Wait time of less than 6 and greater than 18 months predicts hepatocellular carcinoma recurrence after liver transplantation: Proposing a wait time "sweet Spot"

It has been postulated that short wait time before liver transplant (LT) for hepatocellular carcinoma (HCC) results in the inclusion of tumors with aggressive biology, but prolonged wait time could result in a shift to more aggressive tumor behavior. We therefore test the hypothesis that a wait time "sweet spot" exists with a lower risk for HCC recurrence compared with the other 2 extremes. Methods. This multicenter study included 911 patients from 3 LTcenters with short, medium, and long wait times (median of 4, 7, and 13 months, respectively) who receivedModel for End Stage Liver Disease exception listing for HCC from 2002 to 2012. Results.Wait time, defined as time from initial HCC diagnosis to LT, was less than 6months in 32.4%, 6 to 18 months in 53.7%, and greater than 18months in 13.9%.Waitlist dropout was observed in 18.4%at a median of 11.3 months. Probability of HCC recurrence at 1 and 5 years were 6.4% and 15.5% with wait time of less than 6 or greater than 18 months (n = 343) versus 4.5% and 9.8% with wait time of 6 to 18 months (n = 397), respectively (P = 0.049). When only pre-LT factors were considered, wait time of less than 6 or greater than 18 months (HR, 1.6; P = 0.043) and AFP greater than 400 at HCC diagnosis (HR, 3.0; P < 0.001) predicted HCC recurrence in multivariable analysis. Conclusions. This large multicenter study provides evidence of an association between very short (<6 months) or very long (>18 months) wait times and an increased risk for HCC recurrence post-LT. The so-called sweet spot of 6 to 18 months should be the target to minimize HCC recurrence.