title: Priority of candidates with hepatocellular carcinoma awaiting liver transplantation can be reduced after successful bridge therapy.
abstract: The allocation rules for patients with hepatocellular carcinoma (HCC) who are awaiting liver transplantation (LT) are a difficult issue and are continually evolving. To reduce tumor progression or down-stage advanced disease, most transplant centers have adopted the practice of treating HCC candidates with resection or locoregional therapies. This study was designed to assess the effectiveness of bridge therapy in preventing removal from the waiting list for death/sickness severity or tumor progression beyond the Milan criteria and in determining posttransplant outcomes. The removal rates for 315 adult patients with HCC who were listed for LT were analyzed and were correlated to responses to bridge therapy with a competing risk analysis. The 3-, 6-, and 12-month dropout rates were 3.5%, 6.5%, and 19.9%, respectively, and they were significantly affected by the Model for End-Stage Liver Disease score (P = 0.032), the tumor stage at diagnosis (P = 0.041), and the response to bridge therapy (P < 0.001). The stratification of candidates by the tumor stage and the response to bridge therapy showed that patients with T2 tumors who achieved only a partial response or no response to bridge therapy had the highest dropout rates, and they were followed by patients with successfully down-staged T3-T4a tumors (P = 0.037). Patients with T2 tumors who had a complete response and patients with T1 tumors had similar dropout rates (P = 0.964). The response to bridge therapy significantly affected both the recurrence rate of 176 transplant patients (P = 0.017) and the overall intention-to-treat survival rate (P = 0.001). In conclusion, the response to therapy is a potentially effective tool for prioritizing HCC patients for LT as well as select cases with different risks of tumor recurrence after transplantation.
authors.affiliation: Liver and Multiorgan Transplant Unit, Department of General Surgery, University of Bologna, Bologna, Italy. aleqko@libero.it
authors.forename: Alessandro
authors.initials: A
authors.lastname: Cucchetti
authors.forename: Matteo
authors.initials: M
authors.lastname: Cescon
authors.forename: Eleonora
authors.initials: E
authors.lastname: Bigonzi
authors.forename: Fabio
authors.initials: F
authors.lastname: Piscaglia
authors.forename: Rita
authors.initials: R
authors.lastname: Golfieri
authors.forename: Giorgio
authors.initials: G
authors.lastname: Ercolani
authors.forename: Maria
authors.initials: M
authors.lastname: Cristina Morelli
authors.forename: Matteo
authors.initials: M
authors.lastname: Ravaioli
authors.forename: Antonio
authors.initials: A
authors.lastname: Daniele Pinna
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000601:surgery / Q000628:therapy; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000601:surgery / Q000628:therapy; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000628:therapy; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D018579:Patient Selection; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014850:Waiting Lists / Q000401:mortality*; D055815:Young Adult