Waitlist Priority for Hepatocellular Carcinoma Beyond Milan Criteria: A Potentially Appropriate Decision Without a Structured Approach

Bittermann, Therese; Niu, Ben; Hoteit, Maarouf; Goldberg, David S.

doi:10.1111/ajt.12530

Cited by 29 publications

(27 citation statements)

References 15 publications

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“…Higher dropout rates have also been reported previously in patients with HCC beyond the traditional criteria [29,30]. Both AFP and tumor progression (tumor biological factors), but not tumor burden (size and numbers) were independently associated with dropout.…”

Section: Discussionsupporting

confidence: 67%

Liver Transplantation is a Preferable Alternative to Palliative Therapy for Selected Patients with Advanced Hepatocellular Carcinoma

et al. 2017

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Background:Patients with hepatocellular carcinoma (HCC) beyond the traditional criteria (advanced HCC) are typically offered palliation, which is associated with a 3-year survival rate lower than 30%. This study aimed to describe the outcomes for a subset of patients with advanced HCC who satisfied the Extended Toronto Criteria (ETC) and were listed for liver transplantation (LT). Materials & Methods: All patients listed in the Toronto liver transplant program with HCC beyond both the Milan and University of California, San Francisco criteria were included in this study. Data were extracted from the prospectively collected electronic database. All radiological images were reviewed by two independent radiologists. The primary endpoint was patient survival. Results: Between January 1999 and August 2014, 96 patients with advanced HCC were listed for LT, and 62 (65%) of these patients received bridging therapy while on the waiting list. Bridging therapy led to a significant reduction in tumor progression (p=0.02) and tumor burden (p <0.001). The majority of those listed underwent LT (n=69, 72%). Both tumor progression on waiting list .464], p=0.006) and peak AFP ≥400ng/ml ], p=0.003) were independently associated with waiting list dropout. Post-LT HCC recurrence occurred in 35% (n=24). Among those with HCC recurrence, survival was significantly better for those who received curative treatment (p=0.004). The overall actuarial survival rates from the listing were 76% at 1 year, 56% at 3 years, and 47% at 5 years, and the corresponding rates from LT were 93%, 71%, and 66%. Conclusion: LT provides significantly better survival rates than palliation for patients with selected advanced HCC. SYNOPSISIn most Western centers, palliation remains the only option for patients with advanced HCC with a 3-year survival <30%. This study reports an improved survival with liver transplantation (71%, 66% at 3, 5 years) of selected patients with advanced HCC.

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Section: Discussionsupporting

confidence: 67%

Liver Transplantation is a Preferable Alternative to Palliative Therapy for Selected Patients with Advanced Hepatocellular Carcinoma

et al. 2017

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“…Recently, Bittermann et al (17) demonstrated that expanding indication for LT in HCC patients beyond Milan may be secure in terms of five-yr mortality when specific factors of tumor biology are taken into account and a strict surveillance of patients on the waiting list is performed.…”

Section: Discussionmentioning

confidence: 99%

Eurotransplant donor‐risk‐index and recipient factors: influence on long‐term outcome after liver transplantation – A large single‐center experience

Schoening

Helbig

Buescher

et al. 2016

Clinical Transplantation

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The organ shortage has led to increased use of marginal organs. The Eurotransplant Donor-Risk-Index (ET-DRI) was established to estimate outcome after Liver Transplantation (LT). Currently, data on impact of ET-DRI on long-term outcome for different indications and recipient conditions are missing. Retrospective, single-center analysis of long-term graft survival (GS) of 1767 adult primary LTs according to indication, labMELDcategory (1: ≤18; 2: >18-25; 3: >25-35; 4: >35), and ET-DRI. Mean ET-DRI in our cohort was 1.63 (±0.43). One-, 10, and 15-yr GS was 83.5%, 63.3%, and 54.8%. Long-term GS was significantly influenced by ET-DRI. Accordingly, four ET-DRI categories were defined and analyzed with respect to underlying disease. Significant impact of these categories was observed for: Alcohol, cholestatic/autoimmune diseases (CD/AIH), and HCV, but not for HCC, HBV, cryptogenic cirrhosis, and acute liver failure. labMELD categories showed no significant influence on graft, but on patient survival. Matching ET-DRI categories with labMELD revealed significant differences in long-term GS for labMELDcategories 1, 2, and 3, but not 4. In multivariate analysis, HCV combined with ET-DRI > 2 and labMELDcategory 3 combined with ET-DRI > 2 emerged as negative predictors. To achieve excellent long-term graft survival, higher risk organs (ET-DRI > 1.4) should be used restrictively for patients with CD/AIH or HCV. Organs with ET-DRI > 2 should be avoided in patients with a labMELD of >25-35.

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“…hepatopulmonary syndrome (10)) or consensus recommendations (i.e. primary sclerosing cholangitis and recurrent bacterial cholangitis (11) or hepatocellular carcinoma beyond Milan criteria (12)) for allocating exception points, the data used to award such points and the compliance with guidelines or recommendations are suboptimal. The goal of this study was to evaluate the current POPH exception policy and its implementation.…”

Section: Introductionmentioning

confidence: 99%

MELD Exceptions for Portopulmonary Hypertension: Current Policy and Future Implementation

Goldberg

Batra

Sahay

et al. 2014

American Journal of Transplantation

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Since 2006, waitlist candidates with portopulmonary hypertension (POPH) have been eligible for standardized Model for End-Stage Liver Disease (MELD) exception points. However, there are no data evaluating the current POPH exception policy and its implementation. We used Organ Procurement and Transplantation Network (OPTN) data to compare outcomes of patients with approved POPH MELD exceptions from 2006 to 2012 to all nonexception waitlist candidates during this period. Since 2006, 155 waitlist candidates had approved POPH MELD exceptions, with only 73 (47.1%) meeting the formal OPTN exception criteria. Furthermore, over one-third of those with approved POPH exceptions either did not fulfill hemodynamic criteria consistent with POPH or had missing data, with 80% of such patients receiving a transplant based on receiving exception points. In multivariable multistate survival models, waitlist candidates with POPH MELD exceptions had an increased risk of death compared to nonexception waitlist candidates, regardless of whether they did (hazard ratio [HR]: 2.46, 95% confidence interval [CI]: 1.73–3.52; n = 100) or did not (HR: 1.60, 95% CI: 1.04–2.47; n = 55) have hemodynamic criteria consistent with POPH. These data highlight the need for OPTN/UNOS to reconsider not only the policy for POPH MELD exceptions, but also the process by which such points are awarded.

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Waitlist Priority for Hepatocellular Carcinoma Beyond Milan Criteria: A Potentially Appropriate Decision Without a Structured Approach

Cited by 29 publications

References 15 publications

Liver Transplantation is a Preferable Alternative to Palliative Therapy for Selected Patients with Advanced Hepatocellular Carcinoma

Liver Transplantation is a Preferable Alternative to Palliative Therapy for Selected Patients with Advanced Hepatocellular Carcinoma

Eurotransplant donor‐risk‐index and recipient factors: influence on long‐term outcome after liver transplantation – A large single‐center experience

MELD Exceptions for Portopulmonary Hypertension: Current Policy and Future Implementation

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