30 Outcome of patients with hepatocellular carcinoma listed for liver transplantation within the eurotransplant allocation system

Abstract

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 ␣ 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 ␣ 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. Liver Transpl 14: [526][527][528][529][530][531][532][533] 2008. © 2008 AASLD. Received 15 February 2007; accepted 16 October 2007.Liver transplantation (LTX) is now accepted as a curative modality for early stage hepatocellular carcinoma (HCC) on the basis of excellent 5-year survival rates (71%-75%). These rates are comparable to those for patients with advanced cirrhosis without malignancies, 1 Even outside the Milan criteria 2 but within the moderate expansion criteria of the University of California, San Francisco (UCSF), patients with HCC have an acceptable 5-year period of survival. Nevertheless, the results of LTX for HCC in the literature are still discrepant. They derive from series including a heterogeneous mixture of individuals in terms of liver function, tumor stage, and definition of outcomes (such as dropout for progressive malignancy, recurrence of malignancy, and assessment of survival on an intention-to-treat basis versus posttransplantation). The use of pre-LTX adjuvant therapy such as liver resection, chemoembolization, or radiofrequency abla-