1 Multi-organ transplant program, University Health Network, University of Toronto.
2 Department of General Surgery, University of Toronto, Canada.
3 Joint Department of Imaging, Division of Interventional Radiology, University Health Network, University of Toronto, Canada.
4 Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada.
5 Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Canada.
There is a lack of information about survival after dropout from the liver transplant waiting list. Therefore, we aimed to assess the overall survival, and risk factors for death, after waiting list dropout due to hepatocellular carcinoma (HCC) progression.
We assessed patients who dropped out of the liver transplant waiting list between 2000 to 2016 in a single, large academic North-American center. Patients were divided into 3 groups according to the type(s) of HCC progression: locally advanced disease (LAD), extrahepatic disease (EHD), and macrovascular invasion (MVI). The primary outcome was overall survival. Survival was assessed by the Kaplan-Meier method. Predictors of death after dropout were assessed by multivariable Cox regression.
During the study period, 172 patients dropped out due to HCC progression. Of those, 37 (21.5%), 74 (43%) and 61 (35.5%) dropped out due to LAD, EHD and MVI, respectively. Median survival according to cause of dropout (LAD, EHD or MVI) was 1.0, 4.4 and 3.3 months, respectively (P = .01). MELD score [HR = 1.04, 95%CI, 1.01-1.08)], alcoholic liver disease [HR = 1.66 (95%CI 1.02-2.71), and alpha fetoprotein >1000 ng/mL [HR = 1.86 (95%CI 1.22-2.84)] were predictors of mortality after dropout. Dropout due to EHD [HR = 0.61 (95%CI 0.38-0.98)] and undergoing treatment after dropout were protective factors [0.32 95%CI 0.21-0.48)] for death.
Patient prognosis after dropout is dismal. However, a subgroup of patients may have longer survival. The present study identifies the patterns of waitlist dropout in patients with HCC and provides evidence for the effectiveness of treatment strategies offered to HCC patients after dropout.