title: Alpha-fetoprotein and (18)F-FDG positron emission tomography predict tumor recurrence better than Milan criteria in living donor liver transplantation.
abstract: OBJECTIVE
  Given the organ shortage for liver transplantation (LT) and the limitations of the current morphology-based selection criteria, improved criteria are needed to achieve the maximum benefit of LT for hepatocellular carcinoma (HCC). We hypothesized that a combination of biological markers may better predict the prognosis than the Milan criteria.
  
  
  METHODS
  HCC patients (n=123) with preoperative data on serum alpha-fetoprotein (AFP) levels and (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) positivity underwent live-donor LT between January 2003 and December 2009. The cut-off values for serum AFP levels (200 ng/ml) and (18)F-FDG PET positivity (1.10) for tumor recurrence were determined by c-statistics using receiver operating characteristic curves. Univariate and multivariate analyses with preoperative variables were performed to find pre-transplant prognostic factors. Disease-free survival rates and overall survival rates were analysed with regard to serum AFP levels and (18)F-FDG PET positivity.
  
  
  RESULTS
  The 5-year disease-free survival rates and overall survival rates were 80.3% and 81.6% respectively. (18)F-FDG PET positivity (hazard ratio (HR) 9.766, 95% CI 3.557-26.816; p<0.001) and serum AFP level (HR 6.234, 95% CI 2.643-14.707; p<0.001) were the only significant pre-transplant prognostic factors in the multivariate analysis; tumor number and size were not significant. A combination of criteria showed that the biologically high-risk group (AFP level ⩾200 ng/ml and PET-positive) had an HR of 29.069 (95% CI 8.797-96.053; p<0.001) compared with the double-negative group. Use of the Milan criteria yielded an HR of 1.351 (95% CI 0.500-3.652; p=0.553).
  
  
  CONCLUSIONS
  The combination of the serum AFP level and (18)F-FDG PET data predicted better outcomes than those using the Milan criteria, improving objectivity when adult-to-adult living donor LT is contemplated.
authors.affiliation: Department of Surgery, Ewha Womans University, School of Medicine, South Korea.
authors.forename: Geun
authors.initials: G
authors.lastname: Hong
authors.affiliation: Department of Surgery, Seoul National University, College of Medicine, South Korea. Electronic address: kssuh@snu.ac.kr.
authors.forename: Kyung-Suk
authors.initials: KS
authors.lastname: Suh
authors.affiliation: Department of Surgery, Seoul National University, College of Medicine, South Korea.
authors.forename: Suk-Won
authors.initials: SW
authors.lastname: Suh
authors.affiliation: Department of Surgery, Seoul National University, College of Medicine, South Korea.
authors.forename: Tae
authors.initials: T
authors.lastname: Yoo
authors.affiliation: Department of Surgery, Seoul National University, College of Medicine, South Korea.
authors.forename: Hyeyoung
authors.initials: H
authors.lastname: Kim
authors.affiliation: Department of Surgery, Seoul National University, College of Medicine, South Korea.
authors.forename: Min-Su
authors.initials: MS
authors.lastname: Park
authors.affiliation: Department of Surgery, Seoul National University, College of Medicine, South Korea.
authors.forename: YoungRok
authors.initials: Y
authors.lastname: Choi
authors.affiliation: Department of Nuclear Medicine, Seoul National University, College of Medicine, South Korea.
authors.forename: Jin Chul
authors.initials: JC
authors.lastname: Paeng
authors.affiliation: Department of Surgery, Seoul National University, College of Medicine, South Korea.
authors.forename: Nam-Joon
authors.initials: NJ
authors.lastname: Yi
authors.affiliation: Department of Surgery, Seoul National University, College of Medicine, South Korea.
authors.forename: Kwang-Woong
authors.initials: KW
authors.lastname: Lee
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000601:surgery*; D005260:Female; D019788:Fluorodeoxyglucose F18; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis*; D049268:Positron-Emission Tomography; D000509:alpha-Fetoproteins / Q000032:analysis*
chemical_list: D000509:alpha-Fetoproteins; D019788:Fluorodeoxyglucose F18
keywords: Alpha-fetoproteins; Biological factors; Fluorodeoxyglucose F18; Hepatocellular carcinoma; Liver transplantation; Living donors; Positron emission tomography