"Too many patients have a so-called curative resection for hepatocellular cancer, but the recurrence rate at three years is around 60%," said Dr. Jan Paul Lerut of the University of Louvain in Brussels in email to Reuters Health. "Most resected patients would have been cured for the long term by LDLT."
As reported in JAMA Surgery, Dr. Lerut and colleagues did an intention-to-treat analysis of data on 3,052 HCC patients on waiting lists for a primary transplant at 12 centers in Europe, Asia and the U.S. The median age at first referral was 58 and 80% were men. Roughly one-third of the patients had a potential LDLT; the others were waiting for deceased donor liver transplants (DDLT).
An additional single-center cohort from Toronto included 906 patients with similar demographics, with roughly one in four patients having a potential LDLT.
LDLT candidates more often had disease that exceeded the Milan criteria for liver transplant candidacy.
Intention-to-treat death was defined as a patient death that occurred for any reason and was calculated from the time of waiting list inscription to the last follow-up date (December 31, 2019). The overall median follow-up was 3.3 years.
The average wait for DDLT was six months. During that time, nearly 15% of patients dropped out as a result of death on the waiting list, tumor progression, or other factors. The average wait for LDLT was one month; no patients dropped out because of tumor progression or death. Roughly 8% of LDLT candidates moved to the DDLT waiting list because of the availability of a deceased donor or insufficient liver volume in the live donor.
Excluding the Toronto patients, after an inverse probability of treatment weighting (IPTW) analysis, the 5- and 10-year intention-to-treat survival rates were 79% and 64%, respectively, in LDLT group and 72% and 49%, respectively, in the DDLT group. The pattern was similar in the Toronto cohort.
LDLT reduced the risk of overall death by 33% in the post-IPTW analysis; in the Toronto cohort, LDLT reduced the overall mortality risk by 48% in the post-IPTW analysis.
During the follow-up period, HCC recurrence rates were similar in LDLT and DDLT recipients.
Dr. David Gerber of the University of North Carolina at Chapel Hill, coauthor of a related editorial, commented in an email to Reuters Health, "LDLT is a way to expand the (donor) pool, but it needs to be done in a way that we can identify patients who are at very high risk of recurrent cancer, as they would be poor candidates for transplant of either type."
Dr. Antonio Di Carlo, Chief of Abdominal Organ Transplant Surgery at the Lewis Katz School of Medicine at Temple University, and Surgical Director of Kidney, Liver and Pancreas Transplantation, and Living Donation at Temple University Hospital in Philadelphia also commented by email.
"The largest concern is the omitted impact on living donors, who are healthy humans that do not need to undergo extensive liver surgery," he said. "The reality is that even in the U.S., we will increase the amount of living donor liver transplants in the next few years. However, we cannot simply evaluate the benefit of living donation liver transplant without assessing the impact on the living human donors. This study fails to consider the donors when describing the outcomes of the recipients."
"The selection of living donors and recipients must be done responsibly," he continued. "Moreover, in an era of increasing technology, it behooves us to expand the 'deceased organ donor pool' so as not to put undue pressure on healthy humans."
"There now exists the technology to 'condition' livers from deceased donors that were previously discarded," he added. "A more innovative and current study would measure outcomes in comparison to this organ pool."
SOURCE: https://bit.ly/36UGqy8 and https://bit.ly/3hVsE4p JAMA Surgery, online July 14, 2021.
By Marilynn Larkin
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