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• W2972002672 abstract "Allocation of liver grafts worldwide – Is there a best system?Journal of HepatologyVol. 71Issue 4PreviewLiver transplantation (LT) has been undoubtedly one of the most successful procedures developed in the late 20th century, and as a consequence allocation of scarce liver grafts has caused many controversies (Figs. 1, 2).1 In the early stages of the procedure, from the 1980s until the mid-1990s, liver grafts were prioritized in the USA based on the degree of sickness and localization of the patients in the hospital.2 For example, candidates admitted to an intensive care unit (ICU) received the highest priority, ahead of patients hospitalized in a non-ICU setting and outpatients, somewhat independently of their accumulated waiting time. Full-Text PDF Reply to: “Canadian liver transplant allocation for hepatocellular carcinoma”Journal of HepatologyVol. 71Issue 5PreviewWe read with interest the letter by Congly et al. regarding our original article,1 and thank the authors for providing further details on allocation of liver grafts in Canada, including the total number of adult transplants performed in 2017, as well as donation after cardiac death rates and living liver donations. Their comments fit well with the spirit of our worldwide initiative to stimulate a conversation with the aim of arriving at a consensus on the allocation of deceased liver grafts for malignant and non-malignant diseases. Full-Text PDF We read with great interest the recent review by Tschuor et al.[1]Tschuor C. Ferrarese A. Kümmerli C. Dutkowski P. Burra P. Clavien P.-A. et al.Allocation of liver grafts worldwide is there a best system?.J Hepatol. 2019; 71: 707-718https://doi.org/10.1016/j.jhep.2019.05.025Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar reviewing the allocation policies of liver grafts worldwide. The authors should be congratulated on their hard work on this very important document. However, the description of allocation policies for liver cancer in liver transplantation in Canada and the number of liver transplants performed are not completely accurate and as such, we would like to clarify the details. In Canada, there are 7 transplant programs in 5 different provinces each based out of university institutions: University of British Columbia (Vancouver, British Columbia), University of Alberta (Edmonton, Alberta), Western University (London, Ontario), University of Toronto (Toronto, Ontario), McGill University (Montreal Quebec), Université de Montréal (Montreal, Quebec) and Dalhousie University (Halifax, Nova Scotia). In 2017, 530 adult liver transplants were performed in Canada; 53 (10%) coming from donors after cardiac death and 43 coming from living donors, corresponding to a rate of 14.5 donors/million population;[2]Canadian Organ Replacement Register. e-Statistics on Organ Transplants, Waiting Lists and Donors 2017 2018.Google Scholar these are significantly higher than reported in Table 1 of their manuscript.[1]Tschuor C. Ferrarese A. Kümmerli C. Dutkowski P. Burra P. Clavien P.-A. et al.Allocation of liver grafts worldwide is there a best system?.J Hepatol. 2019; 71: 707-718https://doi.org/10.1016/j.jhep.2019.05.025Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Each province has a slightly different policy for listing patients with liver cancer and the award of exception points, which include using Milan,[3]Mazzaferro V. Regalia E. Doci R. Andreola S. Pulvirenti A. Bozzetti F. et al.Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis.N Engl J Med. 1996; 334: 693-699https://doi.org/10.1056/NEJM199603143341104Crossref PubMed Scopus (5647) Google Scholar total tumour volume and alpha-fetoprotein,[4]Toso C. Trotter J. Wei A. Bigam D.L. Shah S. Lancaster J. et al.Total tumor volume predicts risk of recurrence following liver transplantation in patients with hepatocellular carcinoma.Liver Transpl. 2008; 14: 1107-1115https://doi.org/10.1002/lt.21484Crossref PubMed Scopus (190) Google Scholar USCF[5]Yao F.Y. Ferrell L. Bass N.M. Watson J.J. Bacchetti P. Venook A. et al.Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival.Hepatology. 2001; 33: 1394-1403https://doi.org/10.1053/jhep.2001.24563Crossref PubMed Scopus (1760) Google Scholar and placing a cap on the maximum points awarded. All programs permit downstaging of HCC. We summarize the Canadian policies below (Table 1).Table 1Canadian Criteria for HCC listing and exception points.ProvinceListing criteriaCriteria for exception pointsException points awardedDownstagingDelisting criteriaCap on exception pointsBritish ColumbiaMilan criteriaLesion >2 cmStart at 15, increase by 3 points every 3 monthsAcceptable if in Milan criteria before listingExceeds UCSF criteria or TTVORExtrahepatic spreadORVascular invasionYes30AlbertaTTV <115 cm3 ANDAFP <400 ng/mlLesion >2 cmORMultiple lesionsORRecurrence of lesion after ablationNatural MELD-Na for 6 months, then 26 points; increase by 2 points every 3 monthsAcceptable if TTV <250 cm3 and AFP ≤400 ng/ml for 6 monthsTTV >115 cm3ORAFP >400 ng/mlORExtrahepatic spreadORVascular invasionNoOntarioTTV <145 cm3 ANDAFP <1,000 ng/mlLesion >2 cmORMultiple lesions >1 cmORRecurrence of lesion after ablationStart at 22, increase by 3 points every 3 monthsAcceptable if TTV <145 cm3 andAFP <1,000 ng/ml for 3 monthsTTV >145 cm3ORAFP >1,000 ng/mlORExtrahepatic spreadORVascular invasionNoQuebecMilan criteriaORTTV ≤115 cm3ANDAFP ≤400 ng/mlIf ≥1 tumour >2 cm, 16–25 points depending on HCC characteristics[6]Bhat M. Ghali P. Dupont B. Hilzenrat R. Tazari M. Roy A. et al.Proposal of a novel MELD exception point system for hepatocellular carcinoma based on tumor characteristics and dynamics.J Hepatol. 2017; 66: 374-381https://doi.org/10.1016/j.jhep.2016.10.008Abstract Full Text Full Text PDF PubMed Scopus (19) Google ScholarOR25 points if TTV ≤115 cm3 and AFP ≤400 ng/mlAcceptable if in Milan criteria before listingTTP >115 cm3ORAFP >400 ng/mlORExtrahepatic spreadORVascular invasionNoNova ScotiaTTV <115 cm3 ANDAFP <400 ng/mlLesion >2 cmORMultiple lesionsNatural MELD-NaORAssign 22 pointsAcceptable if TTV <250 cm3 and AFP <400 ng/ml for 3 monthsTTV >115 cm3ORAFP >400 ng/mlORExtrahepatic spreadORVascular invasionORECOG performance score >3[7]Oken M.M. Creech R.H. Tormey D.C. Horton J. Davis T.E. McFadden E.T. et al.Toxicity and response criteria of the Eastern Cooperative Oncology Group.Am J Clin Oncol. 1982; 5: 649-655Crossref PubMed Scopus (8221) Google ScholarNoMilan[3]Mazzaferro V. Regalia E. Doci R. Andreola S. Pulvirenti A. Bozzetti F. et al.Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis.N Engl J Med. 1996; 334: 693-699https://doi.org/10.1056/NEJM199603143341104Crossref PubMed Scopus (5647) Google Scholar = 1 tumour <5 cm or 3 tumours <3 cm.UCSF[5]Yao F.Y. Ferrell L. Bass N.M. Watson J.J. Bacchetti P. Venook A. et al.Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival.Hepatology. 2001; 33: 1394-1403https://doi.org/10.1053/jhep.2001.24563Crossref PubMed Scopus (1760) Google Scholar = Maximum tumour size <6.5 cm, maximum of 3 total tumors with none >4.5 cm, and cumulative tumor size <8 cm).ECOG >3[7]Oken M.M. Creech R.H. Tormey D.C. Horton J. Davis T.E. McFadden E.T. et al.Toxicity and response criteria of the Eastern Cooperative Oncology Group.Am J Clin Oncol. 1982; 5: 649-655Crossref PubMed Scopus (8221) Google Scholar = Completely disabled; cannot carry on any selfcare; totally confined to bed or chair.AFP, alpha-fetoprotein; ECOG, Eastern Cooperative Oncology Group; MELD, model for end-stage liver disease; TTV, total tumor volume; UCSF, University of California, San Francisco. Open table in a new tab Milan[3]Mazzaferro V. Regalia E. Doci R. Andreola S. Pulvirenti A. Bozzetti F. et al.Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis.N Engl J Med. 1996; 334: 693-699https://doi.org/10.1056/NEJM199603143341104Crossref PubMed Scopus (5647) Google Scholar = 1 tumour <5 cm or 3 tumours <3 cm. UCSF[5]Yao F.Y. Ferrell L. Bass N.M. Watson J.J. Bacchetti P. Venook A. et al.Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival.Hepatology. 2001; 33: 1394-1403https://doi.org/10.1053/jhep.2001.24563Crossref PubMed Scopus (1760) Google Scholar = Maximum tumour size <6.5 cm, maximum of 3 total tumors with none >4.5 cm, and cumulative tumor size <8 cm). ECOG >3[7]Oken M.M. Creech R.H. Tormey D.C. Horton J. Davis T.E. McFadden E.T. et al.Toxicity and response criteria of the Eastern Cooperative Oncology Group.Am J Clin Oncol. 1982; 5: 649-655Crossref PubMed Scopus (8221) Google Scholar = Completely disabled; cannot carry on any selfcare; totally confined to bed or chair. AFP, alpha-fetoprotein; ECOG, Eastern Cooperative Oncology Group; MELD, model for end-stage liver disease; TTV, total tumor volume; UCSF, University of California, San Francisco. We agree with the authors that unfortunately there is significant regional heterogeneity in listing criteria for HCC in Canada, although there are generally more similarities than differences. Work is being carried out to establish a national consensus for allocation criteria nationwide, which should include regular evaluation of the impact of the exception points awarded and criteria used. We support this initiative to try and help ensure more equitable care for patients throughout Canada. The authors received no financial support to produce this manuscript. The authors declare no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details. Letter concept and design (Brahmania, Burak, Congly); Acquisition and analysis of data (Brahmania, Marquez, Bhat, Marleau, Wong, Peletekian, Congly); Drafting of the manuscript (Brahmania, Kneteman, Wong, Congly). The following are the Supplementary data to this article: Download .pdf (.31 MB) Help with pdf files Supplementary Data 1" @default.
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