Selecting liver transplantation candidate for hepatocellular carcinoma patients beyond the milan criteria

Jeong Hoon Lee, Yuri Cho, Hwi Young Kim, Eun Ju Cho, Dong Hyeon Lee, Su Jong Yu, Jae Woo Lee, Nam Joon Yi, Kwang Woong Lee, Seoung Hoon Kim, Jong Man Kim, Jae Won Joh, Lewis W. Teperman, James S. Park, Yoon Jun Kim, Kyung Suk Suh, Jung Hwan Yoon

Research output: Contribution to journalArticlepeer-review

66 Scopus citations

Abstract

Objective: To develop and validate a model to predict tumor recurrence after living donor liver transplantation (LDLT) (MoRAL) for hepatocellular carcinoma (HCC) beyond the Milan criteria (MC). Background: Some subgroups of HCC exceeding the MC experience substantial benefit from LDLT. Methods: This multicenter study included a total of 566 consecutive patients who underwent LDLT in Korea: the beyond-MC cohort (n = 205, the derivation [n = 92] and validation [n = 113] sets) and the within-MC cohort (n = 361). The primary endpoint was time-to-recurrence. Results: Using multivariate Cox proportional hazard model, we derived the MoRAL score using serum levels of protein induced by vitamin K absence-II and alpha-fetoprotein, which provided a good discriminant function on timeto- recurrence (concordance index = 0.88). Concordance index was maintained similarly on both internal and external validations (mean 0.87 and 0.84, respectively). At cut off of 314.8 (75th percentile value), a low MoRAL score (≤314.8) was associated with significantly longer recurrence-free (versus > 314.8, HR = 5.29, P < 0.001) and overall survivals (HR = 2.59, P = 0.001) in the beyond-MC cohort. The 5-year recurrence-free and overall survival rates of beyond-MC patients with a low MoRAL score were as high as 66.3% and 82.6%, respectively. The within-MC patients with a high MoRAL score showed a higher risk of recurrence than beyond-MC patients with a low MoRAL score (HR = 2.56, P = 0.035). The MoRAL score was significantly correlated with explant histology. Conclusions: This new model using protein induced by vitamin K absence-II and alpha-fetoprotein provides refined prognostication. Among beyond-MC HCC patients, those with a MoRAL score ≤314.8 and without extrahepatic metastasis might be potential candidates for LDLT.

Original languageEnglish
Pages (from-to)842-850
Number of pages9
JournalAnnals of Surgery
Volume263
Issue number5
DOIs
StatePublished - 2016

Keywords

  • Beyond the Milan criteria
  • Hepatocellular carcinoma
  • Living donor liver transplantation
  • MoRAL score

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