Combination of morphologic criteria and α-fetoprotein in selection of patients with hepatocellular carcinoma for liver transplantation minimizes the problem of posttransplant tumor recurrence

Abstract

Background: Serum α-fetoprotein concentration (AFP) might be a useful addition to morphologic criteria for selecting patients with hepatocellular carcinoma (HCC) for liver transplantation (LT). The aim of this study was to evaluate the role of AFP in selecting HCC patients at minimal risk of posttransplant tumor recurrence in the setting of existing criteria.

Methods: This retrospective cohort study was based on 121 HCC patients after LT performed at a single institution. AFP was evaluated as a predictor of posttransplant tumor recurrence with respect to fulfillment of the Milan, University of California, San Francisco (UCSF), and Up-to-7 criteria.

Results: There was a nearly linear association between AFP and the risk of HCC recurrence (p < 0.001 for linear effect; p = 0.434 for nonlinear effect). AFP predicted HCC recurrence in patients (1) beyond the Milan criteria (p < 0.001; optimal cutoff 200 ng/ml); (2) within the UCSF criteria (p = 0.001; optimal cutoff 100 ng/ml) and beyond them (p = 0.015; optimal cutoff 200 ng/ml); and (3) within the Up-to-7 criteria (p = 0.001; optimal cutoff 100 ng/ml) and beyond them (p = 0.023; optimal cutoff 100 ng/ml) but not in patients within the Milan criteria (p = 0.834). Patients within either UCSF and Up-to-7 criteria with AFP level <100 ng/ml exhibited superior (100 %) 5-year recurrence-free survival-significantly higher than those within UCSF (p = 0.005) or Up-to-7 (p = 0.001) criteria with AFP levels higher than the estimated cutoffs or beyond with AFP levels less than the estimated cutoffs.

Conclusions: Combining the UCSF and Up-to-7 criteria with an AFP level <100 ng/ml is associated with minimal risk of tumor recurrence. Hence, this combination might be useful for selecting HCC patients for LT.

Fig. 1

Associations between serum α-fetoprotein (AFP) concentration and the risk of posttransplant tumor recurrence in the univariate analysis (a) and adjusted for the impact of potential confounders, including general factors (b), tumor-related factors (c), intraoperative factors (d), and fulfillment of selection criteria (e). Risk curves (solid lines) are presented with 95 % confidence intervals (dotted lines)

Fig. 2

Estimation of the optimal cutoffs for serum AFP concentration for predicting posttransplant tumor recurrence in patients within the University of California, San Francisco (UCSF) (a) and Up-to-7 (b) criteria and beyond the Milan (c), UCSF (d), and Up-to-7 (e) criteria

Fig. 3

Recurrence-free survivals. a Patients within the Milan criteria (dashed line) and beyond the Milan criteria (solid line) with AFP <200 ng/ml. b Patients within UCSF criteria with AFP <100 ng/ml (dashed line) and >100 ng/ml (dashed-dotted line) and beyond the UCSF criteria with AFP <200 ng/ml (solid line). c Patients within Up-to-7 criteria with AFP <100 ng/ml (dashed line) and >100 ng/ml (dashed-dotted line) and beyond Up-to-7 criteria (solid line) with AFP <100 ng/ml. Survival curves are presented with 95 % confidence intervals