Wait and Transplant for Stage 2 Hepatocellular Carcinoma With Deceased-Donor Liver Grafts

Abstract

The method which donor organs are allocated to individuals on the waiting list for transplant is an important topic for research and debate. In recent years, there has been growing interest in applying the concept of utilitarianism to the organ allocation system, seeking the maximum survival benefit of the patient population as a whole, rather than that of an individual patient (1). Ideally, exceptions points were created to allow hepatocellular carcinoma (HCC) patients a fair access to the donor pool. However, the current allocation Model for End-stage Liver Disease exception points seem to overestimate the risk disease progression and dropout in HCC patients, and the likelihood of undergoing a liver transplantation still remains higher for HCC candidates in the United States (2). Therefore, an intention-to-treat analysis, such as that published in Transplantation by Chan et al. (3), is a promising tool to optimize organ donation in a more fair way. Tumor size has been associated with the risk of metastasis and HCC progression (4). Whether or not the Milan criteria could be extended without increasing waiting list mortality for non-HCC candidates depends on the availability of organs in each specific region. Thus, an optimal selection of the HCC patients for liver transplantation has an upmost importance in regions with a low donation rate. The wait-and-transplant policy proposed by Chan et al. provided almost the same chances of being transplanted for HCC and non-HCC patients, and the survival rates of those who were transplanted were almost the same in both groups (40.4% vs. 37.9%, respectively). However, most of the HCC patients in the waiting list died (n=18) or had to be excluded because of disease progression (7), and at the end of study, only 5 patients remained in conditions of being transplanted. As a matter of a fact, liver transplantation could not be offered in 48.2% (25/52) of the HCC patients. On the other hand, only 26.2% (27/103) of the non-HCC patients died in the waiting list during the same period, so 34.9% (35/103) of the non-HCC patients still had chances of receiving a liver graft when the study was ended. According to the intention-to-treat analysis, all alive and active patients should be considered as having a potential for long-term survival, regardless if they were transplanted or not. Although the outcomes of the patients who were still alive in the waiting list are unpredictable, a significant fraction of them probably will be transplanted in the following months, increasing the transplant patient rate and, consequently, the overall survival in the non-HCC group. We agree that wait-and-transplant policy is an interesting idea to avoid unnecessary liver transplant for patients at great risk of early tumor progression and recurrence, like the HCC candidates beyond the Milan criteria. The scenario of organ shortage increases even more the need to improve patient selection, but it seems to us that a shorter waiting period policy (3 months) could also combine the selection benefits of the 6-month wait-and-transplant policy with a lower dropout and mortality rate on the waiting list. Another argument reinforcing this idea is the fact that HCC patients who underwent living donor liver transplantation in the same study also achieved excellent postoperative survival outcomes despite a medium waiting time to transplant of 8.5 days. Cleber Rosito Pinto Kruel Aljamir D. Chedid Tomaz J.M. Grezzana-Filho Serviço de Cirurgia Digestiva Hospital de Clínicas de Porto Alegre Ramiro Barcelos, Porto Alegre RS, Brazil