Transplant versus resection for the management of hepatocellular carcinoma meeting Milan Criteria in the MELD exception era at a single institution in a UNOS region with short wait times

Abstract

Background Management of hepatocellular carcinoma (HCC) in the Model for End-Stage Liver Disease (MELD) exception era remains regionally variable. Outcomes were compared for patients undergoing transplant versus resection at a single institution in a UNOS region with short wait times for organ availability. Methods All patients who underwent resection of HCC from January 2000 to August 2012 and patients who underwent transplant post-January 2006, during the Milan Criteria (MC)-based MELD exception policy for HCC, were identified. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). Results Two hundred fifty-seven patients were analyzed, of whom 131 underwent transplant and 126 underwent resection. All transplant patients met MC; 45 (36%) resection patients met MC. Median follow-up time was 30 months. Median wait time to transplant was 55 days; no patients dropped off the waitlist while awaiting an organ. Among patients meeting MC, transplant demonstrated significantly greater 5-year OS (65.7% vs. 43.8%; P = 0.005) and RFS (85.3% vs. 22.7%; P < 0.001) versus resection. For patients with hepatitis C, transplant (n = 87) demonstrated significantly improved 5-year outcomes compared to patients meeting MC who underwent resection (n = 21; OS: 63.5% vs. 23.3%; P = 0.001; RFS: 83.5% vs. 23.7%; P < 0.001). Conclusion In a region with short waitlist times for organ availability, liver transplant is associated with improved survival compared to resection for HCC within MC and should be considered for all patients meeting MC, particularly those with hepatitis C.

Hepatocellular carcinoma: A comprehensive review

“…Individuals having hepatitis C, with transplant, (n = 87) showed significant improvement in 5year results as correlated with individuals within Milan have undergone resection (n = 21; OS: 63.5% vs 23.3%; P = 0.001; RFS: 83.5% vs 23.7%; P < 0.001) [68] . In this study, they showed that transplant not only increased longevity from recurrence but improved five-year survival, illustrated as well for subjects having preserved synthetic function or low MELD.…”

“…This also depends on the wait time of a particular country or United Network for Organ Sharing region. In a recent study by Squires et al [68] , they looked at 257 patients, of which 131 individuals had transplant compared to 126 that underwent resection. MC was met in all transplant patients, and only in 45 (36%) patients who had a resection.…”

Concordance of hypervascular liver nodule characterization between the organ procurement and transplant network and liver imaging reporting and data system classifications

“…Since the relevant question for this study was concordance between the two systems for the determination of HCC (category 5 in both), nodule categories were reduced to a binary classification of "definitely HCC" or "not definitely HCC." Finally, each imaging examination was defined using the Milan criteria as "below transplant criteria" (no definite HCC ≥2 cm in diameter), "within transplant criteria" (one definite HCC ≥2 cm but ≤5 cm, or up to three definite HCCs each no more than 3 cm), or "beyond transplant criteria" (at least one definite HCC >5 cm, 1–3 definite HCCs with at least one >3 cm, or more than 3 definite HCCs) …”

“…Liver transplantation is the most effective treatment for HCC within the Milan criteria, and patients with definite HCC are eligible for additional transplant priority . In the United States, organ allocation is regulated by the Organ Procurement and Transplant Network (OPTN), which utilizes a standardized system for establishing the diagnosis of HCC by imaging .…”

Options for the treatment of intrahepatic recurrent hepatocellular carcinoma: Salvage liver transplantation or rehepatectomy?

“…Hepatocellular carcinoma (HCC) ranks fifth in malignant tumor incidence worldwide 1 and is the second leading cause of cancer death in China 2 . Liver transplantation is the most effective treatment for HCC because it removes both the tumor and diseased liver tissue at the same time, thereby avoiding the possibility of malignant transformation of residual liver tissue 3 . Studies have shown that the survival rate of patients with primary HCC after liver transplantation is significantly higher than that of patients with liver resection, especially in patients with combined cirrhosis 4‐6 .…”