Outcome of patients with hepatocellular carcinoma listed for liver transplantation within the Eurotransplant allocation system.
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.
Adler
Michael
M
Medico-Surgical Department of Gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium. michael.adler@erasme.ulb.ac.be
De Pauw
Filip
F
Vereerstraeten
Pierre
P
Fancello
Agnese
A
Lerut
Jan
J
Starkel
Peter
P
Van Vlierberghe
Hans
H
Troisi
Roberto
R
Donckier
Vincent
V
Detry
Olivier
O
Delwaide
Jean
J
Michielsen
Peter
P
Chapelle
Thierry
T
Pirenne
Jacques
J
Nevens
Frederik
F
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