A decision analysis model identifies the interval of efficacy for transarterial chemoembolization (TACE) in cirrhotic patients with hepatocellular carcinoma awaiting liver transplantation.
BACKGROUND
For liver transplant candidates with hepatocellular carcinoma (HCC), the ability of neoadjuvant transarterial chemoembolization (TACE) to improve outcomes remains unproven. The objective of our study was to determine if there was a specific time interval where neoadjuvant TACE would decrease the number of HCC patients removed from the pretransplant waitlist.


METHODS
A decision model was developed to simulate a randomized trial of neoadjuvant treatment with TACE vs. no TACE in 600 virtual patients with HCC and cirrhosis. Transition probabilities for TACE morbidity (1 +/- 1%), TACE response rates (30 +/- 20%), and disease progression (7 +/- 7% per month) were assigned by systematic review of the literature (18 reports). Sensitivity analyses were performed to determine time thresholds where TACE would decrease the number of delisted patients.


RESULTS
TACE treatment had statistical benefit at waitlist time breakpoints of 4 and 9 months (P < 0.05). When waitlist times were less than 4 months, waitlist attrition was similar (20% vs. 34%, P = 0.08). When waitlist times exceed 9 months, waitlist dropout rates re-equilibrated (33% vs. 46%, P = 0.06). Review of the current literature determined that only those studies reporting on patients with waitlist times between 4 and 9 months found a benefit to neoadjuvant TACE.


CONCLUSIONS
This analysis indicates that the benefit of neoadjuvant TACE may be limited to those patients transplanted from 4 to 9 months from first TACE. These data may help transplant programs to tailor TACE treatments based on predicted waitlist times to achieve optimal resource utilization and improved organ allocation efficiency.
Division of Abdominal Transplantation and Hepatobiliary Surgery, Department of Surgery, Baylor College of Medicine, 1709 Dryden, Suite 15.37, Houston, TX 77030, USA. taaloia@tmhs.org
Thomas A
TA
Aloia
René
R
Adam
Didier
D
Samuel
Daniel
D
Azoulay
Denis
D
Castaing
D006528:Carcinoma, Hepatocellular / Q000628:therapy*; D003661:Decision Support Techniques; D018450:Disease Progression; D004621:Embolization, Therapeutic; D006801:Humans; D008113:Liver Neoplasms / Q000628:therapy*; D016031:Liver Transplantation; D010352:Patient Dropouts; D013997:Time Factors; D014850:Waiting Lists