TY - JOUR
T1 - UNOS Down-Staging Criteria for Liver Transplantation of Hepatocellular Carcinoma
T2 - Systematic Review and Meta-Analysis of 25 Studies
AU - Tan, Darren Jun Hao
AU - Lim, Wen Hui
AU - Yong, Jie Ning
AU - Ng, Cheng Han
AU - Muthiah, Mark D.
AU - Tan, Eunice X.
AU - Xiao, Jieling
AU - Lim, Snow Yunni
AU - Pin Tang, Ansel Shao
AU - Pan, Xin Hui
AU - Kabir, Tousif
AU - Bonney, Glenn K.
AU - Sundar, Raghav
AU - Syn, Nicholas
AU - Kim, Beom Kyung
AU - Dan, Yock Young
AU - Noureddin, Mazen
AU - Loomba, Rohit
AU - Huang, Daniel Q.
N1 - Funding Information:
Darren Jun Hao Tan (Conceptualization: Lead; Data curation: Lead; Formal analysis: Lead; Writing – original draft: Lead; Writing – review & editing: Lead), Wen Hui Lim (Data curation: Lead; Validation: Lead; Writing – review & editing: Lead), Jie Ning Yong (Data curation: Lead; Formal analysis: Lead; Writing – original draft: Lead; Writing – review & editing: Lead), Cheng Han Ng (Conceptualization: Lead; Data curation: Lead; Formal analysis: Lead; Writing – original draft: Lead; Writing – review & editing: Lead), Mark D. Muthiah (Supervision: Lead; Writing – review & editing: Lead), Eunice X. Tan (Writing – review & editing: Lead), Jieling Xiao (Data curation: Lead; Validation: Lead; Writing – review & editing: Lead), Snow Yunni Lim (Data curation: Lead; Validation: Lead; Writing – review & editing: Lead), Ansel Shao Pin Tang (Data curation: Lead; Validation: Lead; Writing – review & editing: Lead), Xin Hui Pan (Data curation: Lead; Validation: Lead; Writing – review & editing: Lead), Tousif Kabir (Writing – review & editing: Lead), Glenn K. Bonney (Writing – review & editing: Lead), Raghav Sundar (Writing – review & editing: Lead), Nicholas Syn (Formal analysis: Lead; Writing – review & editing: Lead), Beom Kyung Kim (Writing – review & editing: Lead), Yock Young Dan (Writing – review & editing: Lead), Mazen Noureddin (Writing – review & editing: Lead), Rohit Loomba (Supervision: Lead; Writing – review & editing: Lead), Daniel Huang, MBBS, MRCP (Conceptualization: Lead; Supervision: Lead; Writing – original draft: Lead; Writing – review & editing: Lead)
Publisher Copyright:
© 2023 AGA Institute
PY - 2023/6
Y1 - 2023/6
N2 - BACKGROUND & AIMS: Down-staging is commonly used to select patients with hepatocellular carcinoma (HCC) beyond Milan criteria (MC) for liver transplantation (LT), but outcomes are heterogenous. We aimed to estimate pooled down-staging success rates, HCC recurrence, and overall survival (OS), stratified by criteria used for baseline tumor burden.METHODS: We searched Pubmed and EMBASE databases from inception until August 2021 for studies reporting down-staging success (reduction of tumor burden to within MC) and outcomes of adult HCC patients. In addition, we performed a pooled analysis using reconstructed individual participant data to obtain robust estimates for OS.RESULTS: We screened 1059 articles and included 25 articles involving 3997 patients. Overall, 55.16% (45.49%-64.46%) underwent successful down-staging, and 31.52% (24.03%-40.11%) received LT (by intention-to-treat analysis [ITT]). Among patients who received LT, 16.01% (11.80%-21.37%) developed HCC recurrence. Comparing studies that used the United Network for Organ Sharing Down-Staging (UNOS-DS) criteria versus studies beyond UNOS-DS or did not specify criteria, down-staging success (by ITT) was 83.21% versus 45.93%, P < .001; the proportion who received LT (by ITT) was 48.61% vs 28.60%, P = .030; and HCC recurrence (among patients who received LT) occurred in 9.06% versus 20.42%, P < .001. Among studies that used UNOS-DS criteria, ITT 1- and 5-year OS from the initiation of down-staging treatment was 86% and 58%, respectively, whereas 1- and 5-year post-LT OS was 94% and 74%, respectively.CONCLUSIONS: Among studies that adhered to UNOS-DS criteria, down-staging was successful in four-fifths of patients, >50% received LT, and post-LT outcomes were excellent. These data provide clinical validation for the utilization of UNOS-DS criteria.
AB - BACKGROUND & AIMS: Down-staging is commonly used to select patients with hepatocellular carcinoma (HCC) beyond Milan criteria (MC) for liver transplantation (LT), but outcomes are heterogenous. We aimed to estimate pooled down-staging success rates, HCC recurrence, and overall survival (OS), stratified by criteria used for baseline tumor burden.METHODS: We searched Pubmed and EMBASE databases from inception until August 2021 for studies reporting down-staging success (reduction of tumor burden to within MC) and outcomes of adult HCC patients. In addition, we performed a pooled analysis using reconstructed individual participant data to obtain robust estimates for OS.RESULTS: We screened 1059 articles and included 25 articles involving 3997 patients. Overall, 55.16% (45.49%-64.46%) underwent successful down-staging, and 31.52% (24.03%-40.11%) received LT (by intention-to-treat analysis [ITT]). Among patients who received LT, 16.01% (11.80%-21.37%) developed HCC recurrence. Comparing studies that used the United Network for Organ Sharing Down-Staging (UNOS-DS) criteria versus studies beyond UNOS-DS or did not specify criteria, down-staging success (by ITT) was 83.21% versus 45.93%, P < .001; the proportion who received LT (by ITT) was 48.61% vs 28.60%, P = .030; and HCC recurrence (among patients who received LT) occurred in 9.06% versus 20.42%, P < .001. Among studies that used UNOS-DS criteria, ITT 1- and 5-year OS from the initiation of down-staging treatment was 86% and 58%, respectively, whereas 1- and 5-year post-LT OS was 94% and 74%, respectively.CONCLUSIONS: Among studies that adhered to UNOS-DS criteria, down-staging was successful in four-fifths of patients, >50% received LT, and post-LT outcomes were excellent. These data provide clinical validation for the utilization of UNOS-DS criteria.
KW - Down-Staging
KW - Hepatocellular Carcinoma
KW - Liver Transplantation
KW - Liver Neoplasms/pathology
KW - Carcinoma, Hepatocellular/pathology
KW - Humans
KW - Adult
KW - Treatment Outcome
KW - Retrospective Studies
KW - Liver Transplantation/adverse effects
KW - Neoplasm Staging
KW - Neoplasm Recurrence, Local/pathology
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U2 - 10.1016/j.cgh.2022.02.018
DO - 10.1016/j.cgh.2022.02.018
M3 - Review article
C2 - 35181565
AN - SCOPUS:85127020959
SN - 1542-3565
VL - 21
SP - 1475
EP - 1484
JO - Clinical Gastroenterology and Hepatology
JF - Clinical Gastroenterology and Hepatology
IS - 6
ER -