Alpha-fetoprotein-expressing HCCs predict poorer transplant outcome

Last Updated: 2016-10-12

By David Douglas

NEW YORK (Reuters Health) - The substantial minority of hepatocellular carcinoma (HCC) patients with tumors not expressing alpha-fetoprotein (AFP) have better outcomes following liver transplantation, according to a retrospective study.

"Alpha-fetoprotein has long been known to be a biomarker in hepatocellular carcinoma, however, a significant proportion of patients with HCC do not express the biomarker," Dr. Vatche G. Agopian told Reuters Health by email.

He added, "We specifically examined the cancer outcomes of patients who had tumors which did not express AFP, and found that controlling for other factors such as tumor size and number, patients whose tumors do not express AFP were more likely to have more favorable pathologic characteristics and diminished post-transplant HCC recurrence."

As reported October 5 online in JAMA Surgery, Dr. Agopian of the David Geffen School of Medicine at UCLA and colleagues studied 655 patients who underwent liver transplantation between 1989 and 2013. About two-thirds - 68.7% - had AFP-producing tumors. The remaining 38.3% did not.

Both groups had similar characteristics, but non-AFP tumors were more likely to be smaller, fewer and less poorly differentiated. The non-AFP group had significantly superior recurrence-free survival at one year (88% versus 76%), three years (747% versus 59%) and five years (67% versus 51%). Five-year recurrence rates were also lower (8.8% versus 22.0%).

"Even for patients who did experience posttransplant recurrence, the median time to recurrence was significantly longer for the patients with non-AFP-producing tumor," the researchers report.

Overall five-year survival was better, and recurrence lowest, among patients with non-AFP-producing tumors within the Milan criteria (71% survival and 6% recurrence) and survival was poorest, and recurrence highest, for patients with AFP-producing tumors outside the Milan criteria (40% survival and 42% recurrence).

Among significant predictors of recurrence among patients with non-AFP-producing tumors were radiologic findings of more than two tumors (hazard ratio, 4.98), cumulative diameter outside the Milan criteria (HR, 10.0) and microvascular (HR, 3.07) and macrovascular invasion (HR, 8.75).

Our findings, say the investigators, "are consistent with the few prior studies demonstrating this association of AFP status with pathologic differentiation and vascular invasion."

Summing up, Dr. Agopian said, "Incorporating serum AFP to the current radiological selection criteria may significantly improve transplant candidate selection."

In an editorial, Drs. Barry Schlansky and Susan L. Orloff of Oregon Health and Science University in Portland observe, "Evidence supports a role for AFP in identifying patients with a poor prognosis after (liver transplantation), but it remains elusive how to incorporate AFP status into liver allocation policy, which prioritizes patients by medical urgency."

Nevertheless, they conclude, "As the incidence of HCC surges despite a relatively fixed donor pool, the inclusion of AFP status into the allocation policy could facilitate the redistribution of scarce organs to patients with or without HCC likely to benefit the most."

SOURCE: http://bit.ly/2e9Mq9Z and http://bit.ly/2dMqMg7

JAMA Surg 2016.