Reframing the approach to patients with hepatocellular carcinoma: Longitudinal assessment with hazard associated with liver transplantation for HCC (HALTHCC) improves ablate and wait strategy

Abstract

HALTHCC is superior in assessing tumor risk in candidates awaiting LT, and its utility increases over time. Peri-LRT relative change in HALTHCC outperforms mRECIST in stratifying risk of dropout, mortality, and recurrence post-LT. With improving estimates of post-LT outcomes, it is reasonable to consider allocation using HALTHCC and not just waiting time. Furthermore, this study supports a shift in perspective, from listing to allocation, to better utilize precious donor organs. (Hepatology 2018).

The Intention‐to‐Treat Effect of Bridging Treatments in the Setting of Milan Criteria–In Patients Waiting for Liver Transplantation

“…This observation is in line with many studies showing the detrimental role of poor radiological response on delisting, intention‐to‐treat death, transplant benefit, posttransplant tumor recurrence, and posttransplant death . The diameter of the largest lesion, AFP levels at first referral, and MELD scores were also risk factors for HCC‐dependent failure by previous reports …”

“…Second, studies comparing no‐LRT and LRT patients focus only on posttransplant data, thereby failing to obtain intention‐to‐treat results. It is only recently that the importance of intention‐to‐treat analyses in the setting of LT has been recognized . For the first time, the present study has investigated the intention‐to‐treat effect of LRT against upfront LT in MC‐in HCC patients.…”

Charting the Path Forward for Risk Prediction in Liver Transplant for Hepatocellular Carcinoma: International Validation of HALTHCC Among 4,089 Patients

“…We believed that balancing statistical accuracy with a minimally complex model would increase the number of LT for HCC without adversely affecting outcomes. In fact, there is evidence that priority allocation using HALTHCC would allow fine‐tuning of “acceptable outcomes” and serve as a simple metric for transplant center comparison across regions . Furthermore, a continuous risk score is advantageous compared to a dichotomous model given that the continuous score can be recalibrated easily when necessary, as was the case with the MELD and MELD‐Na scores previously.…”

“…A consensus meeting is necessary to finalize the form and composition of predictive models our community would like to explore before embarking on prospective trials. For example, we previously demonstrated the value of including MELD‐Na in HALTHCC to improve prediction of OS; however, it has relatively less impact on modeling recurrence . Clearly, recurrence is of prime interest in LT for HCC; however, whereas 3‐year recurrence runs 7%‐10%, transplant‐related mortality at 3 years is 15%‐20%; candidate selection is about more than tumor size, and number and transplantation is not benign.…”

“…Its value is calculated by common clinical variables which were determined in a single center to be relevant for post‐LT survival and validated among the entire national experience of the United States . It was also validated for post‐LT recurrence, and its longitudinal measurement was associated with dropout in a multicenter study …”