P = 0.47). When identically prioritized, LT candidates with CCA have increased wait‐list dropout compared with those with HCC. More granular data are necessary to discern ways to mitigate this wait‐list disadvantage and improve survival for patients with CCA.

Liver transplantation in malignant disease

“…The impressive results obtained by the neoadjuvant therapy and subsequent liver transplantation led to the introduction of a MELD exception for pCC in the U.S. (UNOS) and also in Eurotransplant[ 109 , 110 ]. Nonetheless, prioritization is currently performed similar to HCC which in turn leads to higher waitlist drop out in patients with pCC[ 111 ]. Hence, refinement of the current practice is warranted.…”

Selected Patients with Unresectable Perihilar Cholangiocarcinoma (pCCA) Derive Long-Term Benefit from Liver Transplantation

“…However, a recent study focused on the waitlist drop-out and post-transplant graft survival rates for both hepatocellular carcinoma (HCC) and pCCA based on the Scientific Registry of Transplant Recipients (SRTR). When matched for the Organ Procurement and Transplantation Network (OPTN) region and listing date, patients with pCCA had a significantly higher waitlist drop-out rate (six-and 12-month drop-out rates of 13.2% and 23.9%, respectively) than patients with HCC (six-and 12-month drop-out rates of 7.3% and 12.7%, respectively) [25]. Furthermore, transplants for pCCA were associated with lower rates of graft survival than with HCC: 60.7% vs. 81.6% at three years, respectively [25].…”

“…When matched for the Organ Procurement and Transplantation Network (OPTN) region and listing date, patients with pCCA had a significantly higher waitlist drop-out rate (six-and 12-month drop-out rates of 13.2% and 23.9%, respectively) than patients with HCC (six-and 12-month drop-out rates of 7.3% and 12.7%, respectively) [25]. Furthermore, transplants for pCCA were associated with lower rates of graft survival than with HCC: 60.7% vs. 81.6% at three years, respectively [25]. The recurrence of CCA is most likely what is driving the higher risk of graft loss in patients who undergo transplant for pCCA, as perioperative vascular complications (which are likely associated with radiation injury) are commonly managed without the consequence of graft loss [23].…”

Precarious Windows of Opportunity: Adverse Wait‐List Dropout for Cholangiocarcinoma Versus Hepatocellular Carcinoma Patients

“…In the current issue, Ziogas et al address this question. (2) Employing the Scientific Registry of Transplant Recipients (SRTR) database, they examined wait-list and posttransplant graft outcomes comparing HCC to pCCA deceased donor liver transplantation (DDLT) recipients. Data were examined by listing date, Organ Procurement Transplantation Network (OPTN) region, and center volume.…”