A follow-up analysis of the pattern and predictors of dropout from the waiting list for liver transplantation in patients with hepatocellular carcinoma: implications for the current organ allocation policy.
Since our interim report of the intention-to-treat outcome of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC), we have performed a follow-up analysis of an expanded cohort of 70 patients to further assess whether the observed pattern and predictors of dropout are consistent with the rationale behind current HCC-adjusted Model for End Stage Liver Disease (MELD) organ allocation scheme. All except one patient had pretransplantation staging meeting our proposed expanded criteria-a single lesion < or =6.5 cm, or three or fewer lesions none >4.5 cm and total tumor diameter < or =8 cm. Thirty-eight patients received OLT. The cumulative probabilities of dropout at 6, 12, and 18 months were 7.2%, 37.8%, and 55.1%, respectively. The respective dropout probabilities would have been 11.0%, 57.4%, and 68.7% if the United Network for Organ Sharing (UNOS) criteria for exclusion (single lesion < or =5 cm or three or fewer lesions none >3 cm) were applied. Predictors of dropout with either criteria included three tumor nodules and a single lesion >3 cm at initial presentation, whereas preoperative chemoembolization or ablation therapies were associated with a lower risk for dropout only when applying the UNOS criteria for patient exclusion. In the subgroup with two or three lesions or a solitary tumor >3 cm, the cumulative probabilities of dropout were nine-fold higher than those with a single lesion < or =3 cm (P =.004). In conclusion, the low dropout rate in the first 6 months and the differing dropout risks based on tumor characteristics support further refinements in the HCC-adjusted MELD organ allocation scheme.
Yao
Francis Y
FY
Department of Medicine, Division of Gastroenterology, University of California, San Francisco 94143, USA. yaofyk@itsa.ucsf.edu
Bass
Nathan M
NM
Nikolai
Bev
B
Merriman
Raphael
R
Davern
Timothy J
TJ
Kerlan
Robert
R
Ascher
Nancy L
NL
Roberts
John P
JP
D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D015276:Health Care Rationing / Q000458:organization & administration*; D006801:Humans; D008113:Liver Neoplasms / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D010352:Patient Dropouts; D011237:Predictive Value of Tests; D011446:Prospective Studies; D019737:Transplants / Q000600:supply & distribution*; D014850:Waiting Lists