Abstract：
OBJECTIVE: To maximize utility and prevent premature liver transplantation (LT), a delayed LT strategy (DS) was adopted in France in 2015 in patients listed for any single HCC treated with resection or thermal ablation during the waiting phase. The DS involves postponing LT until recurrence. The purpose of this study was to evaluate the DS to make sure that it did not hamper pre- and post-LT outcomes.
METHODS: Patients listed for HCC in France between 2015 and 2018 were studied. After data extraction from the national LT database, 2,025 patients were identified and classified according to six groups: single tumor entering DS, single tumor not entering DS, multiple tumors, no curative treatment, untreatable HCC or T1 tumors. Kaplan-Meier estimates of the 18-month risk of dropout for death, too sick to be transplanted or tumor progression before LT, 5-year post-LT HCC recurrence and post-LT survival rates were compared.
RESULTS: Median waiting-time in the DS group was 910 days. Pre-LT dropout probability was significantly lower in the DS group compared to other groups (13% vs. 19%, p = 0.0043) and significantly higher in the T1 group (25.4%, p = 0.05). Post-LT HCC recurrence rate in the multiple nodules group was significantly higher (19.6%, p = 0.019), while 5-year post-LT survival did not differ among groups and was 74% in the DS group (p = 0.22).
CONCLUSIONS: The DELTA-HCC study shows that DS does not negatively impact either pre- nor post-LT patient outcomes, and has the potential to allow for redistribution of organs to patients in more urgent need of LT. It can reasonably be proposed and pursued. The unexpectedly high risk of dropout in T1 patients seems related to the MELD-based offering rules underserving this subgroup.
UNASSIGNED: To maximize utility and prevent premature liver transplantation (LT), a delayed LT strategy was adopted in France in 2015. It involves postponing LT until recurrence in patients listed for any single HCC curatively treated by surgical resection or thermal ablation. The DELTA-HCC study was conducted to evaluate this nationwide strategy. It shows in a European LT program that delayed strategy does not negatively impact pre- nor post-LT patient outcomes and is relevant to up to 20% of LT candidates; thus, it could potentially enable the redistribution of organs to patients in more urgent need of LT. Such a delayed strategy can reasonably be pursued and extended to other LT programs. Of note, an unexpectedly high risk of dropout in T1 patients, seemingly related to MELD-based offering rules which underserve these patients, calls for further scrutinization and revision of allocation rules in this subgroup.
METHODS: Patients listed for HCC in France between 2015 and 2018 were studied. After data extraction from the national LT database, 2,025 patients were identified and classified according to six groups: single tumor entering DS, single tumor not entering DS, multiple tumors, no curative treatment, untreatable HCC or T1 tumors. Kaplan-Meier estimates of the 18-month risk of dropout for death, too sick to be transplanted or tumor progression before LT, 5-year post-LT HCC recurrence and post-LT survival rates were compared.
RESULTS: Median waiting-time in the DS group was 910 days. Pre-LT dropout probability was significantly lower in the DS group compared to other groups (13% vs. 19%, p = 0.0043) and significantly higher in the T1 group (25.4%, p = 0.05). Post-LT HCC recurrence rate in the multiple nodules group was significantly higher (19.6%, p = 0.019), while 5-year post-LT survival did not differ among groups and was 74% in the DS group (p = 0.22).
CONCLUSIONS: The DELTA-HCC study shows that DS does not negatively impact either pre- nor post-LT patient outcomes, and has the potential to allow for redistribution of organs to patients in more urgent need of LT. It can reasonably be proposed and pursued. The unexpectedly high risk of dropout in T1 patients seems related to the MELD-based offering rules underserving this subgroup.
UNASSIGNED: To maximize utility and prevent premature liver transplantation (LT), a delayed LT strategy was adopted in France in 2015. It involves postponing LT until recurrence in patients listed for any single HCC curatively treated by surgical resection or thermal ablation. The DELTA-HCC study was conducted to evaluate this nationwide strategy. It shows in a European LT program that delayed strategy does not negatively impact pre- nor post-LT patient outcomes and is relevant to up to 20% of LT candidates; thus, it could potentially enable the redistribution of organs to patients in more urgent need of LT. Such a delayed strategy can reasonably be pursued and extended to other LT programs. Of note, an unexpectedly high risk of dropout in T1 patients, seemingly related to MELD-based offering rules which underserve these patients, calls for further scrutinization and revision of allocation rules in this subgroup.
摘要：
背景：为了最大限度地发挥效用并防止过早的肝移植（LT），2015年，法国在等待期接受切除或热消融治疗的任何单个HCC患者中采用了延迟LT策略（DS），推迟LT直到复发。这项研究的目的是评估DS，以确保其不会妨碍DS患者的LT前后结局。
方法：研究了2015年至2018年在法国列出的HCC患者。从国家LT数据库中提取数据后，2,025例患者根据6组进行了鉴定和分类：单个肿瘤进入DS，单个肿瘤未进入DS，多发性肿瘤,没有治愈性治疗，无法治疗的HCC或T1肿瘤。18个月的Kaplan-Meier估计因死亡而辍学，在LT之前病得太重，无法移植或肿瘤进展，比较5年LT后HCC复发和LT后生存率。
结果：DS组的平均等待时间为910天。与其他组相比，DS的LT前退出概率显着降低（13％vs19％，p=0.0043），并且在T1组中明显更高（25.4％，p=0.05)。多结节组的LT术后HCC复发率明显较高（19.6%，p=0.019），LT后5年生存率在DS组为74％（p=0.22）。
结论：DELTAHCC研究表明，DS不会对LT前后患者的预后产生负面影响，并有可能将器官重新分配给更迫切需要LT的患者。可以合理地提出和追求。T1患者意外的高辍学风险似乎与基于MELD的驾驶规则不足，呼吁修改分配规则。
■为了最大限度地发挥效用并防止过早的肝移植（LT），法国于2015年采用了延迟LT策略（DS）。它包括推迟LT，直到通过手术切除或热消融治疗的任何单个HCC患者复发。DELTAHCC研究旨在评估这一全国性策略。它显示在一个非美国，欧洲LT计划，DS：-不会对LT患者前后结局产生负面影响，-涉及多达20％的LT候选人-因此有可能将器官重新分配给更迫切需要LT的患者。可以合理地采用这种延迟策略并将其扩展到其他LT计划。值得注意的是，T1患者出现意外的高脱落风险，似乎与基于MELD的提供规则有关，这些规则对这些患者的服务不足，要求进一步审查和修订此子组中的分配规则。
方法：研究了2015年至2018年在法国列出的HCC患者。从国家LT数据库中提取数据后，2,025例患者根据6组进行了鉴定和分类：单个肿瘤进入DS，单个肿瘤未进入DS，多发性肿瘤,没有治愈性治疗，无法治疗的HCC或T1肿瘤。18个月的Kaplan-Meier估计因死亡而辍学，在LT之前病得太重，无法移植或肿瘤进展，比较5年LT后HCC复发和LT后生存率。
结果：DS组的平均等待时间为910天。与其他组相比，DS的LT前退出概率显着降低（13％vs19％，p=0.0043），并且在T1组中明显更高（25.4％，p=0.05)。多结节组的LT术后HCC复发率明显较高（19.6%，p=0.019），LT后5年生存率在DS组为74％（p=0.22）。
结论：DELTAHCC研究表明，DS不会对LT前后患者的预后产生负面影响，并有可能将器官重新分配给更迫切需要LT的患者。可以合理地提出和追求。T1患者意外的高辍学风险似乎与基于MELD的驾驶规则不足，呼吁修改分配规则。
■为了最大限度地发挥效用并防止过早的肝移植（LT），法国于2015年采用了延迟LT策略（DS）。它包括推迟LT，直到通过手术切除或热消融治疗的任何单个HCC患者复发。DELTAHCC研究旨在评估这一全国性策略。它显示在一个非美国，欧洲LT计划，DS：-不会对LT患者前后结局产生负面影响，-涉及多达20％的LT候选人-因此有可能将器官重新分配给更迫切需要LT的患者。可以合理地采用这种延迟策略并将其扩展到其他LT计划。值得注意的是，T1患者出现意外的高脱落风险，似乎与基于MELD的提供规则有关，这些规则对这些患者的服务不足，要求进一步审查和修订此子组中的分配规则。
