Limits to liver transplantation in the UK

Pereira, Stephen P.; Williams, Roger

doi:10.1136/gut.42.6.883

Cited by 33 publications

(19 citation statements)

References 30 publications

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“…5 The probability of patient drop out with a median waiting time of 6 months is 23% 22 and may increase to 30% to 50% when the waiting time exceeds 1 year. 53 In the current study, the median wait time between diagnosis and transplantation was 6.9 months. Given the general increase in wait times, more and more centers have adopted pretransplantation loco-regional therapy.…”

Section: Discussionmentioning

confidence: 97%

Surgical Management of Early-Stage Hepatocellular Carcinoma: Resection or Transplantation?

Bellavance

Lumpkins

Mentha

et al. 2008

Journal of Gastrointestinal Surgery

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Section: Discussionmentioning

confidence: 97%

Surgical Management of Early-Stage Hepatocellular Carcinoma: Resection or Transplantation?

Bellavance

Lumpkins

Mentha

et al. 2008

Journal of Gastrointestinal Surgery

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“…This is not a local problem because the length of the waiting list and the drop-out rate is even higher both in Europe and in the United States. [31][32][33] This discouraging survival rate is clearly less than what should be expected after resection in properly selected patients. The Eastern groups describe the best long-term outcome after resection with 5-year survival rates above 50%, 14,17 whereas the Western experience offers disparate results, but always below that figure .…”

Section: Discussionmentioning

confidence: 99%

Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: Resection versus transplantation

1999

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Liver transplantation is proposed as the best therapy for early hepatocellular carcinoma in cirrhotic patients. However, the confrontation with the results obtained by surgical resection has never been done on an intention-to-treat basis. Between 1989 and 1997, 164 out of 1,265 patients with hepatocellular carcinoma were evaluated for surgery. Seventyseven (48 men, mean 61 years of age, 74 Child-Pugh class A, size 33 ؎ 18 mm) were resected (first line option) and 87 (65 men, mean 55 years of age, 50 Child-Pugh class B/C, size 24 ؎ 14 mm) were selected for transplantation. The 1-, 3-, and 5-year ''intention-to-treat'' survival was 85%, 62%, and 51% for resection and 84%, 69%, and 69% for transplantation (8 drop-outs on waiting list). Bilirubin and clinically relevant portal hypertension were independent survival predictors after resection. Thereby, the 5-year survival of the best candidates (absence of clinically relevant portal hypertension, n ‫؍‬ 35) was 74%, whereas it was 25% for the worst candidates (portal hypertension and bilirubin H1 mg/dL, n ‫؍‬ 27) (P F .00001). The variable ''drop-out on waiting list'' was the sole survival predictor after transplantation. The 2-year survival rate of patients evaluated for transplantation was 84% in the 1989 to 1995 period (mean waiting time, 62 days; no drop-outs) and 54% during 1996 to 1997 (mean waiting time, 162 days; 8 drop-outs)(P F .003). This outcome was significantly lower than that of the best candidates for resection (P ‫؍‬ .002). In conclusion, a proper selection of candidates for resection promotes better results than transplantation, in which the results are significantly hampered by the growing incidence of drop-outs because of the increasing waiting time. (HEPATOLOGY 1999;30:1434-1440.)There are no randomized controlled clinical trials (RCTs) comparing orthotopic liver transplantation (OLT) versus surgical resection for early hepatocellular carcinoma (HCC) in cirrhotic patients. By now, such an RCT should be considered largely unfeasible because it would require a very large sample size, thus involving several centers sharing the same selection criteria and therapeutic skills. Thus, the debate regarding which should be the preferred treatment option is based on the comparison between the outcomes of independent cohorts of patients. This approach suggests that OLT offers better life expectancy, 1-7 but this assumption is misleading. There are no intention-to-treat studies, and this is of paramount importance because a noteworthy proportion of patients will be excluded from the transplantation program because of tumor growth or development of contraindications while waiting for a donor. Spain has the highest liver donation rate throughout the world (20 liver donors/10 6 inhabitants), 8 and the proportion of drop-outs (because of death or appearance of contraindications) is nowadays around 15%. 9 Furthermore, although the encouraging survival data described for HCC patients effectively transplanted (75% at 5 years) are due both to a restrictive selection p...

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“…At the Liver Unit in Barcelona, the probability of patient drop-out with a median waiting time of 6 months is 23% 4 ; other centers have shown that this increases to 30% to 50% when the waiting time exceeds 1 year. 20 These figures emphasize the need to analyze outcomes according to intention-to-treat. In our analysis of OLT for early HCC, in which a short waiting time (no drop-outs) was compared with a longer waiting time (23% drop-out rate), the 2-year survival figures by intention-totreat decreased from 85% to less than 60%.…”

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confidence: 99%

Surgical resection versus transplantation for early hepatocellular carcinoma: clues for the best strategy

2000

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The incidence of hepatocellular carcinoma (HCC) caused by hepatitis C infection is clearly increasing. Although current screening modalities identify about one third of the tumors at a potentially curable stage, 1 the best treatment strategy for early HCC still is far from being established. Current evidence suggests that surgical resection is suitable for only a small subgroup of cirrhotic patients with HCC. European and Japanese centers using highly restrictive selection criteria have reported 5-year survival rates of 60% to 70%. [2][3][4][5] Optimal candidates for resection include Child-Pugh class A cirrhotic patients with normal serum total bilirubin values, absence of clinically relevant portal hypertension, and small asymptomatic tumors. 3,4 Resection should be avoided in the remaining patients since it may reduce their outcome to figures even below the natural history of the disease. 6 In Western countries, where liver cancer typically develops in the setting of well-established cirrhosis, fewer than 5% of HCC patients meet these stringent criteria and are candidates for resection with acceptable risk. 4 In Eastern countries, the applicability of resection could be higher, perhaps reflecting a less advanced liver disease related to chronic hepatitis B virus infection or a higher recognition of hepatitis C virus-positive individuals with silent cirrhosis among the community. 2,5,7 It should be noted also that even in carefully selected patients, the rate of tumor recurrence is 50% after 3 years. 4,7 Regeneration after resection may elicit metachronous tumors; this is a theoretical concern deserving of further attention. Efforts to prevent tumor recurrence have involved administration of retinoids and intra-arterial I 131 labeled lipiodol, 8,9 but the reported benefit of these treatments requires confirmation.Most hepatologists now favor orthotopic liver transplantation (OLT) as the preferred option for early HCC. [10][11][12][13][14] If tumors with a low probability of metastasis are selected and extrahepatic tumor is excluded, OLT removes the entire process and, moreover, can be applied to patients with end-stage liver disease. The first series of OLT reported disappointing results in terms of survival and tumor recurrence because the selection criteria were inappropriate. 10,11 However, more recent data have shown that the restriction of OLT to patients with single tumors less than 5 cm or with three nodules, each less than 3 cm, will result in 5-year survival rates of around 70%. 14-17 Although widely accepted, the data carry certain caveats. Importantly, most of the studies were conducted when program waiting times were relatively short (Ͻ6 months). The average waiting times in 1997 for OLT were 240 and 477 days in Spain and the United States, respectively. 18,19 In view of a 1-year probability of tumor progression of 70%, vascular invasion of 21%, and extrahepatic spread of untreated tumors of 9%, 9 many untreated patients will become ineligible for OLT. At the Liver Unit in Barcelona, the probabilit...

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Limits to liver transplantation in the UK

Cited by 33 publications

References 30 publications

Surgical Management of Early-Stage Hepatocellular Carcinoma: Resection or Transplantation?

Surgical Management of Early-Stage Hepatocellular Carcinoma: Resection or Transplantation?

Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: Resection versus transplantation

Surgical resection versus transplantation for early hepatocellular carcinoma: clues for the best strategy

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