title: Outcome of patients with hepatocellular carcinoma listed for liver transplantation within the Eurotransplant allocation system.
abstract: Although hepatocellular carcinoma (HCC) has become a recognized indication for liver transplantation, the rules governing priority and access to the waiting list are not well defined. Patient- and tumor-related variables were evaluated in 226 patients listed primarily for HCC in Belgium, a region where the allocation system is patient-driven, priority being given to sicker patients, based on the Child-Turcotte-Pugh (CTP) score. Intention-to-treat and posttransplantation survival rates at 4 years were 56.5 and 66%, respectively, and overall HCC recurrence rate was 10%. The most significant predictors of failure to receive a transplant in due time were baseline CTP score equal to or above 9 (relative risk [RR] 4.1; confidence interval [CI]: 1.7-9.9) and alpha fetoprotein above 100 ng/mL (RR 3.0; CI: 1.2-7.1). Independent predictors of posttransplantation mortality were age equal to or above 50 years (RR 2.5; CI: 1.0-3.7) and United Network for Organ Sharing pathological tumor nodule metastasis above the Milan criteria (RR 2.1; CI: 1.0-5.9). Predictors of recurrence (10%) were alpha fetoprotein above 100 ng/mL (RR 3.2; CI:1.1-10) and vascular involvement of the tumor on the explant (RR 3.6; CI: 1.1-11.3). Assessing the value of the pretransplantation staging by imaging compared to explant pathology revealed 34% accuracy, absence of carcinoma in 8.3%, overstaging in 36.2%, and understaging in 10.4%. Allocation rules for HCC should consider not only tumor characteristics but also the degree of liver impairment. Patients older than 50 years with a stage above the Milan criteria at transplantation have a poorer prognosis after transplantation.
authors.affiliation: Medico-Surgical Department of Gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium. michael.adler@erasme.ulb.ac.be
authors.forename: Michael
authors.initials: M
authors.lastname: Adler
authors.forename: Filip
authors.initials: F
authors.lastname: De Pauw
authors.forename: Pierre
authors.initials: P
authors.lastname: Vereerstraeten
authors.forename: Agnese
authors.initials: A
authors.lastname: Fancello
authors.forename: Jan
authors.initials: J
authors.lastname: Lerut
authors.forename: Peter
authors.initials: P
authors.lastname: Starkel
authors.forename: Hans
authors.initials: H
authors.lastname: Van Vlierberghe
authors.forename: Roberto
authors.initials: R
authors.lastname: Troisi
authors.forename: Vincent
authors.initials: V
authors.lastname: Donckier
authors.forename: Olivier
authors.initials: O
authors.lastname: Detry
authors.forename: Jean
authors.initials: J
authors.lastname: Delwaide
authors.forename: Peter
authors.initials: P
authors.lastname: Michielsen
authors.forename: Thierry
authors.initials: T
authors.lastname: Chapelle
authors.forename: Jacques
authors.initials: J
authors.lastname: Pirenne
authors.forename: Frederik
authors.initials: F
authors.lastname: Nevens
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D005060:Europe; D005260:Female; D015276:Health Care Rationing / Q000379:methods*; D006801:Humans; D008113:Liver Neoplasms / Q000601:surgery*; D016031:Liver Transplantation / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D040841:Resource Allocation / Q000379:methods*; D014850:Waiting Lists