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1.
Semin Liver Dis ; 2021 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-33788207

RESUMO

The success of liver transplant (LT) for hepatocellular carcinoma (HCC) is dependent on accurate tumor staging using validated imaging criteria, and adherence to acceptable criteria based on tumor size and number. Other factors including α-fetoprotein (AFP) and response to local regional therapy (LRT) have now played a larger role in candidate selection. Tumor downstaging is defined as reduction in the size of viable tumors using LRT to meet acceptable criteria for LT, and serves as a selection tool for a subgroup of HCC with more favorable biology. The application of tumor downstaging requires a structured approach involving three key components in tumor staging-initial tumor stage and eligibility criteria, tumor viability assessment following LRT, and target tumor stage prior to LT-and incorporation of AFP into staging and treatment response assessments. In this review, we provide in-depth discussions of the key role of these staging definitions in ensuring successful outcome.

2.
AJR Am J Roentgenol ; : 1-8, 2021 Mar 11.
Artigo em Inglês | MEDLINE | ID: mdl-33703926

RESUMO

OBJECTIVE. The purpose of this study was to identify risk factors for and outcomes of hepatotoxicity after selective chemoembolization of hepatocellular carcinoma. MATERIALS AND METHODS. This retrospective study included 182 patients (136 men and 46 women; median age, 63 years [interquartile range, 57-70 years]) who underwent 338 consecutive doxorubicin drug-eluting bead (DEB) chemoembolization procedures between 2011 and 2014. Outcomes were assessed until November 2019. In 97% of procedures, two or fewer segments were targeted. The Barcelona Clinic Liver Cancer (BCLC) stage was 0 or A for 77 procedures (22.8%), B for 75 (22.2%), C for 122 (36.1%), and D for 64 (18.9%). Hepatotoxicity was defined as worsened ascites or encephalopathy or as grade 3 or 4 elevations in liver function test results, creatinine levels, or the international normalized ratio within 30 days. Risk factors were assessed by univariate and multivariable generalized estimating equations. Transplant-free survival was assessed using Cox proportional hazard models. RESULTS. Hepatotoxicity was observed after 84 of 338 procedures (24.9%) performed for 70 of 182 patients (38.5%) and was irreversible for 40 procedures (11.8%). On multivariable analysis, risk factors for irreversible toxicity included Child-Pugh class C liver function (odds ratio [OR], 4.4; 95% CI, 1.0-19.0; p = .04), BCLC stage C (OR, 5.0; 95% CI, 1.6-16.0; p = .006) or D (OR, 7.4; 95% CI, 2.1-25.5; p = .002) disease, TIPS or hepatofugal portal venous flow (OR, 6.3; 95% CI, 2.3-17.0; p < .001), and a serum α-fetoprotein level of 200 ng/mL or greater (OR, 2.6; 95% CI, 1.1-6.1; p = .03). Irreversible toxicity was associated with reduced transplant-free survival among patients who were ineligible for liver transplant (hazard ratio, 2.5; standard error, 0.42; p = .03). CONCLUSION. Irreversible hepatotoxicity was common after selective chemoembolization in patients with advanced stage disease, an elevated serum α-fetoprotein level, or reduced hepatic portal venous perfusion, and it may hasten death among patients who are ineligible for liver transplant.

3.
Artigo em Inglês | MEDLINE | ID: mdl-33524592

RESUMO

Among patients with hepatocellular carcinoma (HCC), elevated α-fetoprotein (AFP) has been shown to predict waitlist dropout, high-risk histopathologic features, and inferior post-liver transplant (LT) outcome.1,2 Nevertheless, many patients with HCC have a normal AFP and yet still experience waitlist dropout or post-LT recurrence.2 Because of the degree of imprecision associated with AFP, there is a quest for other biomarkers that may be complementary to or better than AFP in predicting prognosis in LT. Lectin-reactive AFP (AFP-L3) and des-gamma-carboxyprothrombin (DCP) are biomarkers that have been used in conjunction with AFP as HCC surveillance or diagnostic tools.3,4 However, the utility of these biomarkers in LT for HCC is not established.

4.
Liver Transpl ; 2021 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-33570786

RESUMO

BACKGROUND: We assessed the prognostic significance and the clinical stability of NLR prior to LT in a large cohort of HCC patients from a long wait time region. A high preoperative neutrophil-to-lymphocyte (NLR) ≥ 5 has been reported to predict poor outcomes following liver transplantation (LT) for HCC, and NLR has been incorporated into several prognostic models. METHODS: We evaluated 758 HCC patients listed for LT with MELD exception from 2002-2015 at a single LT center, of which 505 underwent and 253 dropped out prior to LT. NLR was collected in all patients at LT and, if available, between 15-90 days prior to LT (NLR 2) or at dropout. RESULTS: NLR ≥ 5 was associated with microvascular invasion, poorer tumor differentiation, and more advanced pathology on explant. Patients with NLR ≥ 5 exhibited no differences in AFP, tumor burden at listing, or number of LRT compared to patients with NLR < 5. After a median post-LT follow-up of 4.7 years, overall survival and recurrence rates were similar for NLR ≥ 5 vs NLR < 5. The NLR changed frequently, and 47% of patients whose NLR2 was ≥ 5 had an NLR < 5 by LT. NLR was ≥ 5 in 47.6% of patients at dropout, compared with 14.9% of patients undergoing LT. CONCLUSIONS: While NLR at LT correlated with MVI and tumor stage at explant, NLR did not predict post-LT survival or HCC recurrence. NLR appeared to be a relatively unstable inflammatory marker over the immediate three months prior to LT for HCC.

5.
Transpl Infect Dis ; : e13563, 2021 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-33434394

RESUMO

We report a liver transplant patient with disseminated Legionella micdadei infection with pulmonary, laryngeal, and suspected muscle involvement. This organism, which stains weakly acid-fast, primarily affects immunocompromised patients. The diagnosis is difficult to make; in this case, the organism was identified via molecular diagnostics on laryngeal and pulmonary biopsy tissue.

6.
Transplantation ; 2020 Dec 14.
Artigo em Inglês | MEDLINE | ID: mdl-33323764

RESUMO

BACKGROUND: Women with chronic liver disease have lower rates of hepatocellular carcinoma (HCC) as compared to men; it is unknown if there are sex-based differences in HCC recurrence post-liver transplant. METHODS: We conducted an analysis of patients who underwent liver transplant for HCC in the United Network for Organ Sharing/Organ Procurement and Transplantation Network from January 1, 2012 through December 31, 2017. RESULTS: A total of 12,711 patients underwent liver transplant for HCC: 2,909 (23%) women and 9,802 (73%) men. Women had significantly lower rates of post-liver transplant HCC recurrence than men (4.0 v. 5.4%, p=0.002). A cox-regression analysis for post-liver transplant HCC recurrence highlighted that even after accounting for etiology of cirrhosis, alpha-fetoprotein (AFP) at liver transplant, tumor diameter, tumor pathology, and vascular invasion, female sex was associated with a 25% lower risk of post-liver transplant HCC recurrence (95CI 0.57-0.99). There were no interactions between female sex and the following variables: age, type of locoregional therapy, AFP, donor sex, body mass index, or nonalcoholic steatohepatitis etiology (p>0.05 for each). CONCLUSIONS: This study demonstrates an independent effect of sex on risk for HCC recurrence post-liver transplant. Our data highlight an opportunity to better understand HCC tumor biology by investigating the drivers of this sex-based difference in HCC recurrence.

7.
J Hepatol ; 2020 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-33188904

RESUMO

BACKGROUND & AIMS: It has been suggested that patients with hepatocellular carcinoma (HCC) at high risk of waitlist dropout would have done poorly after liver transplantation (LT) due to tumor aggressiveness. To test this hypothesis, we analyzed risk of waitlist dropout among HCC patients in long wait regions (LWR) to create a dropout risk score, and applied this score in short (SWR) and mid wait regions (MWR) to evaluate post-LT outcomes. We sought to identify a threshold in dropout risk that predicts worse post-LT outcome. METHODS: Using the UNOS database including all patients with T2 HCC receiving priority listing from 2010-2014, a dropout risk score was created from a developmental cohort of 2,092 LWR patients, and tested in a validation cohort of 1,735 SWR and 2,894 MWR patients. RESULTS: On multivariable analysis, 1 tumor 3.1-5 cm or 2-3 tumors, AFP >20 ng/ml, and increasing Child-Pugh and MELD-Na scores significantly predicted waitlist dropout. A dropout risk score using these four variables (C-statistic 0.74) was able to stratify 1-year cumulative incidence of dropout from 7.1% with a score <7 to 39.5% with a score >23. Patients with a dropout risk score >30 had 5-year post-LT survival of 60.1% versus 71.8% for those with a score <30 (p=0.004). There were no significant differences in post-LT survival below this threshold. CONCLUSIONS: This study provided evidence that HCC patients with the highest dropout risk have aggressive tumor biology that would also result in poor post-LT outcomes when transplanted quickly. Below this threshold risk score of <30, priority status for organ allocation could be stratified based on the predicted risks of waitlist dropout without significant differences in post-LT survival.

9.
Transplant Direct ; 6(10): e605, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33134485

RESUMO

Nonalcoholic fatty liver disease (NAFLD) is a leading cause of hepatocellular carcinoma (HCC) in the United States. Prior data suggest that NAFLD-HCC patients are less likely to receive liver transplantation (LT) and have worse overall survival; however, the reason for this discrepancy is unknown. Methods: We conducted a retrospective study of 631 HCC patients listed for LT at a large academic center from 2004 to 2013. Waitlist dropout and LT were analyzed using competing risk regression. Results: Compared with other-HCC patients (n = 589), NAFLD-HCC patients (n = 42, 6.7%) were older (65 versus 58, P < 0.001) with more women (50.0 versus 23.6%, P < 0.001), Hispanic ethnicity (40.5 versus 17.7%, P = 0.001), obesity (69.0 versus 29.9%, P < 0.001), diabetes mellitus (59.5 versus 27.8%, P < 0.01), insulin-dependence (23.8 versus 10.2%, P = 0.007), hyperlipidemia (40.5 versus 10.5, P < 0.001), and statin use (33.3 versus 5.3%, P < 0.001). Cumulative incidence of waitlist dropout at 2 y was 17.4% (95% confidence intervals, 7.7-30.4) for NAFLD HCC and 25.4% (95% confidence intervals, 21.9-29.0) for other HCC (P = 0.28). No difference in waitlist dropout or receipt of LT between NAFLD HCC and other HCC was found on regression analysis. Similarly, NAFLD and obesity, obesity alone, diabetes mellitus, insulin-dependence, hyperlipidemia, and statin use were not associated with waitlist outcomes. Finally, we observed no statistically significant difference in 5-y survival from HCC diagnosis between NAFLD HCC and other HCC (78.5% versus 66.9%, P = 0.9). Conclusions: In our single-center cohort, we observed no difference in waitlist outcomes or survival in NAFLD HCC, although conclusions are limited by the small number of NAFLD-HCC patients. Notably, the inclusion of patients with obesity in the NAFLD-HCC group and stratification by individual metabolic factors also showed no difference in waitlist outcomes.

10.
Artigo em Inglês | MEDLINE | ID: mdl-32927050

RESUMO

BACKGROUND & AIMS: Hepatocellular carcinoma (HCC) surveillance rates are suboptimal in clinical practice. We aimed to elicit providers' opinions on the following aspects of HCC surveillance: preferred strategies, barriers and facilitators, and the impact of a patient's HCC risk on the choice of surveillance modality. METHODS: We conducted a web-based survey among gastroenterology and hepatology providers (40% faculty physicians, 21% advanced practice providers, 39% fellow-trainees) from 26 U.S. medical centers in 17 states. RESULTS: Of 654 eligible providers, 305 (47%) completed the survey. Nearly all (98.4%) of the providers endorsed semi-annual HCC surveillance in patients with cirrhosis, with 84.2% recommending ultrasound ± alpha fetoprotein (AFP) and 15.4% recommending computed tomography (CT) or magnetic resonance imaging (MRI). Barriers to surveillance included limited HCC treatment options, screening test effectiveness to reduce mortality, access to transportation, and high out-of-pocket costs. Facilitators of surveillance included professional society guidelines. Most providers (72.1%) would perform surveillance even if HCC risk was low (≤0.5% per year), while 98.7% would perform surveillance if HCC risk was ≥1% per year. As a patient's HCC risk increased from 1% to 3% to 5% per year, providers reported they would be less likely to order ultrasound ± AFP (83.6% to 68.9% to 57.4%; p<0.001) and more likely to order CT or MRI ± AFP (3.9% to 26.2% to 36.1%; p<0.001). CONCLUSION: Providers recommend HCC surveillance even when HCC risk is much lower than the threshold suggested by professional societies. Many appear receptive to risk-based HCC surveillance strategies that depend on patients' estimated HCC risk, instead of our current "one-size-fits all" strategy.

11.
Transplantation ; 104(11): 2215-2220, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32639408

RESUMO

BACKGROUND: The novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) disease has transformed innumerable aspects of medical practice, particularly in the field of transplantation. MAIN BODY: Here we describe a single-center approach to creating a generalizable, comprehensive, and graduated set of recommendations to respond in stepwise fashion to the challenges posed by these conditions, and the underlying principles guiding such decisions. CONCLUSIONS: Creation of a stepwise plan will allow transplant centers to respond in a dynamic fashion to the ongoing challenges posed by the COVID-19 pandemic.


Assuntos
Infecções por Coronavirus/epidemiologia , Transplante de Órgãos/normas , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Betacoronavirus , Recursos em Saúde , Humanos , Imunossupressão , Pandemias , Doadores de Tecidos , Listas de Espera
12.
Hepatology ; 2020 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-32583439

RESUMO

We thank Akbulut et al for their letter to the editor (1) on our study (2) which analyzed patients with hepatocellular carcinoma (HCC) in the UNOS database with at least one measured AFP >1000 ng/ml prior to liver transplant (LT). We validated recently approved national policy (3) by demonstrating significantly improved post-LT outcome among patients with a reduction in AFP to <500 ng/ml with local-regional therapy (LRT). Akbulut et al raised the concern that >70% of patients included in this study did not fulfill this national policy and also pointed out that over one-third of included patients did not receive LRT prior to LT. We absolutely agree that patients with AFP >1000 ng/ml should not undergo LT but instead first undergo LRT with a goal of achieving AFP reduction. We would like to clarify that the study period of 2005-2015 predated OPTN/UNOS HCC policies mandating AFP reduction to <500 ng/ml prior to LT if ever >1000 ng/ml as well as a waiting period of 6 months before granting MELD exception. Prior to this latter policy, some HCC patients were offered LT within a few months after listing (4) and thus often did not receive LRT prior to LT. Since institution of the 6 month wait policy, nearly all listed HCC patients now receive at least one LRT prior to LT (5).

13.
Liver Transpl ; 26(9): 1100-1111, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32531867

RESUMO

Liver transplantation (LT) recipients with hepatocellular carcinoma (HCC) receive a higher proportion of livers from donation after circulatory death (DCD) donors compared with non-HCC etiologies. Nevertheless, data on outcomes in patients with HCC receiving DCD grafts are limited. We evaluated the influence of DCD livers on post-LT outcome among HCC patients. We identified 7563 patients in the United Network for Organ Sharing (UNOS) database who underwent LT with Model for End-Stage Liver Disease score exceptions from 2012 to 2016, including 567 (7.5%) who received a DCD donor organ and 6996 (92.5%) who received a donation after brain death (DBD) donor organ. Kaplan-Meier probabilities of post-LT HCC recurrence at 3 years were 7.6% for DCD and 6.4% for DBD recipients (P = 0.67) and post-LT survival at 3 years was 81.1% versus 85.5%, respectively (P = 0.008). On multivariate analysis, DCD donor (hazard ratio, 1.38; P = 0.005) was an independent predictor of post-LT mortality. However, a survival difference after LT was only observed in subgroups at higher risk for HCC recurrence including Risk Estimation of Tumor Recurrence After Transplant (RETREAT) score ≥4 (DCD 57.0% versus DBD 72.6%; P = 0.02), alpha-fetoprotein (AFP) ≥100 (60.1% versus 76.9%; P = 0.049), and multiple viable tumors on last imaging before LT (69.9% versus 83.1%; P = 0.002). In this analysis of HCC patients receiving DCD versus DBD livers in the UNOS database, we found that patients with a low-to-moderate risk of HCC recurrence (80%-90% of the DCD cohort) had equivalent survival regardless of donor type. It appears that DCD donation can best be used to increase the donor pool for HCC patients with decompensated cirrhosis or partial response/stable disease after locoregional therapy with AFP at LT <100 ng/mL.

14.
Anesthesiology ; 132(6): 1593, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32217868
15.
Transplantation ; 104(6): 1136-1142, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32217938

RESUMO

Liver transplantation (LT) offers excellent long-term outcome for certain patients with hepatocellular carcinoma (HCC), with a push to not simply rely on tumor size and number. Selection criteria should also consider tumor biology (including alpha-fetoprotein), probability of waitlist and post-LT survival (ie, transplant benefit), organ availability, and waitlist composition. These criteria may be expanded for live donor LT (LDLT) compared to deceased donor LT though this should not adversely affect the double equipoise in LDLT, namely ensuring both acceptable recipient outcomes and donor safety. HCC patients with compensated liver disease and minimal tumor burden have low urgency for LT, especially after local-regional therapy with complete response, and do not appear to derive the same benefit from LT as other waitlist candidates. These guidelines were developed to assist in selecting appropriate HCC patients for both deceased donor LT and LDLT.


Assuntos
Carcinoma Hepatocelular/cirurgia , Seleção do Doador/normas , Neoplasias Hepáticas/cirurgia , Transplante de Fígado/normas , Seleção de Pacientes , Carcinoma Hepatocelular/mortalidade , Consenso , Conferências de Consenso como Assunto , Europa (Continente) , Humanos , Neoplasias Hepáticas/mortalidade , Transplante de Fígado/métodos , Doadores Vivos , Oncologia/métodos , Oncologia/normas , Segurança do Paciente , Guias de Prática Clínica como Assunto , Sociedades Médicas/normas , Estados Unidos , Listas de Espera/mortalidade
16.
Hepatology ; 72(5): 1654-1665, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32017165

RESUMO

BACKGROUND AND AIMS: There are limited data on hepatocellular carcinoma (HCC) growth patterns, particularly in Western cohorts, despite implications for surveillance, prognosis, and treatment. Our study's aim was to quantify tumor doubling time (TDT) and identify correlates associated with indolent and rapid growth. APPROACH AND RESULTS: We performed a retrospective multicenter cohort study of patients with cirrhosis diagnosed with HCC from 2008 to 2017 at six US and European health systems with two or more contrast-enhanced imaging studies performed ≥ 30 days apart prior to HCC treatment. Radiologists independently measured tumors in three dimensions to calculate TDT and specific growth rate (SGR). We used multivariable ordinal logistic regression to identify factors associated with indolent (TDT > 365 days) and rapid (TDT < 90 days) tumor growth. In the primary cohort (n = 242 patients from four centers), median TDT was 229 days (interquartile range [IQR], 89-627) and median SGR was 0.3% per day (IQR, 0.1%-0.8%). Over one-third (38%) of HCCs had indolent growth, 36.8% intermediate growth, and 25.2% rapid growth. In multivariable analysis, indolent growth was associated with larger tumor diameter (odds ratio [OR], 1.15, 95% confidence interval [CI], 1.03-1.30) and alpha-fetoprotein < 20 ng/mL (OR, 1.90; 95% CI, 1.12-3.21). Indolent growth was more common in nonviral than viral cirrhosis (50.9% versus 32.1%), particularly in patients with T1 HCC (OR, 3.41; 95% CI, 1.08-10.80). Median TDT (169 days; IQR 74-408 days) and SGR (0.4% per day) were similar in an independent cohort (n = 176 patients from two centers). CONCLUSIONS: In a large Western cohort of patients with HCC, we found heterogeneous tumor growth patterns, with one-fourth exhibiting rapid growth and over one-third having indolent growth. Better understanding different tumor growth patterns may facilitate a precision approach to prognostication and treatment.

17.
Transplantation ; 104(10): 2105-2112, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31972705

RESUMO

BACKGROUND: Currently, no surveillance guidelines for hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) exist. In this retrospective, multicenter study, we have investigated the role of surveillance imaging on postrecurrence outcomes. METHODS: Patients with recurrent HCC after LT from 2002 to 2016 were reviewed from 3 transplant centers (University of California San Francisco, Mayo Clinic Florida, and University of Toronto). For this study, we proposed the term cumulative exposure to surveillance (CETS) as a way to define the cumulative sum of all the protected intervals that each surveillance test provides. In our analysis, CETS has been treated as a continuous variable in months. RESULTS: Two hundred twenty-three patients from 3 centers had recurrent HCC post-LT. The median follow-up was 31.3 months, and median time to recurrence was 13.3 months. Increasing CETS was associated with improved postrecurrence survival (hazard ratio, 0.94; P < 0.01) as was treatment of recurrence with resection or ablation (hazard ratio, 0.31; P < 0.001). An receiver operating characteristic curve (area under the curve, 0.64) for CETS covariate showed that 252 days of coverage (or 3 surveillance scans) within the first 24 months provided the highest probability for aggressive postrecurrence treatment. CONCLUSIONS: In this review of 223 patients with post-LT HCC recurrence, we found that increasing CETS does lead to improved postrecurrence survival as well as a higher probability for aggressive recurrence treatment. We found that 252 days of monitoring (ie, 3 surveillance scans) in the first 24 months was associated with the ability to offer potentially curative treatment.

18.
Am J Transplant ; 20(2): 333-347, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31710773

RESUMO

Hepatocellular carcinoma (HCC) is an increasingly common indication for liver transplantation (LT) in the United States and in many parts of the world. In the last decade, significant work has been done to better understand how to risk stratify LT candidates for recurrence of HCC following transplant using a combination of biomarker and imaging findings. However, despite the high frequency of HCC in the LT population, guidance regarding posttransplant management is lacking. In particular, there is no current evidence to support specific post-LT surveillance strategies, leading to significant heterogeneity in practices. In addition, there are no current recommendations regarding recurrence prevention, including immunosuppression regimen or secondary prevention with adjuvant chemotherapy. Finally, guidance on treatment of disease recurrence is also lacking and there is significant controversy about the use of immunotherapy in transplant recipients due to the risk of rejection. Thus, outcomes for patients with recurrence are poor. This paper therefore provides a comprehensive review of the current literature on post-LT management of patients with HCC and identifies gaps in our current knowledge that are in urgent need of further investigation.

19.
Hepatology ; 71(3): 943-954, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31344273

RESUMO

BACKGROUND AND AIMS: United Network for Organ Sharing (UNOS) recently implemented a national policy granting priority listing for liver transplantation (LT) in patients who achieved down-staging of hepatocellular carcinoma (HCC) to Milan criteria. We aimed to evaluate the national experience on down-staging by comparing two down-staging groups with (1) tumor burden meeting UNOS down-staging (UNOS-DS) inclusion criteria and (2) "all-comers" (AC-DS) with initial tumor burden beyond UNOS-DS criteria versus patients always within Milan. APPROACH AND RESULTS: This is a retrospective analysis of the UNOS database of 3,819 patients who underwent LT from 2012 to 2015, classified as always within Milan (n = 3,276), UNOS-DS (n = 422), and AC-DS (n = 121). Median time to LT was 12.8 months in long wait regions, 6.5 months in mid wait regions (MWR), and 2.6 months in short wait regions (SWR). On explant, vascular invasion was found in 23.7% of AC-DS versus 16.9% of UNOS-DS and 14.4% of Milan (P = 0.002). Kaplan-Meier 3-year post-LT survival was 83.2% for Milan, 79.1% for UNOS-DS (P = 0.17 vs. Milan), and 71.4% for AC-DS (P = 0.04 vs. Milan). Within down-staging groups, risk of post-LT death in multivariable analysis was increased in SWR or MWR (hazard ratio [HR], 3.1; P = 0.005) and with alpha-fetoprotein (AFP) ≥ 100 ng/mL at LT (HR, 2.4; P = 0.009). The 3-year HCC recurrence probability was 6.9% for Milan, 12.8% for UNOS-DS, and 16.7% for AC-DS (P < 0.001). In down-staging groups, AFP ≥ 100 (HR, 2.6; P = 0.02) was the only independent predictor of HCC recurrence. CONCLUSIONS: Our results validated UNOS-DS criteria based on comparable 3-year survival between UNOS-DS and Milan groups. Additional refinements based on AFP and wait time may further improve post-LT outcomes in down-staging groups, especially given that reported 3-year recurrence was higher than in those always within Milan criteria.

20.
Liver Transpl ; 26(5): 662-672, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31833634

RESUMO

For patients with hepatocellular carcinoma (HCC) listed for liver transplantation (LT), United Network for Organ Sharing (UNOS) enacted policy changes in 2015 to improve equity between HCC and non-HCC patients. We evaluated the impact of these changes on regional disparities in wait-list dropout and LT. We included patients in the UNOS database listed with Model for End-Stage Liver Disease HCC exceptions in long-wait regions (LWRs), mid-wait regions (MWRs), and short-wait regions (SWRs) before these policy changes (era 1, January 1 to December 31, 2013) and after (era 2, October 7, 2015, to October 7, 2016). Cumulative incidence of wait-list dropout and LT were evaluated using competing risk regression. Median time to LT increased by 3.6 months (3.1 to 6.7 months) in SWRs and 1.3 months (6.9 to 8.2 months) in MWRs (P < 0.001), with a slight decrease in LWRs (13.4 to 12.9 months; P = 0.02). The 2-year cumulative incidence of dropout increased from 9.7% to 14.8% in SWRs (P = 0.03) and from 18.9% to 22.6% in MWRs (P = 0.18) but decreased in LWRs from 26.7% to 24.8% (P = 0.31). Factors predicting wait-list dropout included listing in era 2 (hazard ratio [HR], 1.17), in LWRs (HR, 2.56), and in MWRs (HR, 1.91). Regional differences in wait-list outcomes decreased with policy changes, but HCC patients in SWRs remain advantaged. Recent policy change may narrow these disparities.

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