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).

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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.