title: Wait Time of Less Than 6 and Greater Than 18 Months Predicts Hepatocellular Carcinoma Recurrence After Liver Transplantation: Proposing a Wait Time "Sweet Spot".
abstract: It has been postulated that short wait time before liver transplant (LT) for hepatocellular carcinoma (HCC) results in the inclusion of tumors with aggressive biology, but prolonged wait time could result in a shift to more aggressive tumor behavior. We therefore test the hypothesis that a wait time "sweet spot" exists with a lower risk for HCC recurrence compared with the other 2 extremes.
  
  
  
  This multicenter study included 911 patients from 3 LT centers with short, medium, and long wait times (median of 4, 7, and 13 months, respectively) who received Model for End Stage Liver Disease exception listing for HCC from 2002 to 2012.
  
  
  
  Wait time, defined as time from initial HCC diagnosis to LT, was less than 6 months in 32.4%, 6 to 18 months in 53.7%, and greater than 18 months in 13.9%. Waitlist dropout was observed in 18.4% at a median of 11.3 months. Probability of HCC recurrence at 1 and 5 years were 6.4% and 15.5% with wait time of less than 6 or greater than 18 months (n = 343) versus 4.5% and 9.8% with wait time of 6 to 18 months (n = 397), respectively (P = 0.049). When only pre-LT factors were considered, wait time of less than 6 or greater than 18 months (HR, 1.6; P = 0.043) and AFP greater than 400 at HCC diagnosis (HR, 3.0; P < 0.001) predicted HCC recurrence in multivariable analysis.
  
  
  
  This large multicenter study provides evidence of an association between very short (<6 months) or very long (>18 months) wait times and an increased risk for HCC recurrence post-LT. The so-called sweet spot of 6 to 18 months should be the target to minimize HCC recurrence.
authors.affiliation: 1 Division of Gastroenterology, Department of Medicine, University of California, San Francisco, CA. 2 Division of Transplantation, Department of Surgery, Mayo Clinic, Rochester, MN. 3 Department of Transplantation, Mayo Clinic, Jacksonville, FL. 4 Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA. 5 Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Neil
authors.initials: N
authors.lastname: Mehta
authors.forename: Julie
authors.initials: J
authors.lastname: Heimbach
authors.forename: David
authors.initials: D
authors.lastname: Lee
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Dodge
authors.forename: Denise
authors.initials: D
authors.lastname: Harnois
authors.forename: Justin
authors.initials: J
authors.lastname: Burns
authors.forename: William
authors.initials: W
authors.lastname: Sanchez
authors.forename: John P
authors.initials: JP
authors.lastname: Roberts
authors.forename: Francis Y
authors.initials: FY
authors.lastname: Yao
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D018450:Disease Progression; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008111:Liver Function Tests; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local; D010352:Patient Dropouts; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014481:United States; D014850:Waiting Lists / Q000401:mortality