Survival outcomes of liver transplantation for hepatocellular carcinoma in patients with normal, high and very high preoperative alpha-fetoprotein levels

Establishment and Validation of the LI-RADS Morphologic Type II Hepatocellular Carcinoma Early Recurrence Risk Scoring System

BACKGROUND

Tumor morphology links to early recurrence of hepatocellular carcinoma. Controversy exists regarding the recurrence risk of Liver Imaging Reporting and Data System morphologic Type II hepatocellular carcinoma. This study aims to explore risk factors for early recurrence of Type II hepatocellular carcinoma.

METHODS

Retrospective analysis of hepatocellular carcinoma patients who underwent curative resection and preoperative contrast-enhanced MRI from June 2016 to June 2020. Our patients formed the development set, and hepatocellular carcinoma patients from the TCIA database served as validation. Univariable and multivariable Cox regression identified independent risk factors for early recurrence. A risk scoring system was established for risk stratification, and an early recurrence prediction model was developed and validated.

RESULTS

95 Type II hepatocellular carcinoma patients were in the development set, and 29 cases were in the validation set. Early recurrence rates were 33.7% and 37.9%, respectively. Multivariate analysis revealed age, histological grade, AFP, and intratumoral hemorrhage as independent risk factors for early recurrence. The model's diagnostic performance for early recurrence was AUC = 0.817 in the development set. A scoring system classified patients into low-risk (scores ≤ 3) and high-risk (scores > 3) groups. The high-risk group had significantly lower recurrence-free survival (40.0% vs 73.2%, P = 0.001), consistent with the validation set (25.0% vs 73.3%, P = 0.028).

CONCLUSIONS

The risk scoring system demonstrated excellent discrimination and predictive ability, aiding clinicians in assessing early recurrence risk and identifying high-risk individuals effectively.

Updates and Expert Opinions on Liver Transplantation for Gastrointestinal Malignancies

Transplant oncology is a relatively new field in which transplantation is used to treat patients who would otherwise be unresectable. New anticancer treatment paradigms using tumor and transplant immunology and cancer immunogenomics are emerging. In turn, liver transplantation (LT) has become a potential therapy for certain patients with colorectal cancer (CRC) with liver metastasis, hepatocellular (HCC), cholangiocarcinoma (CCA), and metastatic neuroendocrine tumor (NET) of the liver. Although there are established criteria for LT in HCC, evidence regarding LT as a treatment modality for certain gastrointestinal malignancies is still debated. The aim of this review is to highlight updates in the role of LT for certain malignancies, including HCC, metastatic CRC, hilar CCA, and neuroendocrine tumor (NET), as well as contextualize LT use and discuss controversies in transplant oncology.

Can living donor liver transplantation provide similar outcomes to deceased-donor liver transplantation for hepatocellular carcinoma? A systematic review and meta-analysis

BACKGROUND AND AIM

A potential solution to the deceased organ shortage is to include live organ donations and to identify patients with lower rates of HCC recurrence to fairly allocate liver grafts. Our aims were to detect the long-term outcomes of LDLT versus DDLT for HCC and predictors of recurrence after transplantation.

METHODS

PubMed, Scopus, Web of Science, Cochrane library were searched for eligible studies from inception to July 2021 and a systematic review and meta-analysis were done.

RESULTS

35 studies with a total of 7822 patients were included. The 1-, 3-, 4 year-OS showed trivial improvement for LDLT recipients. However, the two modalities had similar 5-, 6- and 10-year OS. A significant improvement in the ITT-OS was observed for LDLT recipients. Regarding the DFS and recurrence after transplantation, no significant difference was observed between LDLT and DDLT. In addition to that, the pooled hazard ratio of the included studies showed that Milan criteria, level of AFP, presence of vascular invasion, tumor differentiation were significant predictors of recurrence.

CONCLUSION

The cancer biology (not the graft type) is the most important determinant of recurrence and survival after LT. However, LDLT provided much better survival benefits to HCC patients especially in regions that suffer from low deceased organ availability.

A feasibility study of different GSI noise indexes and concentrations of contrast medium in hepatic CT angiography of overweight patients: image quality, radiation dose, and iodine intake

PURPOSE

To conduct a comparative study of image quality, radiation dose, and iodine intake in hepatic computed tomographic angiography (CTA) of overweight patients with different Gemstone Spectral Imaging (GSI) noise indexes combined with different concentrations of contrast medium.

MATERIALS AND METHODS

Ninety patients with a body mass index of ≥ 25 kg/m² were divided into three groups (A, B and C), each with 30 patients. The three groups underwent hepatic CTA with different NI of 7, 11 and 15, respectively, and were injected with different iodine concentrations of 370, 350 and 320 mgI/mL, respectively. Five sets of images at 40-60 keV (interval, 5 keV) were reconstructed in each group. The CT value, image noise, contrast-to-noise ratio (CNR) and subjective score of the hepatic artery and vein, and portal vein in different monochromatic image sets were analyzed to select the optimal energy level in each group. The differences in CT value, image noise, CNR and a subjective score of hepatic artery and vein, portal vein in the optimal monochromatic images among the three groups were compared, the volume CT dose index (CTDIvol) and dose-length product (DLP) were recorded, and the effective dose and iodine intake were calculated.

RESULTS

The 40 keV was determined to be the optimal energy level for the monochromatic image sets in each group. No significant group differences were noted in the CT value, image noise, CNR, and subjective image scores of the hepatic artery and vein, and portal vein for the optimal monochromatic images (P > 0.05). Compared with group A, the effective dose and iodine intake in group B were reduced by 50.18% and 9.3%, and by 58.12% and 14.23% in group C, respectively.

CONCLUSION

A low-concentration contrast medium combined with a high-noise GSI index in hepatic CTA of overweight patients can reduce the radiation dose and iodine intake while ensuring image quality.

Research progress of spontaneous ruptured hepatocellular carcinoma: Systematic review and meta-analysis

Background

Spontaneously ruptured hepatocellular carcinoma (rHCC) with hemorrhage is characterized by rapid onset and progression. The aim of this systematic review was to explore the current studies on rHCC with hemorrhage and determine the optimum treatment strategy.

Method

The PubMed, Web of Science, Embase, and the Cochrane Library databases were searched for studies reporting survival outcomes with comparison between emergency resection (ER) and transarterial embolization following staged hepatectomy (SH) were included by inclusion and exclusion criteria, the perioperative and survival data were statistically summarized using Review Manager 5.3 software.

Result

A total of 8 retrospective studies were included, with a total sample size of 556, including 285 (51.3%) in the ER group and 271 (48.7%) in the SH group. The perioperative blood loss and blood transfusion volume in the SH group were less than those in the ER group, and there were no significant differences in the operative time, incidence of complications, mortality and recurrence rate of tumors between the two groups. The 1-, 2-, 3-year overall survival and 1-, 2-, 3-, 5-year disease-free survival of the ER group were not significantly different from those of the SH group, and the 5-year overall survival rate of ER group was lower than that of the SH group (hazard ratios=1.52; 95% confidence intervals: 1.14-2.03, P=0.005).

Conclusion

There was no significant difference in the short-term efficacy of ER or SH in the treatment of ruptured HCC, and SH was superior to ER in the long-term survival.

Liver Transplantation for Hepatocellular Carcinoma: How Should We Improve the Thresholds?

Simple Summary

The ideal treatment for hepatocellular carcinoma (HCC) is liver transplantation (LT), which both eliminates the HCC and cures the diseased liver. Once considered an experimental treatment with dismal survival rates, LT for HCC entered a new era with the establishment of the Milan criteria over 20 years ago. However, over the last two decades, the Milan criteria, which are based on tumor morphology, have come under intense scrutiny and are now largely regarded as too restrictive, and limit the access of transplantation for many patients who would otherwise achieve good clinical outcomes. The liver transplant community has been making every effort to reach a goal of establishing more reliable selection criteria. This article addresses how the criteria have been extended, as well as the concept of pre-transplant down-staging to maximize the eligibility.

Abstract

Hepatocellular carcinoma (HCC) is the third highest cause of cancer-related mortality, and liver transplantation is the ideal treatment for this disease. The Milan criteria provided the opportunity for HCC patients to undergo LT with favorable outcomes and have been the international gold standard and benchmark. With the accumulation of data, however, the Milan criteria are not regarded as too restrictive. After the implementation of the Milan criteria, many extended criteria have been proposed, which increases the limitations regarding the morphological tumor burden, and incorporates the tumor’s biological behavior using surrogate markers. The paradigm for the patient selection for LT appears to be shifting from morphologic criteria to a combination of biologic, histologic, and morphologic criteria, and to the establishment of a model for predicting post-transplant recurrence and outcomes. This review article aims to characterize the various patient selection criteria for LT, with reference to several surrogate markers for the biological behavior of HCC (e.g., AFP, PIVKA-II, NLR, 18F-FDG PET/CT, liquid biopsy), and the response to locoregional therapy. Furthermore, the allocation rules in each country and the present evidence on the role of down-staging large tumors are addressed.

Alpha-Fetoprotein in Predicting Survival of Patients with Ruptured Hepatocellular Carcinoma after Resection

Background/Aim: Alpha-fetoprotein (AFP) had been used as a prognostic factor in hepatocellular carcinoma but it was unknown what level of AFP could predict the survival of patients with ruptured hepatocellular carcinoma (rHCC) after resection. This retrospective study was to identify the best cutoff value of AFP for this prediction.Methods: Data of patients having hepatectomy for rHCC from 1989 to 2015 were reviewed. The receiver operating characteristic curve and Youden's index were used to identify the cutoff value of AFP affecting survival. The patients were then divided into two groups by the cutoff for comparison.Results: Totally 114 patients were included. An AFP level of 256 ng/ml was found to affect survival (area under curve 63.1%, 95% confidence interval 0.514-0.748, p = 0.027; sensitivity 0.6, specificity 0.706). The 114 patients were divided into Group A (AFP < 256 ng/ml, n = 56) and Group B (AFP ≥ 256 ng/ml, n = 58). The median AFP level was 13.0 ng/ml (range, 2-253 ng/ml) in Group A and 11206.5 ng/ml (range, 259-481,000 ng/ml) in Group B (p < 0.001). Group A had a larger proportion of patients receiving transarterial embolization at the time of rupture, and the time to hepatectomy was longer in this group. Patients in Group B had more blood loss, more complications, larger tumors, and more cases of macrovascular/microvascular invasion. Overall survival (p = 0.013) and disease-free survival (p = 0.024) were significantly better in Group A. On multivariate analysis, AFP ≥ 256 ng/ml was an independent risk factor for overall survival.Conclusion: AFP ≥ 256 ng/ml had an adverse impact on the survival of patients with rHCC after resection.

The Outcomes of Systemic Treatment in Recurrent Hepatocellular Carcinomas Following Liver Transplants

BACKGROUND

Treatment of hepatocellular carcinoma (HCC) recurrences following liver transplant (LT) is challenging. Most clinical trials of systemic therapies for advanced HCC excluded patients with any history of organ transplant. We aimed to assess the outcomes in using various systemic therapies in patients with post-LT recurrence.

METHODS

Consecutive patients with HCC and recurrences following LT at a large tertiary centre from 2005 to 2018 were reviewed. Overall survival (OS), response rates and adverse events (AEs) were analysed.

RESULTS

Forty-three consecutive patients with a recurrence of HCC following LT were identified from 2005 to 2018. Median OS from diagnosis of recurrence was 17 months (CI 11.3, 22.7). Early recurrence within 12 months of transplant was associated with a significantly worse median survival of 10 months (CI 8.5, 11.4) compared to 26 months (CI 18.8, 33.2) when recurrences occurred after 12 months from transplant (p < 0.001) with a hazard ratio of 0.104 (log-rank test, p < 0.001). A total of 41 patients had received systemic therapies and 79.1% of them were on sorafenib as the first-line treatment. Among these patients treated with sorafenib, median OS from recurrence was 14 months (CI 7.3, 20.7). Hand-foot syndrome (34.7%) was most common among AEs followed by diarrhoea (26.7%). Overall, AEs led to dose interruptions in 8.8% of patients. Notably, 47.1% of patients received subsequent lines of systemic therapies after sorafenib.

CONCLUSIONS

Early recurrence within 1 year from transplant was the most significant risk factor. Treatment efficacy and adverse events and tolerability of sorafenib were comparable with those in the setting of advanced HCC without transplant.

mTOR Inhibition Is Most Beneficial After Liver Transplantation for Hepatocellular Carcinoma in Patients With Active Tumors

OBJECTIVE

The aim of this study was to evaluate the survival benefit of sirolimus in patients undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC) (exploratory analysis of the SiLVER-trial).

SUMMARY AND BACKGROUND DATA

Patients receiving LT) for HCC are at a high risk for tumor recurrence. Calcineurin inhibitors have shown evidence to promote cancer growth, whereas mammalian target of rapamycin (mTOR) inhibitors like sirolimus have anticancer effects. In the SiLVER-trial (Clinicaltrials.gov: NCT00355862), the effect of sirolimus on the recurrence of HCC after LT was investigated in a prospective randomized trial. Although the primary endpoint of improved disease-free survival (DFS) with sirolimus was not met, outcomes were improved for patients in the sirolimus-treatment arm in the first 3 to 5 years. To learn more about the key variables, a multivariate analysis was performed on the SiLVER-trial data.

PATIENTS AND METHODS

Data from 508 patients of the intention-to-treat analysis were included in exploratory univariate and multivariate models for overall survival (OS), DFS and a competing risk analysis for HCC recurrence.

RESULTS

Sirolimus use for ≥3 months after LT for HCC independently reduced the hazard for death in the multivariate analysis [hazard ratio (HR): 0.7 (95% confidence interval, CI: 0.52-0.96, P = 0.02). Most strikingly, patients with an alpha-fetoprotein (AFP) ≥10 ng/mL and having used sirolimus for ≥3 months, benefited most with regard to OS, DFS, and HCC-recurrence (HR: 0.49-0.59, P = 0.0079-0.0245).

CONCLUSIONS

mTOR-inhibitor treatment with sirolimus for ≥3 months improves outcomes in LT for HCC, especially in patients with AFP-evidence of higher tumor activity, advocating particularly for mTOR inhibitor use in this subgroup of patients.

CLINICAL TRIAL REGISTRATION

EudraCT: 2005-005362-36 CLINICALTRIALS.GOV:: NCT00355862.

Liver transplant mortality and morbidity following preoperative radiotherapy for hepatocellular carcinoma

BACKGROUND

Radiotherapy (RT) can be used for tumor downstaging and as a bridge to transplantation in hepatocellular carcinoma (HCC), but its effect on surgical complications is unknown. Therefore, we investigated post-transplant mortality and acute readmission rates in HCC with and without preoperative RT using the National Cancer Database (NCDB).

METHODS

After exclusion, 11,091 transplant patients were analyzed, 165 of whom received RT prior to transplant. Multivariable binomial logistic regression analysis identified characteristics associated with use of RT, and factors associated with increased 30/90-day mortality and 30-day readmission, following propensity matching.

RESULTS

Although RT (median 40 Gy in 5 fractions) was more often delivered to larger tumors and advanced stages, it resulted in 59% downstaging rate, 39% pathologic complete response rate, and a median of 4 additional months to transplantation. Crude 30/90-day mortality rates were both 1.2% with preoperative RT, compared to 2.7% and 4.4% without. The 30-day readmission rate was 5.5% with RT and 10.7% without it. Propensity matched analysis demonstrated no statistical differences in 30/90-day mortality and a lower 30-day readmission rate with preoperative RT. Age >58, stage III disease, lack of transarterial chemoembolization, and shorter time to transplant independently predicted higher 90-day mortality.

CONCLUSION

Preoperative RT for HCC did not increase postoperative mortality or length of stay following liver transplant.

Liver Disease and Hemostasis (Review) Part 2. Cholestatic Liver Disease and Hemostasis

The presence or development of liver disorders can significantly complicate the course of critical illness and terminal conditions. Systemic hemostatic disorders are common in Intensive Care Units patients with cholestatic liver diseases, so the study of the mechanisms of their development can contribute to the understanding of the development of multiorgan failure in critical illness.

The review discusses current data on changes in hemostatic parameters in patients with cholestatic liver diseases, proposes a mechanism for the development of such disorders, which involve interactions of phospholipids with platelet and endotheliocyte membranes. It is suggested that a trend for thrombosis in patients with cholestatic liver disease is due to increased accumulation of bile acids in the systemic circulation. Available data demonstrate that the antiphospholipid syndrome may predispose to the formation of blood clots due to alterations of phospholipid composition of membranes of platelets and vascular endothelial cells by circulating antiphospholipid antibodies. Clarifying the mechanisms contributing to changes of the blood coagulation system parameters in liver disorders will aid to development of optimal correction of hemostatic disorders in patients with chronic liver diseases.

Defining the chance of cure after resection for hepatocellular carcinoma within and beyond the Barcelona Clinic Liver Cancer guidelines: A multi-institutional analysis of 1,010 patients

BACKGROUND

Surgery is considered the only potentially curative treatment option for patients with hepatocellular carcinoma. However, the chance that patients will eventually be "cured" after liver resection for hepatocellular carcinoma remains ill defined.

METHODS

Patients who underwent curative-intent hepatectomy for hepatocellular carcinoma between 1998 and 2017 were identified using an international multi-institutional database. A nonmixture cure model was used with disease-free survival as a primary measure to estimate cure fractions after matching patients with the general population by age, race, and sex.

RESULTS

Among 1,010 patients, the median and 5-year disease-free survival were 2.8 years and 36.6%, respectively. The probability of being cured after hepatocellular carcinoma resection was 42.2% and the median time to cure was 3.35 years. The multivariable cure model revealed preoperative alpha-fetoprotein level, tumor size, tumor number, and margin status as independent predictors of cure. The cure fraction for patients with an alpha-fetoprotein level ≤ 10 ng/mL, largest tumor size ≤5 cm, ≤3 nodules, and R0 resection was 61.6%. In contrast, patients who had all 4 unfavorable prognostic factors (ie, alpha-fetoprotein >11 ng/mL, nodules ≥4, size >5cm, R1 resection) had a cure fraction of 15.8%. Although the probability of cure was 47.6% among Barcelona Clinic Liver Cancer-A patients, patients undergoing resection for Barcelona Clinic Liver Cancer-B hepatocellular carcinoma had a 37.6% cure fraction. Only alpha-fetoprotein levels predicted the probability of cure among Barcelona Clinic Liver Cancer-B patients.

CONCLUSION

Roughly 4 in 10 patients could be considered "cured" after liver resection for hepatocellular carcinoma. Although cure was achieved more often after resection for Barcelona Clinic Liver Cancer-A hepatocellular carcinoma, surgery still provided a reasonable probability of cure among select patients with Barcelona Clinic Liver Cancer-B hepatocellular carcinoma.

Liver graft rejection following immune checkpoint inhibitors treatment: a review

Immune checkpoint inhibitors (ICIs) have demonstrated remarkable efficacy in a variety of solid tumors; nonetheless, they have not been well investigated and are still recognized as a relative contraindication for patients with a liver transplantation (LT) history, since ICIs treatment might potentially lead to graft rejection. The program death-1 (PD-1) and the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) pathways are implicated in the tolerance of transplanted organ, as well as blockade of the pathways, which contribute to eliminating tumors and may inadvertently lead to peripheral transplant rejection. Currently, no guidelines are available regarding the treatment for ICIs patients with a prior LT history. Therefore, this study was carried out to review the recent studies, attempting to introduce the ICIs-related graft rejection after LT from various aspects. We believed that ICIs could be given for the well-informed patients receiving LT and developed recurrence in a controlled setting. Typically, these patients should be treated according to a clinical care path or a prospective clinical trial, so as obtain a persistent anti-tumor immune response in the meantime of avoiding graft rejection, adjust the immunosuppression, reduce the possibility of graft loss following rejection, and have the opportunity to develop biomarkers for tumor response and transplant rejection.

Detection of fusion transcripts in the serum samples of patients with hepatocellular carcinoma

Hepatocellular carcinoma is one of the most lethal cancers in the United States. Early detection of the disease is crucial for reducing the mortality of this malignancy. Recently, we identified a panel of fusion genes present in several types of human cancers, including hepatocellular carcinoma. Among 8 fusion genes, MAN2A1-FER, TRMT11-GRIK2 and CCNH-C5orf30 appear most frequently in hepatocellular carcinoma samples. In this study, we showed that the fusion transcripts of MAN2A1-FER, CCNH-C5orf30 and SLC45A2-AMACR were detected in the serum samples of liver cancer patients as circulating cell-free RNA. The distributions of these gene fusion RNA fragments largely matched those of the primary HCC samples. In contrast, the sera of all healthy individuals free of human malignancies were shown to be negative for these fusion genes. These results suggest that gene fusion RNA is frequently shed from liver cancer cells. The detection of serum cell-free fusion transcripts may provide a new approach to aid in the diagnosis, follow-up or therapy of liver cancers.

Cost-Utility Analysis of Imaging for Surveillance and Diagnosis of Hepatocellular Carcinoma

OBJECTIVE. The purpose of this study is to compare imaging-based surveillance and diagnostic strategies in patients at risk for hepatocellular carcinoma (HCC) while taking into account technically inadequate examinations and patient compliance. MATERIALS AND METHODS. A Markov model simulated seven strategies for HCC surveillance and diagnosis in patients with cirrhosis: strategy A, ultrasound (US) for surveillance and CT for diagnosis; strategy B, US for surveillance and complete MRI for diagnosis; strategy C, US for surveillance and CT for inadequate or positive surveillance; strategy D, US for surveillance and complete MRI for inadequate or positive surveillance; strategy E, surveillance and diagnosis with CT followed by complete MRI for inadequate surveillance; strategy F, surveillance and diagnosis with complete MRI followed by CT for inadequate surveillance; and strategy G, surveillance with abbreviated MRI followed by CT for inadequate surveillance or complete MRI for positive surveillance. Two compliance scenarios were evaluated: optimal and conservative. For each scenario, the most cost-effective strategy was based on a willingness-to-pay threshold of $50,000 (Canadian) per quality-adjusted life year (QALY). Sensitivity analyses were performed. RESULTS. Base-case analysis revealed that strategy E was the most cost-effective when compliance was optimal ($13,631/QALY), and strategy G was the most cost-effective when compliance was conservative ($39,681/QALY). Sensitivity analyses supported the base-case analysis in the optimal compliance scenario, but several parameters altered the most cost-effective strategy in the conservative compliance scenario. CONCLUSION. In an optimal compliance scenario, CT for HCC surveillance and diagnosis and complete MRI for inadequate CT was most cost-effective. In a conservative compliance scenario, abbreviated MRI may be an alternative to US-based surveillance.

Serum biomarkers and risk of hepatocellular carcinoma recurrence after liver transplantation

Liver transplantation (LT) is the only potentially curative treatment for selected patients with cirrhosis and hepatocellular carcinoma (HCC) who are not candidates for resection. When the Milan criteria are strictly applied, 75% to 85%of 3- to 4-year actuarial survival rates are achieved, but up to 20% of the patients experience HCC recurrence after transplantation. The Milan criteria are based on the preoperative tumor macromorphology, tumor size and number on computed tomography or magnetic resonance imaging that neither correlate well with posttransplant histological study of the liver explant nor accurately predict HCC recurrence after LT, since they do not include objective measures of tumor biology. Preoperative biological markers, including alpha-fetoprotein, des-gamma-carboxiprothrombin or neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio, can predict the risk for HCC recurrence after transplantation. These biomarkers have been proposed as surrogate markers of tumor differentiation and vascular invasion, with varied risk magnitudes depending on the defined cutoffs. Different studies have shown that the combination of one or several biomarkers integrated into prognostic models predict the risk of HCC recurrence after LT more accurately than Milan criteria alone. In this review, we focus on the potential utility of these serum biological markers to improve the performance of Milan criteria to identify patients at high risk of tumoral recurrence after LT.

Serological Risk Index Based on Alpha-Fetoprotein and C-Reactive Protein to Indicate Futile Liver Transplantation Among Patients with Advanced Hepatocellular Carcinoma

BACKGROUND

The aim of this study was to establish a preoperatively available serological risk index using alpha-fetoprotein (AFP) and C-reactive protein (CRP) for predicting oncologically futile liver transplantation (LT) in hepatocellular carcinoma (HCC) patients.

METHODS

A total of 119 liver transplant patients with HCC were retrospectively analyzed. The prognostic impact of clinical and histopathologic factors including pre-LT serum AFP and CRP values was determined.

RESULTS

Apart from microvascular tumor invasion (MVI; odds ratio [OR] 15.77), pretransplant serum levels of AFP > 100 ng/ml (OR 13.31) and CRP > 0.8 mg/dl (OR 13.97) were identified as independent predictors of HCC recurrence. The cumulative risk of HCC relapse at 5 years post-LT was 2.3% in low serological tumor activity (STA) index (AFP ≤ 100 ng/ml + CRP ≤ 0.8 mg/dl), 17.1% in intermediate STA (AFP ≤ 100 ng/ml or CRP ≤ 0.8 mg/dl), and 91.6% in high STA index (AFP > 100 ng/ml + CRP > 0.8 mg/dl; p < 0.001), respectively. High STA index was identified as most powerful pre-LT available predictor of MVI (OR 15.31) and posttransplant HCC recurrence (OR 54.44). Five-year recurrence-free survival rate in Milan Out patients with high STA was 0%, compared to 91.7% and 83.6% in those with low or intermediate STA index (p < 0.001), respectively.

CONCLUSION

Our proposed serological risk index based on pretransplant serum AFP and CRP values is able to predict oncologically futile LT among advanced HCC patients.