Outcomes of liver transplantation for hepatocellular carcinoma (HCC) are determined by cancer-related and non-related events.
Treatments for hepatitis C virus infection have reduced non-cancer events among patients receiving liver transplants, so reducing HCC-related death might be an actionable end point.
Dr Vincenzo Mazzaferro and colleagues from Italy performed a competing-risk analysis to evaluate factors associated with survival of patients with HCC and developed a prognostic model based on features of HCC patients before liver transplantation.
The researchers performed multivariable competing-risk regression analysis to identify factors associated with HCC-specific death of patients who underwent liver transplantation.
|To have a 70% chance of HCC-specific survival 5 years after transplantation, the level of AFP should be <200 ng/mL|
The training set comprized 1018 patients who underwent liver transplantation for HCC from 2000 through 2013 at 3 tertiary centers in Italy.
The validation set comprized 341 consecutive patients who underwent liver transplantation for HCC during the same period at the Liver Cancer Institute in Shanghai, China.
The researchers collected pretransplantation data on etiology of liver disease, number and size of tumors, patient level of α-fetoprotein (AFP), model for end-stage liver disease score, tumor stage, numbers and types of treatment, response to treatments, tumor grade, microvascular invasion, dates, and causes of death.
Death was defined as HCC-specific when related to HCC recurrence after transplantation, disseminated extra- and/or intrahepatic tumor relapse and worsened liver function in presence of tumor spread.
The cumulative incidence of death was segregated for hepatitis C virus status.
The research team found that the sum of tumor number and size and of log10 level of AFP were significantly associated with HCC-specific death, returning an average c-statistic of 0.780.
The team noted that 5-year cumulative incidence of non−HCC-related death was 9% in HCV-negative patients, and 18% in HCV-positive patients.
The researchers observed that for patients with HCC to have a 70% chance of HCC-specific survival 5 years after transplantation, their level of AFP should be <200 ng/mL and the sum of number and size of tumors should not exceed 7.
If the level of AFP was 200−400 ng/mL, the sum of the number and size of tumors should be ≤5.
The team noted that if their level of AFP was 400−1000 ng/mL, the sum of the number and size of tumors should be ≤4.
In the validation set, the model identified patients who survived 5 years after liver transplantation with 0.721 accuracy.
The team's model, based on patients’ level of AFP and HCC number and size, outperformed the Milan; University of California, San Francisco; Shanghai-Fudan; Up-to-7 criteria; and AFP French model to predict which patients will survive for 5 years after liver transplantation.
Dr Mazzaferro's team concludes, "We developed a model based on level of AFP, tumor size, and tumor number, to determine risk of death from HCC-related factors after liver transplantation."
"This model might be used to select end points and refine selection criteria for liver transplantation for patients with HCC."
"To predict 5-year survival and risk of HCC-related death using an online calculator, please see www.hcc-olt-metroticket.org/."