Abstract

BACKGROUND & AIMS:

The aim of this study was to generate an improved prognostic model for predicting recurrence in liver transplant candidates with hepatocellular carcinoma (HCC).

METHODS:

Predictors of recurrence were tested by a Cox model analysis in a training cohort of 537 patients transplanted for HCC. A prognostic score was developed, and validated in a national cohort of 435 patients followed prospectively.

RESULTS:

AFP independently predicted tumor recurrence and correlated with vascular invasion and differentiation. At a Cox score threshold of 0.7 (AUROC: 0.701, (95% CI: 0.63-0.76), accuracy: 75.8%), a model combining log10 AFP, tumor size and number was highly predictive of tumor recurrence and death. Using a simplified version of the model, with untransformed AFP values, a cut-off value of 2 was identified. In the validation cohort, a score > 2 predicted a marked increase in 5-year risk of recurrence (50.6 ±10.2% vs 8.8±1.7%, p<0.001) and decreased survival (47.5±8.1% vs. 67.8 ±3.4%, p=0.002) as compared with others. Among patients exceeding Milan criteria, a score ≤ 2 identified a subgroup of patients with AFP < 100 ng/mL with a low 5-year risk of recurrence (14.4±5.3% vs. 47.6±11.1% (p=0.006)). Among patients within Milan criteria, a score > 2 identified a subgroup of patients with AFP > 1000 ng/mL at high risk of recurrence (37.1±8.9% vs. 13.3±2.0%, p<0.001). NRI showed that predictability of the AFP model was superior to Milan criteria.

CONCLUSIONS:

Prediction of tumor recurrence is significantly improved by a model which incorporates AFP. We propose the adoption of new selection criteria for HCC transplant candidates, taking into account AFP.