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Allocation policy for hepatocellular carcinoma in the MELD era: Room for improvement

Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA 94143-0780, USA.
Liver Transplantation (Impact Factor: 3.79). 11/2007; 13(11 Suppl 2):S36-43. DOI: 10.1002/lt.21329
Source: PubMed

ABSTRACT Currently, liver transplantation is the optimal cure for hepatocellular cancer (HCC) limited to the liver. The requisite use of a scarce resource and the effective "competition" between transplant candidates with and without HCC necessitates an allocation policy that defines the subset of HCC patients appropriate for transplantation and their equitable waiting-list prioritization relative to non-HCC patients. Under Model for End-Stage Liver Disease (MELD) allocation, HCC candidates must meet the Milan criteria (single tumor < or =5 cm in diameter or 2 or 3 tumors, each <3 cm in diameter) to qualify for exceptional HCC waiting-list consideration. Their waiting-list prioritization is based on estimating progression risk beyond the Milan criteria (termed dropout), an event for HCC patients considered equivalent to death for non-HCC patients. Although the Milan criteria may be too restrictive, thereby denying deserving patients access to transplantation, high rates of understaging by pretransplantation radiographic imaging and concern for erosion of recurrence-free survival rates have dampened enthusiasm for relaxation of tumor guidelines. The efficacy of pretransplantation locoregional therapies to reduce dropout, downstage patients, and/or decrease posttransplantation recurrence remains to be determined. Genomic, molecular, or clinical criteria to accurately differentiate HCC patients whose disease will recur from those whose disease will not recur would resolve much of the current controversy regarding appropriate criteria for HCC patients to qualify for transplantation.

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    • "It was noted that the dropout rate for T1 tumours in the pre-MELD era was under 10%, which is less than the overall waiting list mortality. This has thus led to elimination of the score upgrading for T1 lesions and a lesser upgrade for T2 lesions [17] [18]. This has not necessarily had an adverse impact on survival, and there has been a significant increase in the number of transplants performed for early HCC in cirrhosis [19] "
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    ABSTRACT: With rising incidence and emergence of effective treatment options, the management of hepatocellular carcinoma (HCC) is a complex multidisciplinary process. There is still little consensus and uniformity about clinicopathological staging systems. Resection and liver transplantation have been the cornerstone of curative surgical treatments with recent emergence of ablative techniques. Improvements in diagnostics, surgical techniques, and postoperative care have lead to dramatically improved results over the years. The most appropriate treatment plan has to be individualised and depends on a variety of patient and tumour-related factors. Very small HCCs discovered on surveillance have the best outcomes. Patients with advanced cirrhosis and tumours within Milan criteria should be offered transplantation. Resection is best for small solitary tumours with preserved liver function. Ablative techniques are suitable for low volume tumours in patients unfit for either resection or transplantation. The role of downstaging and bridging therapy is not clearly established.
    06/2011; 2011:686074. DOI:10.4061/2011/686074
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    ABSTRACT: There are only few malignant tumours where organ transplantation is the treatment of choice. Transplantation can be considered individually in certain lung carcinomas, unresectable heart tumours, cholangiocellular carcinoma and Klatskin tumour. It is acceptable in unresectable chemosensitive hepatoblastoma, epitheloid haemangioendothelioma, liver metastasis of neuroendocrine tumours and as the most common indication, the early hepatocellular carcinoma (HCC) in cirrhotic liver. Results of liver transplantation (LT) for HCC according to Milan criteria as a “gold standard” are excellent. Time of LT has a great influence on the results. While patients are on waiting list, locoregional therapies may help prevent tumour progress. Living donor LT is an acceptable treatment of HCC. The greatest experience with this procedure is in Asia. Despite the favourable results, LT as the treatment of HCC is debated and raises several questions: regarding indication and expectable outcome. Milan criteria seem to answer this questions although they are too strict. The number and size of HCC foci per se is not sufficient predictor of eligibility to transplantation and for prognosis. Majority of the prognostic factors can be evaluated only after transplantation with pathological examination of HCC. Aim of the present research is to find prognostic factors that are characteristic of biological behaviour of HCC, which can be detected before LT in order to select patients who have the greatest benefit from LT. Re-definition of eligibility criteria is an actual question; an international consensus based on additional prospective studies is required for the “new” recommendation. KeywordsBridging therapy–Bronchioloalveolar carcinoma–Des-gamma-carboxy prothrombin–Extended criteria–Heart sarcomas–Hepatocellular carcinoma–Living donor liver transplantation–Liver transplantation–Milan criteria–Proliferation signal inhibitor
    Pathology & Oncology Research 18(1):1-10. · 1.81 Impact Factor
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    ABSTRACT: During the past years, several therapeutic procedures have been proposed as bridging treatments in patients with hepatocellular carcinoma waiting for liver transplantation. Resective surgery, transarterial chemoembolization, radiofrequency thermal ablation and percutaneous ethanol injection are the most experienced, with the aim to decrease the rate of drop-out from LT waiting list, and the risk of HCC recurrence after transplant. Indeed, for patients within the Milan criteria, a time on waiting list exceeding 6-12 months is a known risk factor of tumor progression and drop out. For this reason, the application of bridging treatments in these patients might be reasonable and several studies in recent years have documented their usefulness to control tumor progression before the transplant. However, the favourable impact of these treatments on post-transplant patients' survival is still under investigation and the available studies provide controversial results. Bridging therapies have also been used for the downstaging of tumors exceeding the conventional "Milan criteria". Some recent data regarding multimodal sequential therapies seem to report promising results in terms of overall and disease-free survival of treated patients attaining effective downstaging before transplant.
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