Liver transplantation for hepatocellular carcinoma: a model including alpha-fetoprotein improves the performance of Milan criteria
Menée sur deux cohortes incluant au total 972 patients ayant reçu une greffe de foie pour un carcinome hépatocellulaire, cette étude évalue, par rapport aux critères de Milan, l'intérêt d'un système de score incorporant le taux d'alpha-fœtoprotéine pour prédire le risque de récidive
The aim of this study was to generate an improved prognostic model for predicting recurrence in liver transplant candidates with hepatocellular carcinoma (HCC). Predictors of recurrence were tested by a Cox model analysis in a training cohort of 537 patients transplanted for HCC. A prognostic score was developed, and validated in a national cohort of 435 patients followed prospectively. AFP independently predicted tumor recurrence and correlated with vascular invasion and differentiation. At a Cox score threshold of 0.7 (AUROC: 0.701, (95% CI: 0.63-0.76), accuracy: 75.8%), a model combining log10 AFP, tumor size and number was highly predictive of tumor recurrence and death. Using a simplified version of the model, with untransformed AFP values, a cut-off value of 2 was identified. In the validation cohort, a score > 2 predicted a marked increase in 5-year risk of recurrence (50.6 ±10.2% vs 8.8±1.7%, p<0.001) and decreased survival (47.5±8.1% vs. 67.8 ±3.4%, p=0.002) as compared with others. Among patients exceeding Milan criteria, a score ≤ 2 identified a subgroup of patients with AFP < 100 ng/mL with a low 5-year risk of recurrence (14.4±5.3% vs. 47.6±11.1% (p=0.006)). Among patients within Milan criteria, a score > 2 identified a subgroup of patients with AFP > 1000 ng/mL at high risk of recurrence (37.1±8.9% vs. 13.3±2.0%, p<0.001). NRI showed that predictability of the AFP model was superior to Milan criteria. Prediction of tumor recurrence is significantly improved by a model which incorporates AFP. We propose the adoption of new selection criteria for HCC transplant candidates, taking into account AFP.
Gastroenterology , résumé, 2011