Alpha-fetoprotein and ¹⁸F-FDG positron emission tomography predict tumor recurrence better than Milan criteria in living donor liver transplantation

Background & Aims Given the organ shortage for liver transplantation (LT) and the limitations of the current morphology-based selection criteria, improved criteria are needed to achieve the maximum benefit of LT for hepatocellular carcinoma (HCC). We hypothesized that a combination of biological markers may better predict the prognosis than the Milan criteria. Methods HCC patients (n = 123) with preoperative data on serum alpha-fetoprotein (AFP) levels and ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) positivity underwent live-donor LT between January 2003 and December 2009. The cut-off values for serum AFP levels (200 ng/ml) and ¹⁸F-FDG PET positivity (1.10) for tumor recurrence were determined by c-statistics using receiver operating characteristic curves. Univariate and multivariate analyses with preoperative variables were performed to find pre-transplant prognostic factors. Disease-free survival rates and overall survival rates were analysed with regard to serum AFP levels and ¹⁸F-FDG PET positivity. Results The 5-year disease-free survival rates and overall survival rates were 80.3% and 81.6% respectively. ¹⁸F-FDG PET positivity (hazard ratio (HR) 9.766, 95% CI 3.557-26.816; p <0.001) and serum AFP level (HR 6.234, 95% CI 2.643-14.707; p <0.001) were the only significant pre-transplant prognostic factors in the multivariate analysis; tumor number and size were not significant. A combination of criteria showed that the biologically high-risk group (AFP level ≥200 ng/ml and PET-positive) had an HR of 29.069 (95% CI 8.797-96.053; p <0.001) compared with the double-negative group. Use of the Milan criteria yielded an HR of 1.351 (95% CI 0.500-3.652; p = 0.553). Conclusions The combination of the serum AFP level and ¹⁸F-FDG PET data predicted better outcomes than those using the Milan criteria, improving objectivity when adult-to-adult living donor LT is contemplated.