title: Proposal of a novel MELD exception point system for hepatocellular carcinoma based on tumor characteristics and dynamics.
abstract: Patients listed with exception points for hepatocellular carcinoma (HCC) have been more likely to be transplanted than those listed for chronic liver failure (LF) based on the model for end-stage liver disease (MELD) score. The aim of this study was to determine outcomes in the 5-year experience of a scoring system designed to reflect heterogeneity of tumor load of patients listed for HCC.
  
  
  
  A novel MELD exception point system based on size and number of HCC was implemented in July 2009. This system allows stratification of patients based on risk of dropping out from the waiting list according to Milan criteria. LF patients were listed according to biological MELD sodium score; HCC patients were reassigned points every three months upon repeat imaging.
  
  
  
  Among 624 patients listed for liver transplant (LT), 505 were eligible. 94 (18.6%) were assigned MELD HCC points. Only 24.7% required changes in allocated points over time. Transplantation rates (HCC 83% vs. LF 73%, p=0.04) and waiting time in days (HCC 258 vs. LF 325; p=0.07) were similar. The method of competing risk analysis revealed that HCC patients were more likely to be transplanted than LF during the 5-year period preceding implementation, whereas transplant rates became equivalent for HCC and non-HCC in 2009-2014. One- and two-year survivals were similar between the two groups.
  
  
  
  Our study demonstrates that a novel MELD point system for HCC, taking into account dynamics in tumor size and number, allows for equitable liver allocation without compromising graft and patient survival.
  
  
  
  It has historically been difficult to achieve equitable liver allocation for liver cancer and chronic liver failure with the allocation systems currently in place in many countries worldwide. We designed a new system to help improve access to organs for liver failure patients in Québec, Canada. Our 5-year experience demonstrates that this unique system renders access to transplant similar for both liver cancer and liver failure indications.
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, McGill University, Canada.
authors.forename: Mamatha
authors.initials: M
authors.lastname: Bhat
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, McGill University, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Ghali
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, McGill University, Canada.
authors.forename: Benoît
authors.initials: B
authors.lastname: Dupont
authors.affiliation: Department of Medicine, Liver Unit, Centre hospitalier de l'Université de Montréal, Canada.
authors.forename: Roy
authors.initials: R
authors.lastname: Hilzenrat
authors.affiliation: Multi-Organ Transplant Program, University Health Network, Toronto, Canada.
authors.forename: Mahmood
authors.initials: M
authors.lastname: Tazari
authors.affiliation: Department of Surgery, Centre hospitalier de l'Université de Montréal, Canada.
authors.forename: André
authors.initials: A
authors.lastname: Roy
authors.affiliation: Department of Surgery, McGill University Health Centre, Canada.
authors.forename: Prosanto
authors.initials: P
authors.lastname: Chaudhury
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, CHU Sainte-Justine, Department of Pediatrics, Université de Montréal, Canada.
authors.forename: Fernando
authors.initials: F
authors.lastname: Alvarez
authors.affiliation: Transplant-Québec, Canada.
authors.forename: Michel
authors.initials: M
authors.lastname: Carrier
authors.affiliation: Department of Medicine, Liver Unit, Centre hospitalier de l'Université de Montréal, Canada. Electronic address: marc.bilodeau@umontreal.ca.
authors.forename: Marc
authors.initials: M
authors.lastname: Bilodeau
mesh_terms: D000328:Adult; D002170:Canada / Q000453:epidemiology; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology / Q000601:surgery; D058625:End Stage Liver Disease / Q000401:mortality / Q000601:surgery; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement; D009927:Tissue and Organ Procurement / Q000379:methods / Q000458:organization & administration; D014850:Waiting Lists / Q000401:mortality
keywords: Exception points; Hepatocellular carcinoma; Liver transplantation; Malignancy; Organ allocation