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Published on: September 30, 2021
Are Current National Review Board Downstaging Protocols for Hepatocellular Carcinoma Too Restrictive?
Ola Ahmed1, Neeta Vachharajani1, Kris P Croome2
1From the Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO (Ahmed, Vachharajani, Chapman, Doyle).
Liver transplantation (LT) for hepatocellular carcinoma (HCC) is effective even for patients initially beyond expanded UCSF criteria. Current United Network for Organ Sharing National Liver Review Board (NLRB) criteria may be too restrictive, potentially excluding suitable candidates.
Area of Science:
- Hepatology
- Transplant Surgery
- Oncology
Background:
- Liver transplantation (LT) is a key treatment for unresectable hepatocellular carcinoma (HCC).
- Current United Network for Organ Sharing National Liver Review Board (NLRB) criteria for LT exception points require tumor burden within expanded University of California San Francisco (W-eUCSF) criteria.
- Existing NLRB criteria may be overly restrictive, as initial tumor burden may not predict LT outcomes if tumors downstage.
Purpose of the Study:
- To evaluate LT outcomes for HCC patients initially presenting with tumor burden beyond the expanded UCSF (B-eUCSF) criteria.
- To compare survival and recurrence rates between B-eUCSF and W-eUCSF HCC patients undergoing LT.
- To inform potential revisions of current NLRB listing criteria.
Main Methods:
- Retrospective analysis of a multi-institutional database of LT recipients with HCC from 2001-2017.
- Comparison of survival outcomes (overall and disease-free) between B-eUCSF and W-eUCSF groups using Kaplan-Meier and Cox regression.
- Assessment of tumor recurrence and post-recurrence survival rates.
Main Results:
- Out of 1,846 LT recipients with HCC, 86 (5%) initially met B-eUCSF criteria.
- Despite greater initial tumor burden, B-eUCSF patients showed comparable 1-, 5-, and 10-year overall and disease-free survival rates to W-eUCSF patients.
- While B-eUCSF patients had higher recurrence rates (24% vs 10%), their post-recurrence survival was similar to W-eUCSF patients.
Conclusions:
- LT for HCC patients initially B-eUCSF criteria yields survival outcomes comparable to those meeting W-eUCSF criteria.
- The current NLRB policy appears too stringent and may warrant reconsideration for broader inclusion criteria.
- Expanding LT eligibility criteria could benefit more HCC patients without compromising transplant outcomes.
