Statistical Model With a-Fetoprotein Response Better Predicts Success of Liver Transplant in Patients With Hepatocellular Carcinoma Recurrence

Hepatocellular carcinoma
Hepatocellular carcinoma
Researchers aimed to validate use of the NCYA score and its incorporation of AFP-R in the selection of patients for liver transplant due to HCC recurrence.

A retrospective, multicenter prognostic analysis of patients undergoing liver transplant for hepatocellular carcinoma (HCC) recurrence validated the importance of including a-fetoprotein response (AFP-R) into HCC selection tools. These findings were published in JAMA Surgery.

Patients (N=2236) undergoing liver transplant at 4 centers in North America and 4 centers in Europe were prospectively enrolled in this study between 2001 and 2013. Patients were assessed by HCC selection tools for recurrence-free and overall survival outcomes following their procedure.

Patients were 80.9% men aged mean 58.3 (SD, 7.96) years. Patients in the North American cohort were more likely to have hepatitis C (60.1%) and the European cohort was dominated by alcohol-related liver disease (37.2%; P <.001).

Patients with AFP levels >10,000 ng/mL were associated with decreased survival rates compared with patients who had levels between 1000 and 9999 ng/mL.

The New York/California (NYCA) score predicted risk on the basis or tumor size and number at diagnosis as well as AFP response. Low-risk NYCA scores (0-2) were associated with a 9.5% 5-year cumulative recurrence risk, 20.5% for scores of 3 to 6, and 40.5% for scores ³7 (all P <.001).

Vascular invasion was present among 12.8% of the low score cohort, 20.6% of the intermediate, and 37.6% of the high-risk group (P <.001). NYCA scores were also associated with poor differentiation (6.6% vs 9.4% vs 14.8%; P <.001) and pathologic response (24.0% vs 15.8% vs 9.6%; P <.001), respectively.

Overall survival was associated with intermediate NYCA scores (hazard ratio [HR], 1.35; 95% CI, 1.14-1.60; P =.001) and high scores (HR, 2.36; 95% CI, 1.81-3.10; P <.001).

NYCA scores were better at predicting recurrence (Harrell C, 0.66; all P <.001) compared with Metroticket 2.0 (Harrell C, 0.60), French AFP (Harrell C, 0.57), and Milan Criteria (Harrell C, 0.58). A total of 83.1% (n=453) of the patients who did not meet the Milan Criteria, 76.1% (n=292) of those not meeting Metroticket 2.0, and 69.2% (n=213) of those not meeting French AFP were categorized as low or intermediate risk under the NYCA criteria, having >75% 5-year recurrence-free survival and >70% overall survival.

This study was limited by its retrospective, multicenter design as well as its discovery of significant between-center variability among treatments administered and procedural success.

This study validated the NYCA score and the importance of incorporating dynamic AFP-R into models predicting liver transplant success in patients with HCC recurrence.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Halazun K J, Rosenblatt RE, Mehta N, et al. Dynamic α-fetoprotein response and outcomes after liver transplant for hepatocellular carcinoma. JAMA Surg. 2021; 156(6):559-567. doi: 10.1001/jamasurg.2021.0954.