Transplantation For Hcc: A National Analysis Of Recipient Selection Criteria

Abstract

Presenter: Mackenzie Morris MD | University of Cincinnati Background: Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy with the Milan criteria being the standard to identify and prioritize patients for liver transplantation (LT). However, many centers in the United States are now performing LT in patients beyond Milan. In this study, we evaluated the outcomes of patients within and outside of Milan at LT as well as the impact of downstaging on outcomes after LT. Methods: The United Network of Organ Sharing (UNOS) database was queried for all patients with a diagnosis of HCC who underwent LT from 2009 to 2019. Pediatric patients and those without tumor-specific data were excluded. Patients were divided into three groups at LT: within Milan criteria (within Milan), within the University of California San Francisco (UCSF) criteria but beyond Milan (beyond Milan, within UCSF), and beyond both Milan and UCSF criteria (beyond UCSF) at the time of LT. Additionally, a subset analysis was performed for patients originally outside Milan, but within Milan or within UCSF at the time of LT. The cause of death variable was used to identify patients who died due to HCC in order to examine cause-specific survival. Results: A total of 16,883 patients (within Milan, n=16,165; beyond Milan, within UCSF, n=535; beyond UCSF, n=183) were identified who met inclusion criteria with a median follow-up of 2.9 (1.0-5.1) years. Kaplan-Meier survival analysis revealed a decreased overall and HCC cause-specific survival in patients within and beyond UCSF compared to those within Milan (p<0.01). In multivariate analysis of overall survival adjusting for recipient and donor specific factors, beyond Milan criteria, AFP > 90 mg/dL, and liver-directed therapy were associated with increased risk of death (Figure - black). In multivariate analysis for HCC cause-specific survival, beyond Milan criteria, AFP >90 mg/dL, and liver-directed therapy were associated with increased risk of death (Figure – grey). Finally, a subset analysis revealed no difference in overall survival in patients who were always within Milan (3-year survival of 82%) compared to those originally outside Milan but downstaged to within Milan (78%) or within UCSF at the time of LT (82%, p=0.44). Conclusion: UCSF criteria have been increasingly proposed to allow for expansion of patients who are able to undergo liver transplantation, but this expansion is not without risk of worse survival. However, patients who are down-staged to within UCSF may have similar Results to those always within Milan or those down-staged to within Milan.