Digestive Diseases and Sciences

, Volume 57, Issue 2, pp 580–586

Predictors of Liver Transplant Eligibility for Patients with Hepatocellular Carcinoma in a Safety Net Hospital

  • Amit G. Singal
  • Vincent Chan
  • Yonas Getachew
  • Richard Guerrero
  • Joan S. Reisch
  • Jennifer A. Cuthbert
Original Article



Liver transplantation for patients with hepatocellular carcinoma (HCC) affords excellent long-term survival but is limited to patients with early stage tumors. Predictors for orthotopic liver transplantation eligibility are not well defined for patients in a safety-net hospital system.


To clarify the clinical presentation of HCC and define predictors for early stage disease in a racially diverse safety-net hospital system.


We retrospectively reviewed records of patients with HCC presenting to a large urban county hospital between January 1998 and October 2007. Logistic regression analysis was used to find predictors of OLT eligibility.


Of the 266 patients with HCC, 62% had multiple tumors, 47% had portal vein thrombosis and only 22% were potential liver transplant candidates based on Milan criteria. Male gender (OR 0.33; 95% CI 0.17–0.65) and AFP levels > 20 ng/mL (OR 0.22; 95% CI 0.11–0.45) were negative predictors of liver transplant eligibility. Age, race, and underlying viral liver disease were not significant predictors of early tumor stage.


A minority of HCC patients in a safety-net hospital are eligible for liver transplant at the time of diagnosis. Men have more advanced tumors at presentation, which may be related to more aggressive tumor biology or differential rates of HCC surveillance.


Hepatocellular carcinoma Presentation Tumor stage Liver transplantation Safety net hospital 



American Association for the Study of Liver Disease


Alpha fetoprotein


Barcelona Clinic Liver Cancer


Nonalcoholic steatohepatitis


Hepatitis B virus


Hepatocellular carcinoma


Hepatitis C virus


Orthotopic liver transplantation


Parkland Memorial Hospital


Portal vein thrombus


Surveillance, Epidemiology, and End Results

Supplementary material

10620_2011_1904_MOESM1_ESM.pdf (411 kb)
Supplementary material 1 (PDF 411 kb)


  1. 1.
    Altekruse SF, McGlynn KA, Reichman ME. Hepatocellular carcinoma incidence, mortality, and survival trends in the United States from 1975 to 2005. J Clin Oncol. 2009;27:1485–1491.PubMedCrossRefGoogle Scholar
  2. 2.
    El-Serag HB, Rudolph KL. Hepatocellular carcinoma: epidemiology and molecular carcinogenesis. Gastroenterology. 2007;132:2557–2576.PubMedCrossRefGoogle Scholar
  3. 3.
    Singal AG, Volk ML, Waljee A, et al. Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis. Aliment Pharmacol Ther. 2009;30:37–47.PubMedCrossRefGoogle Scholar
  4. 4.
    Llovet JM, Bruix J. Early diagnosis and treatment of hepatocellular carcinoma. Baillieres Best Pract Res Clin Gastroenterol. 2000;14:991–1008.PubMedCrossRefGoogle Scholar
  5. 5.
    Ioannou GN, Perkins JD, Carithers RL Jr. Liver transplantation for hepatocellular carcinoma: impact of the MELD allocation system and predictors of survival. Gastroenterology. 2008;134:1342–1351.PubMedCrossRefGoogle Scholar
  6. 6.
    Llovet JM, Bustamante J, Castells A, et al. Natural history of untreated nonsurgical hepatocellular carcinoma: rationale for the design and evaluation of therapeutic trials. Hepatology. 1999;29:62–67.PubMedCrossRefGoogle Scholar
  7. 7.
    Regenstein M, Huang J. Stresses to the safety net: the public hospital perspective. In: Kaiser Commission on Medicaid and the Uninsured. Washington DC: Kaiser Family Foundation; 2005.Google Scholar
  8. 8.
    Younossi ZM, Stepanova M. Hepatitis C virus infection, age, and Hispanic ethnicity increase mortality from liver cancer in the United States. Clin Gastroenterol Hepatol. 2010;8:718–723.PubMedCrossRefGoogle Scholar
  9. 9.
    Artinyan A, Mailey B, Sachez-Leuge N, et al. Race, ethnicity, and socioeconomic status influence the survival of patients with hepatocellular carcinoma in the United States. Cancer. 2010;116:1367–1377.PubMedCrossRefGoogle Scholar
  10. 10.
    Wong RJ, Corley DA. Survival differences by race/ethnicity and treatment for localized hepatocellular carcinoma within the United States. Dig Dis Sci. 2009;54:2031–2039.PubMedCrossRefGoogle Scholar
  11. 11.
    Hendifar AE, Yang D, Iqbal S, Lenz H, El-Khoueiry A. Gender disparities in hepatocellular cancer survival. J Clin Oncol. 2009;27:e15517.Google Scholar
  12. 12.
    Bruix J, Sherman M. Management of hepatocellular carcinoma. Hepatology. 2005;42:1208–1236.PubMedCrossRefGoogle Scholar
  13. 13.
    Onaca N, Davis GL, Jennings LW, et al. Improved results of transplantation for hepatocellular carcinoma: a report from the International Registry of Hepatic Tumors in Liver Transplantation. Liver Transpl. 2009;15:574–580.PubMedCrossRefGoogle Scholar
  14. 14.
    Kemmer N, Neff G, Secic M, et al. Ethnic differences in hepatocellular carcinoma: implications for liver transplantation. Dig Dis Sci. 2008;53:551–555.PubMedCrossRefGoogle Scholar
  15. 15.
    Wong LL, Tasi N, Limm W, et al. Liver transplant for hepatocellular cancer: a treatment for the select few. Clin Transplant. 2004;18:205–210.PubMedCrossRefGoogle Scholar
  16. 16.
    Haque M, Zariat A. Disparities in liver transplantation for localized hepatocellular carcinoma: race or socioeconomic class? Am J Gastroenterol. 2008;103:1839–1840. author reply 1840.PubMedCrossRefGoogle Scholar
  17. 17.
    Axelrod DA, Pomfret EA. Race and sex disparities in liver transplantation: progress toward achieving equal access? JAMA. 2008;300:2425–2426.PubMedCrossRefGoogle Scholar
  18. 18.
    Dohmen K, Sigematsu H, Irie K, et al. Longer survival in female than male with hepatocellular carcinoma. J Gastroenterol Hepatol. 2003;18:267–272.PubMedCrossRefGoogle Scholar
  19. 19.
    Moylan CA, Brady CW, Johnson JL, et al. Disparities in liver transplantation before and after introduction of the MELD score. JAMA. 2008;300:2371–2378.PubMedCrossRefGoogle Scholar
  20. 20.
    Englesbe MJ, Schaubel DE, Cai S, et al. Portal vein thrombosis and liver transplant survival benefit. Liver Transpl. 2010;16:999–1005.PubMedCrossRefGoogle Scholar
  21. 21.
    Han K, Tzimas GN, Barkun JS, et al. Preoperative alpha-fetoprotein slope is predictive of hepatocellular carcinoma recurrence after liver transplantation. Can J Gastroenterol. 2007;21:39–45.PubMedGoogle Scholar
  22. 22.
    Peng SY, Chen WJ, Lai PL, et al. High alpha-fetoprotein level correlates with high stage, early recurrence and poor prognosis of hepatocellular carcinoma: significance of hepatitis virus infection, age, p53 and beta-catenin mutations. Int J Cancer. 2004;112:44–50.PubMedCrossRefGoogle Scholar
  23. 23.
    Browning JD, Szczepaniak LS, Dobbins R, et al. Prevalence of hepatic steatosis in an urban population in the United States: impact of ethnicity. Hepatology. 2004;40:1387–1395.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Amit G. Singal
    • 1
    • 2
    • 3
    • 4
  • Vincent Chan
    • 1
    • 2
  • Yonas Getachew
    • 1
    • 2
  • Richard Guerrero
    • 1
    • 2
  • Joan S. Reisch
    • 3
  • Jennifer A. Cuthbert
    • 1
    • 2
  1. 1.Division of Digestive and Liver Diseases, Department of Internal MedicineUT Southwestern Medical CenterDallasUSA
  2. 2.Parkland Memorial HospitalParkland Health and Hospital SystemDallasUSA
  3. 3.Department of Clinical SciencesUniversity of Texas SouthwesternDallasUSA
  4. 4.Harold C. Simmons Cancer CenterUT Southwestern Medical CenterDallasUSA

Personalised recommendations