A follow-up analysis of the pattern and predictors of dropout from the waiting list for liver transplantation in patients with hepatocellular carcinoma: Implications for the current organ allocation policy

Abstract

Since our interim report of the intention-to-treat outcome of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC), we have performed a follow-up analysis of an expanded cohort of 70 patients to further assess whether the observed pattern and predictors of dropout are consistent with the rationale behind current HCC-adjusted Model for End Stage Liver Disease (MELD) organ allocation scheme. All except one patient had pretransplantation staging meeting our proposed expanded criteria-a single lesion <6.5 cm, or three or fewer lesions none >4.5 cm and total tumor diameter <8 cm. Thirty-eight patients received OLT. The cumulative probabilities of dropout at 6, 12, and 18 months were 7.2%, 37.8%, and 55.1%, respectively. The respective dropout probabilities would have been 11.0%, 57.4%, and 68.7% if the United Network for Organ Sharing (UNOS) criteria for exclusion (single lesion <5 cm or three or fewer lesions none >3 cm) were applied. Predictors of dropout with either criteria included three tumor nodules and a single lesion >3 cm at initial presentation, whereas preoperative chemoembolization or ablation therapies were associated with a lower risk for dropout only when applying the UNOS criteria for patient exclusion. In the subgroup with two or three lesions or a solitary tumor >3 cm, the cumulative probabilities of dropout were nine-fold higher than those with a single lesion <3cm (P ‫؍‬ .004). In conclusion, the low dropout rate in the first 6 months and the differing dropout risks based on tumor characteristics support further refinements in the HCC-adjusted MELD organ allocation scheme. (Liver Transpl 2003;9:684-692.)

Percutaneous radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation†

“…First, waiting list dropout secondary to tumor growth is known to occur in excess of 20%, even in early-stage patients. 7,8,40 One recent study of 54 subjects reported 6 dropouts (11.1%) with a 7-month median waiting time (15% overall cumulative dropout probability at 6 months), even with use of neoadjuvant TACE as an attempt to curb disease progression. 15 In our series, only 3 dropouts (5.8%) from tumor progression were noted in 52 patients, comparing favorably against these historical rates.…”

“…6,8,[42][43][44] Most recently, Ravaioli et al demonstrated a higher recurrence rate in early patients exceeding versus recent ones fulfilling the Milan criteria (37.5% vs. 12.7%). 29 Although these figures highlight marked improvements in outcomes achieved with careful patient selection, they show that recurrence still remains a significant threat.…”

“…6 However, limited supply of donor organs prolongs the waiting time for transplantation and causes high dropout rates from tumor progression. 7,8 This pressure has driven the increased use of living and marginal donors as well as split cadaveric transplantations. [9][10][11][12] Also of concern is whether any increase in tumor burden, even below the current limits warranting removal from transplant candidacy, might adversely affect posttransplantation prognosis.…”

Bridging and downstaging therapy in patients suffering from hepatocellular carcinoma waiting on the list of liver transplantation

“…This is particular the case because of the scarcity supply of the liver grafts, hence patients on the LT waiting list have to suffer from a long period of waiting time, result in disease progression and drop out from the waiting list (19)(20)(21). A predicted 12% probability of 6-month drop out for patients in whom the tumor is left untreated during the waiting period (19,22).…”

Transarterial therapy for hepatocellular cancer

“…Успешное применение такого подхода было продемонстрировано как при традиционной ТАХЭ, так и при использовании микросфер [1,5,6,15,28].…”