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Abstract Details
Are Current National Review Board Downstaging Protocols for Hepatocellular Carcinoma Too Restrictive?
J Am Coll Surg. 2022 Apr 1;234(4):579-588. doi: 10.1097/XCS.0000000000000140.
Ola Ahmed1, Neeta Vachharajani1, Kris P Croome2, Parissa Tabrizian3, Vatche Agopian4, Karim Halazun5, Johnny C Hong6, Leigh Anne Dageforde7, William C Chapman1, Mb Majella Doyle1, Primary Liver Tumor Study Group
Primary Liver Tumor Study Group: Erin Maynard8, Yikyung Park9, Su-Hsin Chang9, Adeel S Khan10
Author information
From the Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO (Ahmed, Vachharajani, Chapman, Doyle).
Department of Transplant, Mayo Clinic Florida, Jacksonville, FL (Croome).
Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY (Tabrizian).
Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA (Agopian).
New York-Presbyterian Hospital, Weill Cornell, New York, NY (Halazun).
Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI (Hong).
Department of Surgery, Division of Transplantation, Massachusetts General Hospital, Boston, MA (Dageforde).
Department of Surgery, Division of Transplant Surgery, Oregon Health and Science University, Portland, OR.
Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO.
Abstract
Background: Liver transplantation (LT) is an effective strategy for patients with unresectable hepatocellular carcinoma (HCC). To qualify for standardized LT model for end-stage liver disease exception points, the United Network for Organ Sharing National Liver Review Board (NLRB) requires that the presenting and final HCC tumor burden be within the University of California San Francisco criteria, which were recently expanded (within expanded UCSF [W-eUCSF]). Current NLRB criteria may be too restrictive because it has been shown previously that the initial burden does not predict LT failure when tumors downstage to UCSF. This study aims to assess LT outcomes for HCC initially presenting beyond expanded UCSF (B-eUCSF) criteria in a large multicenter collaboration.
Study design: Comparisons of B-eUCSF and W-eUCSF candidates undergoing LT at seven academic institutions between 2001 and 2017 were made from a multi-institutional database. Survival outcomes were compared by Kaplan-Meier and Cox regression analyses.
Results: Of 1,846 LT recipients with HCC, 86 (5%) met B-eUCSF criteria at initial presentation, with the remainder meeting W-eUCSF criteria. Despite differences in tumor burden, B-eUCSF candidates achieved comparable 1-, 5- and 10-year overall (89%, 70%, and 55% vs 91%, 74%, and 60%, respectively; p = 0.2) and disease-free (82%, 60%, and 53% vs 89%, 71%, and 59%, respectively; p = 0.07) survival to patients meeting W-eUCSF criteria after LT. Despite increased tumor recurrence in B-eUCSF vs W-eUCSF patients (24% vs 10%, p = 0.0002), post-recurrence survival was similar in both groups (p = 0.69).
Conclusion: Transplantation for patients initially presenting with HCC B-eUSCF criteria offers a survival advantage similar to those with tumors meeting W-eUCSF criteria at presentation. The current NLRB policy is too stringent, and considerations to expand criteria should be discussed.