From Metro Ticket to a Cape-to-Khartoum Pass: Reimagining Liver Transplantation Criteria for HCC in Sub-Saharan Africa

Abstract

BACKGROUND: Current liver transplantation (LT) criteria and the Metroticket model were developed in high-income countries (HICs) and may not be appropriate for hepatocellular carcinoma (HCC) patients in sub-Saharan Africa (SSA). METHODS: A retrospective observational cohort study of 647 HCC patients managed at Groote Schuur Hospital, Cape Town, South Africa was performed. Our LT experience and outcomes were reviewed, and current transplant criteria (Milan, University of California San Franciso, extended Toronto) were applied to non-transplanted patients. An exploratory cohort was then generated and analysed to inform a regionally adapted LT framework for SSA. RESULTS: Six (0.9%) patients underwent LT with a median survival of 2557.5 (range:1049-3076) days. In the non-transplanted group, 31(4.8%) met at least one LT criterion, of whom 19 (61.3%) were eventually treated with resection (12) and ablation (7). The exploratory cohort (n = 140) was predominantly male (84.2%) with advanced HCC (BCLC stage C/D in 79.2%), but preserved liver function (median MELD-Na of 10 and Child-Turcotte-Pugh grade A disease in 61.4%). Only 16.2% of the exploratory cohort received curative-intended therapies. Patients who underwent LT survived significantly longer than the two other patient groups (P < .001). CONCLUSION: This study highlights the potential limited applicability of current LT criteria in SSA, where applying criteria, less than 5% of HCC patients qualify. We propose a novel Cape-to-Khartoum framework incorporating clinical and biological parameters, including tumour markers, tumour differentiation and multi-omic profiling. This model may broaden LT eligibility and improve outcomes for HCC in SSA and warrants further validation through multicentre studies across the region.