Durkin Claire, Kaplan David E, Bittermann Therese
Department of Medicine, University of Pennsylvania, Philadelphia, PA.
Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA.
Transplant Direct. 2020 Aug 21;6(9):e597. doi: 10.1097/TXD.0000000000001039. eCollection 2020 Sep.
A United Network for Organ Sharing policy change in 2015 created a 6-mo delay in the receipt of T2 hepatocellular carcinoma exception points. It was hypothesized that the policy changed locoregional therapy (LRT) practices and explant findings because of longer expected waiting time.
Patients transplanted with a first T2 hepatocellular carcinoma exception application between January 1, 2010 and December 31, 2014 (prepolicy; N = 6562), and those between August 10, 2015 and December 2, 2019 (postpolicy; N = 2345), were descriptively compared using data from United Network for Organ Sharing.
Median time from first application to transplantation was more homogenous across the US postpolicy, due to greater absolute increases in Regions 3, 6, 10, and 11 (>120 d). During waitlisting, postpolicy candidates received more LRT overall ( < 0.001), with more notable increases in previously short-wait regions. Postpolicy explants were overall more likely to have ≥1 tumor with complete necrosis (23.9 versus 18.4%; < 0.001) and less likely have ≥1 tumor with no necrosis (32.6% versus 38.5%; < 0.001). Significant geographic variability in explant treatment response was observed prepolicy with recipients in previously short-wait regions having more frequent tumor viability at transplant. Postpolicy, there were no differences in the prevalence of recipients with ≥1 tumor with 100% or 0% necrosis across regions ( = 0.9 and 0.2, respectively).
The 2015 T2 exception policy has led to reduced geographic variability in the use of pretransplant LRT and in less frequent tumor viability on explant for recipients in previously short-waiting times.
器官共享联合网络（United Network for Organ Sharing）在2015年的一项政策变更导致T2期肝细胞癌例外积分的获取延迟了6个月。据推测，由于预期等待时间延长，该政策改变了局部区域治疗（locoregional therapy, LRT）的实践和肝移植切除标本的结果。
利用器官共享联合网络的数据，对2010年1月1日至2014年12月31日期间（政策实施前；N = 6562）首次申请T2期肝细胞癌例外情况而接受肝移植的患者，以及2015年8月10日至2019年12月2日期间（政策实施后；N = 2345）的患者进行描述性比较。
政策实施后，美国各地从首次申请到肝移植的中位时间更加均匀，这是因为第3、6、10和11地区的绝对增加幅度更大（>120天）。在等待名单期间，政策实施后的候选者总体上接受了更多的LRT（<0.001），之前等待时间短的地区增加更为显著。政策实施后的肝移植切除标本总体上更有可能有≥1个肿瘤出现完全坏死（23.9%对18.4%；<0.001），而有≥1个肿瘤无坏死的可能性更小（32.6%对38.5%；<0.001）。在政策实施前，观察到肝移植切除标本治疗反应存在显著的地理差异，之前等待时间短的地区的受者在肝移植时肿瘤存活的情况更频繁。政策实施后，各地区有≥1个肿瘤且坏死率为100%或0%的受者患病率没有差异（分别为=0.9和0.2）。
2015年的T2例外政策导致了肝移植前LRT使用的地理差异减少，以及之前等待时间短的受者肝移植切除标本中肿瘤存活情况减少。
