Management of Patients with Hepatocellular Carcinoma at a Single Institution
Sarah Liu1, Peter Callas2, Justin Esteban3, Conor O'Neill1
1Surgery, University of Vermont Medical Center, South Burlington, Vermont, United States, 2Biomedical Statistics Research Core, University of Vermont, Burlington, Vermont, United States, 3Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
Objective:
Hepatocellular carcinoma (HCC) is the seventh most common cancer worldwide. Its prevalence is increasing and survival is quite poor. Surgical resection is the mainstay of treatment for surgically-fit patients without portal hypertension, while transplantation can provide excellent outcomes for cirrhotic patients with low-volume disease. The University of Vermont Medical Center (UVMMC) is the only tertiary facility for our rural catchment area. In the absence of transplantation services, patients often require care outside of the region and may face barriers to medical access. We queried our UVM Health Network tumor registry to begin to develop a prediction model for transplantation following out-of-network referral.
Design:
A retrospective cohort study of UVMMC patients with HCC from 2009 until 2021.
Setting:
A 620-bed academic hospital in Burlington, VT serving as a community hospital for the greater Burlington area and as a tertiary center for VT and northern NY.
Patients:
All patients ≥ 18 years of age with HCC identified in our tumor registry during the study period were included, yielding 346 patients of which 91 patients were excluded due to eventual diagnosis of non-HCC lesion or inability to obtain treatment records, for a total of 255 patients.
Interventions:
None
Main Outcome Measures:
Demographic and clinical features associated with successful transplantation in our patient population.
Results:
Tumor staging was 2.7% BCLC-0 (N=7), 44.3% BCLC-A (N=113), 18.8% BCLC-B (N=48), 23.5% BCLC-C (N=60), and 9.8% BCLC-D (N=25). Ultimately 9.4% (N=24) were transplanted: 14% BCLC-0 (N=1/7), 18% BCLC-A (N=20/113), and 6% BCLC-B (N=3/48).
Univariate analysis showed the following: younger patients were more likely to undergo transplant (mean transplanted age 59 vs. non-transplanted 65, p=0.004). Other factors significantly correlated with transplantation included lower Charlson Comorbidity Index score (mean transplanted CCI 7.6 vs. non-transplanted 8.3, p=0.03) and lower MELD score at time of HCC diagnosis (mean transplanted MELD 9.5 vs. non-transplanted 12.1, p=0.005). This held true within the BCLC-A stage, with average MELD at time of diagnosis for transplanted patients was 9.2 compared to 10.1 for non-transplanted. Additionally, patients who underwent transplantation were more likely to have undergone a higher number of total procedures, often TACE or cryotherapy (p=0.002), compared to all other patients.
Conclusions:
In our cohort, patients ultimately selected for transplantation were younger with fewer comorbidities and lower MELD score. However, the likelihood of requiring multiple procedures such as TACE to bridge to eventual transplant may have important ramifications for our patients, who may live several hours away from centers capable of providing such therapies. Further research is warranted to analyze the effect of access to healthcare that may influence treatment options as we work to optimize care delivery across our rural catchment.
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