Should the liver transplant criteria for hepatocellular carcinoma be different for deceased donation and living donation?

Abstract

Should the liver transplant criteria for hepatocellular carcinoma (HCC) be different for deceased donation and living donation? Living donor liver transplantation (LDLT) for HCC offers the opportunity to provide a neoadjuvant treatment organized around a scheduled time for the transplant and to restore excellent liver function with a high-quality graft. However, some centers have been reluctant to offer LDLT for HCC because of concerns about higher rates of cancer recurrence and inferior patient survival after LDLT versus deceased donor liver transplantation (DDLT). 1-6 Theoretical reasons for concerns about the potential for higher rates of HCC recurrence after LDLT include the following: (1) the stimulation of residual cancer cells by growth factors in the regenerating liver 7 ; (2) the relatively brief waiting time for LDLT, which may allow transplantation for patients whose aggressive or rapidly progressive HCC tumors might progress with a longer waiting time and exclude them from transplantation 8 ; and (3) more limited oncological clearance with the inferior vena cava-sparing technique used for LDLT. Another explanation for the reports of higher recurrence rates after LDLT is the presence of programmatic biases that lead these centers to unknowingly offer LDLT to patients with a higher risk of HCC recurrence.To determine whether the liver transplant criteria for HCC should be the same or different for deceased donation and living donation, we examine 2 questions: 1. Are recurrence or cancer-free survival rates after DDLT and LDLT for HCC so inherently different that different transplant criteria are justified? 2. Should LDLT be offered to patients whose tumor stage prevents the use of allocation exception points [eg, Model for End-Stage Liver Disease (MELD) points] and, therefore, limits the availability of deceased donor livers?These questions are analyzed in this article. MATERIALS AND METHODSWe undertook literature searches in June 2010 to identify English publications solely focused on comparisons of outcomes of LDLT and DDLT for HCC. Embase was searched with the following sets of

Living-donorvsdeceased-donor liver transplantation for patients with hepatocellular carcinoma

“…A recent review article by experts [29] concluded as follows: Although there is no strong evidence to support the higher HCC recurrence rates in LDLT than DDLT, the higher recurrence rates in LDLT recipients reported by several authors cannot be ignored. Actually, there are critical differences among societies such as: (1) differences in the allocation system for DDLT and LDLT; (2) differences in the availability of deceased donors; (3) differences in the potential waiting time; and (4) the differences in regional and national organ transplant law.…”

Liver transplantation for hepatocellular carcinoma from living-donor vs. deceased donor

“…A review article by experts (27) concluded as follows: although there is no strong evidence to support the higher HCC recurrence rates in LDLT than DDLT, the reported higher recurrence rates in LDLT recipients cannot be ignored. In addition to taking into account the differences in organ allocation, graft availability, and organ transplant law and allocation system, liver transplant candidates with HCC and their potential live donors should be informed following risks and benefits; the waiting time for DDLT may lead to the dropout due to HCC progression which could be avoided by the prompt LDLT, however, the prompt LDLT may mask the aggressive tumor characteristics which may lead to a higher HCC recurrence rates.…”

Role of Liver Transplantation for Hepatocellular Carcinoma

“…This suggests that perhaps the wait for the organ in the DDLT situation may select patients with better tumor biology for transplant. 7 It may also be that patients beyond Milan criteria progress while waiting for a deceased donor liver while they may have considerably superior outcomes in the LDLT scenario where this wait is eliminated.…”