Ep. 519 Transplantation for HCC: Who, When, and How?

The process of liver transplantation involves many complexities, and each patient's path to transplant is unique. To offer insider perspectives on this process, Dr. Zachary Berman sits down with transplant and hepatobiliary surgeon Dr. John Seal, as well as transplant hepatologists Dr. Heather Patton and Dr. Steve Young. Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion: https://www.cmeuniversity.com/course/take/125740 --- This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific. --- SYNPOSIS The panel begins by discussing the multidisciplinary pre-transplant evaluation process, which assesses factors such as liver function, comorbidities, surgical risk, and the availability of psychosocial support. Once a patient is listed for transplant, they enter a system that prioritizes those with the highest Model for End-Stage Liver Disease (MELD) score. During the waiting period, several comorbidities should be carefully monitored. Dr. Seal explores the impact of portal vein hypertension and portal vein thrombosis, explaining how these conditions may necessitate intraoperative thrombectomy or bypass. Dr. Patton and Dr. Young focus on considerations for using anticoagulation in patients with a high baseline bleeding risk and selecting the appropriate anticoagulant for patients listed for transplant. For patients with hepatocellular carcinoma (HCC), eligibility for MELD exception points may depend on factors such as time spent on the waiting list, adherence to the Milan criteria, and the presence of extrahepatic complications of liver disease. The panel also discusses bridging therapies to transplant, including Y90 and TACE. In the peri-transplant phase, they highlight innovations such as living donor transplants, liver perfusion pumps, and the use of hepatitis C- and HIV-positive organs. Finally, the discussion turns to post-transplant considerations, including surgical complications, organ rejection, immunosuppression, predictors of HCC recurrence, and long-term surveillance. --- TIMESTAMPS 00:00 - Introduction 01:16 - Current Landscape of Liver Transplantation 03:22 - Transplant Evaluation Process 09:48 - Timeline from Listing to Transplantion 11:16 - Treating Portal Vein Thrombosis and Hypertension 18:44 - MELD Exception Points 22:05 - Bridging Therapies 25:34 - Peri-Transplant Considerations 30:53 - Post-Transplant Period 37:39 - Repeat Transplantation --- RESOURCES Model for end-stage liver disease (MELD) and allocation of donor livers (Wiesner et al, 2003): https://www.gastrojournal.org/article/S0016-5085%2803%2950022-1/fulltext Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis- Milan Criteria (Mazzaferro et al, 1996): https://pubmed.ncbi.nlm.nih.gov/8594428/ Validation of the prognostic power of the RETREAT score for hepatocellular carcinoma recurrence using the UNOS database (Mehta et al, 2019): https://pmc.ncbi.nlm.nih.gov/articles/PMC6445634/ CME Accreditation Information: https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf