New score predicts recurrence after liver transplantation for hepatocellular carcinoma

Last Updated: 2016-10-13

By Will Boggs MD

NEW YORK (Reuters Health) - MORAL, a new risk-stratification score, accurately predicts recurrence of hepatocellular carcinoma (HCC) after liver transplcanantation, researchers report.

"HCC tumor biology is the most important predictor of recurrence, and it is crucial that we employ indices of tumor biology in our selection of patients with HCC who are eligible for transplant," Dr. Karim J. Halazun from Weill Cornell Medical College, New York, told Reuters Health by email.

"While in general recurrence rates are low, attempting to move towards zero HCC recurrences, and as such save valuable transplantable organs should be the aim of the entire transplant community," he said.

The Milan criteria are routinely used to assess the extent of tumor and to determine transplant eligibility in patients with HCC. They are based solely on radiological findings and provide little insight into tumor biology.

Dr. Halazun's team previously developed their Model of Recurrence After Liver transplantation (MORAL), a score that incorporates neutrophil-lymphocyte ratio (NLR), alpha-fetal protein (AFP), and tumor characteristics, and showed that it accurately predicted recurrence-free survival (RFS) after liver transplantation.

They now present an update on the original MORAL score, with four-year follow-up data from 339 patients, 50 of whom developed recurrent disease.

Their updated MORAL score based on preoperatively available factors assigned 6 points for elevated NLR >=5, 4 points for maximum AFP >200 ng/mL, and 3 points for largest tumor size >3 cm, whereas their MORAL score based on factors available post-transplantation assigned 6 points for grade-4 tumors, 2 points for vascular invasion, 3 points for largest size on pathology >3 cm, and 2 points for tumor number on pathology >3.

Total scores were used to categorize patients as low risk (0-2), medium risk (3-6), high risk (7-10), and very high risk (>10), the researchers explain in Annals of Surgery, online September 8.

Five-year RFS based on the preoperative MORAL score was 98.6% in the low-risk group, 69.8% in the medium-risk group, and 55.8% in the high-risk group. In the very-high-risk group, RFS was only 17.9% at one year.

Postoperative MORAL scores and a combined MORAL score provided similar discrimination of RFS among the risk groups.

"Perhaps the most interesting result however is that patients with very high-risk MORAL scores within Milan criteria did just as poorly as those outside of Milan criteria with very high-risk MORAL scores," Dr. Halazun said. "Patients outside Milan with low-risk MORAL scores did extremely well with recurrence-free survivals approaching 80% at 5 years."

In a comparison of the MORAL scores with Milan criteria using ROC curves, the C-statistics were lower for the Milan criteria (0.63) than for the preoperative (0.82), post-transplant (0.88), and combined (0.91) MORAL scores.

"MORAL gives us the ability to predict accurately which patients are high-risk for recurrence, and as such identifies a group of patients in whom we need to do research on reducing that risk either pre- or post-transplant," Dr. Halazun said.

"Our original MORAL score provides the most accurate risk stratification model to date for tumor recurrence in patients with HCC undergoing liver transplant," the researchers conclude. "If validated by external groups, this score can act as an adjunct to the Milan criteria allowing for a more objective identification of tumors with aggressive biology and aid in the selection and management of patients with HCC to undergone liver transplantation."

SOURCE: http://bit.ly/2cFFPIe

Ann Surg 2016.