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LIVER ALLOCATION for HCC

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					LIVER ALLOCATION for HCC:

     Where do WE go from here ?

                             Robert A. Fisher MD,FACS




  This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
     are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
1. How much PRIORITY waiting OLT forHCC??




2. Should STAGING criteria change??




3. How should HCC ABLATED pts be staged??

  This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
     are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
MCV/VCU TRX HCC PROTOCOL

    1/98-10/02: Prospect, Neoadjuv, HCC Study
    135HCC/702 pts refer for Trx
    HCC, TNM staged; CX, CTP scored; Met w/up
        MRI,MRA,Ch-CT, Bone Sc-d0, q3m.
    TACE ( Cispl, Doxo,Ethiodol,EmboGoldųmsphere)
    TACI (Cispl, Doxo)--2 wks after TACE,
        routine GCSF prn outpt.
    RFA, Cryo,Etoh, ± reTACE by MRI
    T1,2,3N0M0 , ChB-C CX                                                                  OLTX eval & List

          This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
             are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
                 Patient Survival by Cancer Stage
            1
           0.9
           0.8
           0.7
           0.6
Survival




           0.5
           0.4
           0.3       T1 (n=15)
           0.2       T2 (n=55)
                     T3 (n=25)
           0.1
                     T4 (n=35)
            0
                 0        6                   12                    18                    24                    30                    36                 42   48
                                                                                     Months


                      This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
                         are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
MCV/VCU TRX HCC PROTOCOL

                                                     Stage HCC
                                               Stage Liver Reserve
                                            (Mets, +LN, >5cm+vasc inv)
                                                     non oper


Control HCC Await OLTX Destroy (40%) Sync L HCC                                                               Screen for X L Mets
   TACE, ETOH,RFA         TACI (doxo + cispl)                                                                 Q 3m X L, L Screen
        This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
           are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
MCV/VCU TRX HCC PROTOCOL
   I : HCC                 TACE                         Resect                           TACI                            F-up(6)
   II: HCC                 TACE + Ablate                                                 TACI                             F-up(3)
   III: HCC(Cx)                                 TACE + Ablate                                                      TACI
    List (30)                       OLTX (25)                                             F-up
   IV: HCC(Cx)                                   TACE + Ablate                                                      TACI
    F-up(63)
   V: HCC (advan dz, xL mets, med morb.)
    hospice(16)
   I: Incidental HCC Post Trx. On Explant (12)

          This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
             are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
                          Ablative Procedures
          35




11                                                                                                                Chemoembolization
                                                                                                                  Chemoinfusion
3                                                                                          96                     Cryotherapy
                                                                                                                  Etoh Ablation
                                                                                                                  Radiofrequency Ablation




                                                                                       Total 212
     67




          This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
             are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
     Complications of Ablative Procedures
                              1            1            3
                                                                    2
                                                                                                                   Anorexia
15                                                                                5                                Cough
                                                                                                                   Death
                                                                                                                   Fever
                                                                                                                   GCSF for low WBC
                                                                                             6
                                                                                                                   Hiccups
                                                                                                                   Malaise
                                                                                            1
                                                                                                                   Nausea
                                                                                        3                          Other
                                                                                                                   Pain
                                                                                                                   Pneumothorax
      17                                                                  7




     This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
        are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
MCV/VCU TRX HCC PROTOCOL

   Intent to treat: 1/98-10/02: 35 pts ablated & listed.
            25 pts transplanted: 34m mean f/up, all alive,
               1recur(30m), 7m mean waite t., 2.6abl proced/pt.
            5 pts (14%), delisted(m)—5,5,5,8,14(3dead: 2,HCC;
               1,2ºablation).


   Ablated HCC, OLTX(clin 3), explant path:
            Stage: T1(6), T2(14), T3(2), T4a(3). 16%<staged preop.
            Histo: 22% complete HCC necr., 32HCC’s/25explants,
                   56% microVasc invasion, 92%G2-3,
                   87.5%<10mitoses/HPF

   Incidental HCC, OLTX(clin 3), explant path: 1/98-10/02:
            12/255t(4.7%) pts transplanted: 32m mean f/up, all alive,
                    0 recur, 13m mean waite t., mean CTP 10pts.
             Stage: T1(4), T2(7), T4a(1).
      This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
         are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
                     Patient Survival by Clinical Class
            1
           0.9
           0.8
           0.7
           0.6
Survival




           0.5
           0.4
           0.3
           0.2
           0.1
            0
                 0          6                   12                    18                    24                   30                    36                   42   48
                                                                                       Months
                 Class 1 (n=6)                                       Class 2 (n=3)                                                 Class 3 (n=30) + I (n=12)
                 Class 4 (n=63)                                      Class 5 (n=16)

                         This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
                            are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
Time to XL Mets from Dx: Ablated HCC/CX, No OLTX



   T1 (5): No XL mets

   T2 (42): 5 pts, 19-637d (mean 278d (9m)),med 7m.

   T3 (20): 7 pts, 42-1091d (mean 308d (10m)),med 4m.



   Kamada K etal. Am J Surg 2002; 184 : “TACE vs TACE+PEI for
        T1, T2 HCC & Ch A,B CX.
        32 pts, TACE+PEI:
           Survival: 1yr(90%); 3yr(65%); 5yr(50%)
           Recur: 1yr(42%); 3yr(69%); 5yr(84%)
           Death: 8% hep fail, 92% HCC related


      This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
         are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.
CONCLUSIONS: (with curative intent)




   T2 HCC (CX) should get MELD(24) priority to be
    transplanted within 6m.

   T1 HCC + Ch B-C CX should get MELD(20) priority
    to be transplanted within 6-12m.

   T3, T4a HCC (CX), ABLATED, + NO nodes & NO
    macrovasc invasion on RARE MRI should get
    MELD(24) priority to be transplanted within 6m.

     This presentation is reproduced on this site with the permission of the author(s). All opinions, research citations and analyses
        are those of the author(s) and may not reflect those of OPTN/UNOS committees or the OPTN/UNOS Board of Directors.

				
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posted:3/25/2011
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