Liver transplantation for hepatocellular carcinoma: impact of expansion criteria in a multicenter cohort study from a high waitlist mortality region

Piñero F.; Anders M.; Boin I.F.; Chagas A.; Quiñonez E.; Marciano S.; Vilatobá M.; Santos L.; Hoyos Duque S.; Lima A.S.; Menendez J.; Padilla M.; Poniachik J.; Zapata R.; Soza A.; Maraschio M.; Chong Menéndez R.; Muñoz L.; Arufe D.; Figueroa R.; de Ataide E.C.; Maccali C.; Vergara Sandoval R.; Bermudez C.; Podesta L.G.; McCormack L.; Varón A.; Gadano A.; Mattera J.; Villamil F.; Rubinstein F.; Carrilho F.; Silva M. · Transplant International (2021) · DOI: 10.1111/tri.13767

Resumen

This study aimed to compare liver transplantation (LT) outcomes and evaluate the potential rise in numbers of LT candidates with hepatocellular carcinoma (HCC) of different allocation policies in a high waitlist mortality region. Three policies were applied in two Latin American cohorts (1085 HCC transplanted patients and 917 listed patients for HCC): (i) Milan criteria with expansion according to UCSF downstaging (UCSF-DS), (ii) the AFP score, and (iii) restrictive policy or Double Eligibility Criteria (DEC; within Milan + AFP score ≤2). Increase in HCC patient numbers was evaluated in an Argentinian prospective validation set (INCUCAI; NCT03775863). Expansion criteria in policy A showed that UCSF-DS [28.4% (CI 12.8–56.2)] or “all-comers” [32.9% (CI 11.9–71.3)] had higher 5-year recurrence rates compared to Milan, with 10.9% increase in HCC patients for LT. The policy B showed lower recurrence rates for AFP scores ≤2 points, even expanding beyond Milan criteria, with a 3.3% increase. Patients within DEC had lower 5-year recurrence rates compared with those beyond DEC [13.3% (CI 10.1–17.3) vs 24.2% (CI 17.4–33.1; P = 0.0006], without significant HCC expansion. In conclusion, although the application of a stricter policy may optimize the selection process, this restrictive policy may lead to ethical concerns in organ allocation (NCT03775863).