Journal
ANNALS OF SURGERY
Volume 263, Issue 5, Pages 842-850Publisher
LIPPINCOTT WILLIAMS & WILKINS
DOI: 10.1097/SLA.0000000000001578
Keywords
beyond the Milan criteria; hepatocellular carcinoma; living donor liver transplantation; MoRAL score
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Funding
- National R&D Program for Cancer Control
- Ministry for Health and Welfare, Republic of Korea [1420050]
- Korean Association for Study of the Liver-Korean Liver Foundation
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Objective:To develop and validate a model to predict tumor recurrence after living donor liver transplantation (LDLT) (MoRAL) for hepatocellular carcinoma (HCC) beyond the Milan criteria (MC).Background:Some subgroups of HCC exceeding the MC experience substantial benefit from LDLT.Methods:This multicenter study included a total of 566 consecutive patients who underwent LDLT in Korea: the beyond-MC cohort (n = 205, the derivation [n = 92] and validation [n = 113] sets) and the within-MC cohort (n = 361). The primary endpoint was time-to-recurrence.Results:Using multivariate Cox proportional hazard model, we derived the MoRAL score using serum levels of protein induced by vitamin K absence-II and alpha-fetoprotein, which provided a good discriminant function on time-to-recurrence (concordance index = 0.88). Concordance index was maintained similarly on both internal and external validations (mean 0.87 and 0.84, respectively). At cut off of 314.8 (75th percentile value), a low MoRAL score (314.8) was associated with significantly longer recurrence-free (versus > 314.8, HR = 5.29, P < 0.001) and overall survivals (HR = 2.59, P = 0.001) in the beyond-MC cohort. The 5-year recurrence-free and overall survival rates of beyond-MC patients with a low MoRAL score were as high as 66.3% and 82.6%, respectively. The within-MC patients with a high MoRAL score showed a higher risk of recurrence than beyond-MC patients with a low MoRAL score (HR = 2.56, P = 0.035). The MoRAL score was significantly correlated with explant histology.Conclusions:This new model using protein induced by vitamin K absence-II and alpha-fetoprotein provides refined prognostication. Among beyond-MC HCC patients, those with a MoRAL score 314.8 and without extrahepatic metastasis might be potential candidates for LDLT.
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