title: Evaluating the validity of model for end-stage liver disease exception points for hepatocellular carcinoma patients with multiple nodules <2 cm.
abstract: Liver transplant allocation policy does not give model for end-stage liver disease (MELD) exception points for patients with a single hepatocellular carcinoma (HCC) <2 cm in size, but does give points to patients with multiple small nodules. Because standard-of-care imaging for HCC struggles to differentiate HCC from other nodules, it is possible that a subset of patients receiving liver transplant for multiple nodules <2 cm in size does not have HCC. We evaluate risk of post-transplant HCC recurrence and wait-list dropout for patients with multiple small nodules using competing risks regression based on the Fine and Gray model. We identified 5002 adult HCC patients in the OPTN/UNOS dataset diagnosed and transplanted between January 2006 and September 2010. Compared to patients with >1 tumor <2 cm, risk of developing recurrence was significantly higher in patients with one or more tumors with only one tumor ≥2 cm (SHR 1.63, p = 0.009), as well as in patients with 2-3 tumors ≥2 cm (SHR 1.84, p = 0.02). Dropout risk was not significantly different among size categories. HCC recurrence risk was significantly lower in patients with multiple nodules <2 cm in size than in those with larger tumors, supporting the possibility that some patients received unnecessary transplants. The priority given to these patients must be re-examined.
authors.affiliation: Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Mariya L
authors.initials: ML
authors.lastname: Samoylova
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Dodge
authors.forename: Neil
authors.initials: N
authors.lastname: Mehta
authors.forename: Francis Y
authors.initials: FY
authors.lastname: Yao
authors.forename: John P
authors.initials: JP
authors.lastname: Roberts
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D003661:Decision Support Techniques; D058625:End Stage Liver Disease / Q000150:complications / Q000601:surgery*; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D009364:Neoplasm Recurrence, Local / Q000473:pathology* / Q000517:prevention & control; D018579:Patient Selection; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome; D047368:Tumor Burden; D014850:Waiting Lists
keywords: hepatocellular carcinoma; liver transplant; recurrence; small nodules