Evaluating the validity of model for end‐stage liver disease exception points for hepatocellular carcinoma patients with multiple nodules <2 cm

Abstract

Liver transplant allocation policy does not give model for end-stage liver disease (MELD) exception points for patients with a single hepatocellular carcinoma (HCC) <2 cm in size, but does give points to patients with multiple small nodules. Because standard-of-care imaging for HCC struggles to differentiate HCC from other nodules, it is possible that a subset of patients receiving liver transplant for multiple nodules <2 cm in size does not have HCC. We evaluate risk of post-transplant HCC recurrence and wait-list dropout for patients with multiple small nodules using competing risks regression based on the Fine and Gray model. We identified 5002 adult HCC patients in the OPTN/UNOS dataset diagnosed and transplanted between January 2006 and September 2010. Compared to patients with >1 tumor <2 cm, risk of developing recurrence was significantly higher in patients with one or more tumors with only one tumor ≥2 cm (SHR 1.63, p = 0.009), as well as in patients with 2–3 tumors ≥2 cm (SHR 1.84, p = 0.02). Dropout risk was not significantly different among size categories. HCC recurrence risk was significantly lower in patients with multiple nodules <2 cm in size than in those with larger tumors, supporting the possibility that some patients received unnecessary transplants. The priority given to these patients must be re-examined.

A Simple Measure of Hepatocellular Carcinoma Burden Predicts Tumor Recurrence After Liver Transplantation: The Recurrent Hepatocellular Carcinoma–Initial, Maximum, Last Classification

“…The UNOS database provides an opportunity to capture a large representative sample better reflecting the US transplant experience, which is a strength of the current analysis. Samoylova et al also validated the UNOS post‐LT HCC recurrence data and found the observed HCC recurrence rate was not significantly different from the expected rate at any center, suggesting that the impact of any potential systematic underreporting of HCC recurrence is low . Furthermore, the overall HCC recurrence rate of 7% identified in the current study is similar to other UNOS studies (the 3‐year HCC recurrence rate of 8% as reported by Schlansky et al) although slightly lower than what is reported in other single or multicenter studies where recurrence rates range from approximately 8% to 15% …”

“…Samoylova et al also validated the UNOS post-LT HCC recurrence data and found the observed HCC recurrence rate was not significantly different from the expected rate at any center, suggesting that the impact of any potential systematic underreporting of HCC recurrence is low. (24) Furthermore, the overall HCC recurrence rate of 7% identified in the current study is similar to other UNOS studies (the 3-year HCC recurrence rate of 8% as reported by Schlansky et al (25) ) although slightly lower than what is reported in other single or multicenter studies where recurrence rates range from approximately 8% to 15%. (1,26,27) In conclusion, the RH-IML classification has several advantages relevant to clinical practice.…”

Multicenter validation of a score to predict prognosis after the development of HCC recurrence following liver transplantation

“…Finally, at UCSF the listing and prioritization for HCC patients followed the UNOS based allocation system for the study period. 9 Briefly, between 2001 and 2005 both T1 and T2 patients received exception points. However, beyond the year 2005 only patients with T2 tumors were prioritized on the WL.…”

Misdiagnosis of hepatocellular carcinoma in patients receiving no local‐regional therapy prior to liver transplant: An analysis of the Organ Procurement and Transplantation Network explant pathology form

“…MRI is only 52-62% sensitive for the diagnosis of small tumors <2 cm, 15,16 and smaller tumors appear to show less pronounced delayed washout compared to larger HCC. 17 Samoylova et al 18 previously found that post-LT HCC recurrence risk was significantly lower in patients with 2-3 nodules all <2 cm compared to others within stage T2, raising the suspicion that some of these patients might not even have HCC and received unnecessary LT. However, our analysis did not demonstrate a significant difference in the misdiagnosis rate when comparing this specific category with other subgroups within T2 HCC (Table 3).…”