title: Liver transplantation for hepatocellular carcinoma: a model including α-fetoprotein improves the performance of Milan criteria.
abstract: OBJECTIVE
  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 up prospectively.
  
  
  RESULTS
  α-Fetoprotein (AFP) independently predicted tumor recurrence and correlated with vascular invasion and differentiation. At a Cox score threshold of 0.7 (area under the receiver operating characteristic curve, 0.701; 95% confidence interval, 0.63-0.76; accuracy, 75.8%), a model combining log(10) AFP, tumor size, and number was highly predictive of tumor recurrence and death. By 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 greater than 2 predicted a marked increase in 5-year risk of recurrence (50.6% ± 10.2% vs 8.8% ± 1.7%; P < .001) and decreased survival (47.5% ± 8.1% vs 67.8% ± 3.4%; P = .002) as compared with others. Among patients exceeding Milan criteria, a score of 2 or lower identified a subgroup of patients with AFP levels less than 100 ng/mL with a low 5-year risk of recurrence (14.4% ± 5.3% vs 47.6% ± 11.1%; P = .006). Among patients within Milan criteria, a score greater than 2 identified a subgroup of patients with AFP levels greater than 1000 ng/mL at high risk of recurrence (37.1% ± 8.9% vs 13.3% ± 2.0%; P < .001). Net reclassification improvement showed that predictability of the AFP model was superior to Milan criteria.
  
  
  CONCLUSIONS
  Prediction of tumor recurrence is improved significantly by a model that incorporates AFP. We propose the adoption of new selection criteria for HCC transplant candidates, taking into account AFP.
authors: AP-HP, Groupe Henri-Mondor, Department of Hepatology, Créteil, France. christophe.duvoux@hmn.aphp.fr
authors: Christophe
authors: C
authors: Duvoux
authors: Françoise
authors: F
authors: Roudot-Thoraval
authors: Thomas
authors: T
authors: Decaens
authors: Fabienne
authors: F
authors: Pessione
authors: Hanaa
authors: H
authors: Badran
authors: Tullio
authors: T
authors: Piardi
authors: Claire
authors: C
authors: Francoz
authors: Philippe
authors: P
authors: Compagnon
authors: Claire
authors: C
authors: Vanlemmens
authors: Jérome
authors: J
authors: Dumortier
authors: Sébastien
authors: S
authors: Dharancy
authors: Jean
authors: J
authors: Gugenheim
authors: Pierre-Henri
authors: PH
authors: Bernard
authors: René
authors: R
authors: Adam
authors: Sylvie
authors: S
authors: Radenne
authors: Fabrice
authors: F
authors: Muscari
authors: Filomena
authors: F
authors: Conti
authors: Jean
authors: J
authors: Hardwigsen
authors: Georges-Philippe
authors: GP
authors: Pageaux
authors: Olivier
authors: O
authors: Chazouillères
authors: Ephrem
authors: E
authors: Salame
authors: Marie-Noelle
authors: MN
authors: Hilleret
authors: Pascal
authors: P
authors: Lebray
authors: Armand
authors: A
authors: Abergel
authors: Marilyne
authors: M
authors: Debette-Gratien
authors: Michael D
authors: MD
authors: Kluger
authors: Ariane
authors: A
authors: Mallat
authors: Daniel
authors: D
authors: Azoulay
authors: Daniel
authors: D
authors: Cherqui
mesh_terms: D000328:Adult; D019540:Area Under Curve; D006528:Carcinoma, Hepatocellular / Q000097:blood* / Q000473:pathology / Q000601:surgery; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000097:blood* / Q000473:pathology / Q000601:surgery; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000097:blood*; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D000509:alpha-Fetoproteins / Q000378:metabolism*
chemical_list: D000509:alpha-Fetoproteins