A method for establishing allocation equity among patients with and without hepatocellular carcinoma on a common liver transplant waiting list

Vitale, Alessandro; Volk, Michael L.; Feo, Tullia Maria De; Burra, Patrizia; Frigo, Anna Chiara; Morales, Rafael; Carlis, Luciano De; Belli, Luca; Colledan, M.; Fagiuoli, Stefano; Rossi, G.; Andorno, Enzo; Baccarani, Umberto; Regalia, Enrico; Vivarelli, Marco; Donataccio, M.; Cillo, Umberto

doi:10.1016/j.jhep.2013.10.010

Cited by 97 publications

(116 citation statements)

References 20 publications

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“…A broader ''blended principle model'' including the transplant benefit concept might strike a better balance between urgency and HCC-MELD [19] Criteria for awarding extra points for longer waits and priority class migration on disease progression will be set regionally (regional board approval) § Choice between ''HCC MELD þ extra points for longer waits'' or ''22 points at entry þ extra points for longer waits'' will be decided on a regional basis.…”

Section: Discussionmentioning

confidence: 99%

“…Patients' position within each priority stratum would be based on the only currently-available benefit prognosticator (''HCC-MELD'') (19), and an agreed definition of disease progression (Table 4). Table 4 summarizes the whole prioritization process, including super-urgent cases, MELD patients, MELD exceptions, and HCC patients, all prioritized according to the same incremental numerical scoring system.…”

Section: E2 R2mentioning

confidence: 99%

See 1 more Smart Citation

A Multistep, Consensus-Based Approach to Organ Allocation in Liver Transplantation: Toward a “Blended Principle Model”

Cillo

Burra

Mazzaferro

et al. 2015

American Journal of Transplantation

184

129

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Section: Discussionmentioning

confidence: 99%

Section: E2 R2mentioning

confidence: 99%

A Multistep, Consensus-Based Approach to Organ Allocation in Liver Transplantation: Toward a “Blended Principle Model”

Cillo

Burra

Mazzaferro

et al. 2015

American Journal of Transplantation

184

129

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“…A recent study used Monte-Carlo simulations and multiple logistic regression to calculate a corrected MELD score for HCC patients. The so called HCC-MELD formula included also AFP and provided the same priority for HCC patients as the equivalent of conventional MELD score did for other LT aetiologies [65] . The main limitations were the lack of consideration of tumour volume at listing and tumour progression within the waiting list.…”

Section: Waiting List Management and Bridging Therapymentioning

confidence: 99%

Strategies to improve outcome of patients with hepatocellular carcinoma receiving a liver transplantation

Guerrero-Misas

Rodríguez‐Perálvarez

Mata

2015

WJH

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Liver transplantation is the only therapeutic option which allows to treat both, the hepatocellular carcinoma and the underlying liver disease. Indeed, liver transplantation is considered the standard of care for a subset of patients with cirrhosis and hepatocellular carcinoma.However, tumour recurrence rates are as high as 20%, and once the recurrence is established the therapeutic options are scarce and with little impact on prognosis. Strategies to minimize tumour recurrence and thus to improve outcome may be classified into 3 groups: (1) An adequate selection of candidates for liver transplantation by using the Milan criteria; (2) An optimized management within waiting list including prioritization of patients at high risk of tumour progression, and the implementation of bridging therapies, particularly when the expected length within the waiting list is longer than 6 mo; and (3) Tailored immunosuppression comprising reduced exposure to calcineurin inhibitors, particularly early after liver transplantation, and the addition of mammalian target of rapamycin inhibitors. In the present manuscript the available scientific evidence supporting these strategies is comprehensively reviewed, and future directions are provided for novel research approaches, which may contribute to the final target: to cure more patients with hepatocellular carcinoma and with an improved long term outcome. Core tip: Liver transplantation is the only therapeutic option which allows to treat both, the hepatocellular carcinoma and the underlying liver disease. However, tumour recurrence rates are 15%-20% with a very poor prognosis. Strategies to minimize tumour recurrence and thus to improve outcome are focused in a careful selection of candidates for liver transplantation, an optimized management within waiting list and a tailored immunosuppression. The available scientific evidence supporting these strategies is reviewed, and future directions are provided for novel research approaches, which may contribute to the final target: to cure more REVIEW Submit a

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“…Paradoxically, several years later, it was found that the likelihood of undergoing transplantation was higher for HCC candidates than for other patients [72] , which produced a clear disadvantage for non-HCC patients [73] . For this reason, the "HCC-MELD" equation (1.27/MELD -0.51/ logAFP + 4.59) has been proposed [74] , which takes into account hepatic function and the log of the AFP value, and has been calibrated to the survival of non-HCC patients. This formula gives additional points to patients with HCC, not arbitrarily, but based on a calculation of the benefits of transplantation, in a manner similar to that for patients without HCC.…”

Section: Ref Parameters Importancementioning

confidence: 99%

Selection of patients with hepatocellular carcinoma for liver transplantation: Past and future

Soriano¹

2016

WJH

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The aim of liver transplantation (LT) for hepatocellular carcinoma (HCC) is to ensure a rate of disease-free survival similar to that of patients transplanted due to benign disease. Therefore, we are forced to adopt strict criteria when selecting candidates for LT and prioritizing patients on the waiting list (WL), to have clarified indications for bridging therapy for groups at risk for progression or recurrence, and to establish certain limits for downstaging therapies. Although the Milan criteria (MC) remain the standard and most employed criteria for indication of HCC patients for LT by far, in the coming years, criteria will be consolidated that take into account not only data regarding the size/ volume and number of tumors but also their biology. This criteria will mainly include the alpha fetoprotein (AFP) values and, in view of their wide variability, any of the published logarithmic models for the selection of candidates for LT. Bridging therapy is necessary for HCC patients on the WL who meet the MC and have the possibility of experiencing a delay for LT greater than 6 mo or any of the known risk factors for recurrence. It is difficult to define single AFP values that would indicate bridging therapy (200, 300 or 400 ng/mL); therefore, it is preferable to rely on the criteria of a French AFP model score > 2. Other single indications for bridging therapy include a tumor diameter greater than 3 cm, more than one tumor, and having an AFP slope greater than 15 ng/mL per month or > 50 ng/mL for three months during strict monitoring while on the WL. When considering the inclusion of patients on the WL who do not meet the MC, it is mandatory to determine their eligibility for downstaging therapy prior to inclusion. The upper limit for this therapy could be one lesion up to 8 cm, 2-3 lesions with a total tumor diameter up to 8 cm, or a total tumor volume of 115 cm 3 . Selection of patients with hepatocellular carcinoma for liver transplantation: Past and future the WL should take into account the recently described HCC model for end-stage liver disease, which considers hepatic function, HCC size and the number and the log of AFP values. This formula has been calibrated with the survival data of non-HCC patients and produces a dynamic and more accurate assessment model.

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A method for establishing allocation equity among patients with and without hepatocellular carcinoma on a common liver transplant waiting list

Cited by 97 publications

References 20 publications

A Multistep, Consensus-Based Approach to Organ Allocation in Liver Transplantation: Toward a “Blended Principle Model”

A Multistep, Consensus-Based Approach to Organ Allocation in Liver Transplantation: Toward a “Blended Principle Model”

Strategies to improve outcome of patients with hepatocellular carcinoma receiving a liver transplantation

Selection of patients with hepatocellular carcinoma for liver transplantation: Past and future

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