The Prognostic Value Of Serum Alpha Fetoprotein In Patients Undergoing Living Donor Liver Transplantation For Hepatocellular Carcinoma

Backgroud:Liver caner is one of the most prevalent malignant tumors in the world. It’s the second common cause of cancer death and the fight against liver cancer has always been among the top priorities of health care in China. Hepatocellular carcinoma (HCC) is the most common pathological type of liver cancer and in most cases HCC is complicated with liver cirrhosis. Liver transplantation is considered to be the ideal treatment option for HCC besides hepatectomy because it can treat both cirrhosis and tumor in the same time. It has already been confirmed by a substantial number of studies that patients with HCC who meet the Milan criteria could undergo liver transplantation with satisfactory long-term outcomes. Liver transplantation is recommended by EASL-EORTC as the first-line treatment option for patients who meet the Milan criteria but are not suitable for resection. In spite of excellent clinical outcomes, the application of deceased donor liver transplantation (DDLT) is limited largely because of the shortage of the deceased-donor organs and long waiting time associated with drop-out or progression of tumors. Compared to DDLT, living donor liver transplantation (LDLT) has several advantages such as increasing the availability of organs and shortening the waiting time and has been applied in many liver transplantation centers worldwide in recent years.Alpha-fetoprotein (AFP) is the most commonly used tumor marker for the screen and diagnosis of primary liver cancer. The prognostic value of serum AFP in patients who undergo DDLT for HCC has been confirmed by many studies. In fact, AFP is considered to be the only biomarker that can be used for clinical decision making regarding liver transplantation criteria for HCC. To the best of our knowledge, the data concerning the prognostic value of serum AFP in the patients undergoing LDLT for HCC is scarce. The current study aims to explore the the prognostic value of serum AFP in patients undergoing LDLT for HCC.Methods:38patients were included in this study who met the following criteria:patients who underwent LDLT for HCC in the First Affiliated Hospital of Zhejiang University from January2007to December2013; the diagnosis of HCC was confirmed by pathological analysis after the removal of the liver by surgery. Patients whose pathological diagnosis was combined hapatocellular carcinoma or cholangiocarcinoma were excluded in this study. Patients selected were then divided into two groups (group A with preoperative AFP≤400ng/ml, n=19; group B with preoperative AFP>400ng/ml, n=19)according to the serum level of AFP before LDLT. The clinical and pathological characteristics of the two groups are compared. The differences in the recurrence and survival between the two groups were also investigated. Furthermore, Patients within Milan criteria and outside Milan criteria were further divided into subgroups according to AFP level, followed by the investigation of overall survival(OS) and recurrence-free survival(RFS) of patients in these groups after LDLT. Results:1.Among the38patients,19(50%) belonged to group A and19(50%) to group B. Patients were followed up for a mean47.39months (range,0-83months). The overall incidence of HCC recurrence was34.2%. The mean time between transplantation and the diagnosis of HCC recurrence or metastasis was10.31±7.98months. The two groups were comparable in terms of age, gender, cirrhosis, Child-Pugh score, MELD score, tumor differentiation, Macrovascular invasion, treatment before LDLT and fulfilling theMilan criteria.2.The incidence of HCC recurrence in group A was15.8%, which was significantly lower than that of group B(52.6%). The mean time between transplantation and the diagnosis of HCC recurrence or metastasis was comparable between the two groups (P>0.05).3. The1-and5-year OS in group A were89.5%,78.9%respectively, while those in group B were66.7%,50%respectively. There was a significant difference between the two groups in terms of OS. The1-and5-year RFS in group A were84.2%,78.9%respectively, while those in group B were44.4%,33.3%respectively. There was a significant difference between the two groups in terms of RFS.4.Patients fulfilling the Milan criteria with preoperative AFP≤400ng/ml had better outcomes in terms of OS and RFS than those fulfilling the Milan criteria with AFP>400ng/ml. The OS and RFS of Patients beyond the Milan criteria with AFP≤400ng/ml and those beyond the Milan criteria with AFP>400ng/ml were comparable.Conclusion:1. The level of serum AFP before LDLT is closely related to the incidence of HCC recurrence after LDLT. 2. Patients undergoing LDLT for HCC with AFP≤400ng/ml had significantly better OS and RFS than patients with AFP<400ng/ml. Serum AFP before LDLT could be valuable in predicting outcomes of patients undergoing LDLT for HCC and a cutoff value of400ng/ml for preoperative AFP is valid in this study.3. Patients matching the Milan criteria who underwent LDLT for HCC had significantly different outcomes when they were separately considered by AFP at a cutoff value of400ng/ml. The prognostic value of Milan criteria which is mainly based on tumor size and numbers in LDLT for HCC is limited. Serum AFP before LDLT is an important factor that should be considered in the decision making regarding criteria of LDLT for HCC.