Alpha-fetoprotein and 18F-FDG positron emission tomography predict tumor recurrence better than Milan criteria in living donor liver transplantation

Background & Aims: 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 F-18-fluorodeoxyglucose positron emission tomography (F-18-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 F-18-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 F-18-FDG PET positivity. Results: The 5-year disease-free survival rates and overall survival rates were 80.3% and 81.6% respectively. F-18-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 F-18-FDG PET data predicted better outcomes than those using the Milan criteria, improving objectivity when adult-to-adult living donor LT is contemplated. (C) 2015 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.