Transplant surgery lecture addresses over-prioritization of HCC patients

Issue: December 25, 2012

BOSTON — Elizabeth A. Pomfret, MD, PhD, discussed the prioritization of patients with hepatocellular carcinoma for liver transplantation during a lecture at The Liver Meeting.

Pomfret, who gave the Thomas E. Starzl Transplant Surgery State-of-the-Art Lecture here, is chair of the department of Transplantation at the Lahey Clinic and Professor of Surgery at . She also serves as treasurer of the International Liver Transplant Society, and on the United Network for Organ Sharing (UNOS) Board of Directors, and previously served as chair of the UNOS Liver and Intestine Committee.

Pomfret acknowledged liver transplantation as the only treatment that can potentially cure both the cancer and the underlying liver disease in patients with hepatocellular carcinoma (HCC). “The outcomes for HCC are outstanding; so good that, in fact, it’s led to a number of different issues and controversies,” she said. “... There are ethical dilemmas that lie with it. Is it the optimal therapy in all cases? I would argue no. Is liver transplantation the best use of scarce resources for all patients with HCC? I would argue no.”

Patients with HCC are often given priority for transplantation, Pomfret said, when surgical resection can serve as well or even better in some cases, such as for patients with normal remnant liver parenchyma, Child’s A cirrhosis, no portal hypertension or varices, a single tumor, or HBV infection as opposed to HCV.

“We know that, if you have normal liver parenchyma, it’s demonstrated that surgical resection is the gold standard for HCC,” Pomfret said. “I would argue that, in Child’s A cirrhotics, it’s really a better utilization of scarce, limited organs to do a surgical resection followed by a salvage transplant if the patient recurs.”

Although patients with T1 tumors have not received transplantation priority since Jan. 2004, and MELD scores for T2 tumors have dropped from 29 to 22, Pomfret said that patients with these tumors are still overprioritized compared to patients without HCC, and that non-HCC patients are more likely to die and less likely to receive transplant. She suggested that factors such as tumor size and number, which impact a patient’s likelihood of survival, should be taken into consideration along with other objective risk factors and the patient’s MELD score, when considering transplantation – while also not favoring aggressive tumors that are likely to recur. However, she acknowledged that changes to the allocation process are likely to happen over time. “One of the first things you learn being the chair of the UNOS Liver and Intestine Committee is that nobody likes sweeping changes, and allocation changes are all about baby steps,” she said.

Pomfret also discussed the ethical considerations inherent in live-donor liver transplantation during her lecture. She stated that, even in areas such as the or , with greater access to deceased-donor organs, live-donor transplantation is still a viable option due to organ shortage, as long as the risk to the donor is justified by the anticipated benefit for the recipient.

“HCC within the confines of the Milan Criteria is certainly an appropriate indication for utilizing living-donor grafts,” Pomfret said. “Unlike deceased-owner transplantation, live-donor transplantation is governed by utility concerns … and not by equality and justice. You could even say that for every living donor that occurs, it benefits everybody on the waiting list, because it removes one more person off the list who would otherwise have taken an organ out of the pool.”