Hepatocellular carcinoma in patients listed for liver transplantation: Current and future allocation policy and management strategies for the individual patient

Abstract

Liver transplantation can provide definitive cure for patients with cirrhosis and hepatocellular carcinoma (HCC) when used appropriately. Advances in the management of HCC have allowed improved control of HCC while waiting for liver transplantation and new approaches to candidate selection particularly with regard to tumor burden and downstaging protocols. Additionally, there have been recent changes in allocation policy related to HCC in the U.S. that cap the HCC MELD exception at 34 points and implement a 6-month delay in a HCC MELD exception. This review examines the U.S. liver transplant allocation policy related to HCC, comprehensively details locoregional therapy options in HCC patients awaiting liver transplantation, and considers the impact of an increasing burden of HCC on future liver graft allocation policy. Liver Transpl 21:1543-1552, 2015. V C 2015 AASLD.

Hepatocellular Carcinoma Is the Most Common Indication for Liver Transplantation and Placement on the Waitlist in the United States

“…The policy generally results in HCC registrants with A or O blood type needing to accrue 35 exception points in most regions before receiving LT. 11–13 Despite this change and the decreased probability of receiving LT among HCC registrants, the absolute number of HCC recipients continues to increase due to the rapidly increasing number of HCC registrants. Thus, the ratio of HCC versus non HCC registrants increased in all underlying etiologies, suggesting that the increasing burden of HCC is pervasive among registrants with different etiologies of liver disease.…”

Effectiveness and cost of radiofrequency ablation and stereotactic body radiotherapy for treatment of early‐stage hepatocellular carcinoma: An analysis of SEER‐medicare

“…Early‐stage disease is best treated by surgical resection, liver transplantation or local ablative therapies. Surgical resection is commonly contraindicated due to presence of portal hypertension or other medical comorbidities and liver transplantation can be limited by organ availability and strict candidate selection criteria . Thus in a large proportion of early‐stage patients, local ablative therapies are the mainstay of treatment for early‐stage HCC.…”

“…[3][4][5] organ availability and strict candidate selection criteria. 7 Thus in a large proportion of early-stage patients, local ablative therapies are the mainstay of treatment for early-stage HCC. Results from numerous studies show that the most commonly applied local ablative therapy, thermal (radiofrequency or microwave) ablation, provides local control rates of up to 80-90% for small HCCs (< 4 cm in size).…”

Comparison of two equivalent model for end-stage liver disease scores for hepatocellular carcinoma patients using data from the United Network for Organ Sharing liver transplant waiting list registry

“…Other investigators have discussed this (5, 12, 18-20), and overall utility (combined dropout / post-transplant survival) is included in the model by Vitale et al (10). Comparing that approach with those studied here is of interest, however the evaluation criteria for comparing the Vitale et al score with the MELD EQ / deMELD is difficult to determine given the differences in objectives between the studies.…”