Alpha-Fetoprotein Decrease from > 1,000 to < 500 ng/mL in Patients with Hepatocellular Carcinoma Leads to Improved...

Area of Science:

• Hepatobiliary Surgery
• Transplant Oncology
• Medical Policy Evaluation

Background:

• High alpha-fetoprotein (AFP) levels (> 1,000 ng/mL) are linked to adverse outcomes in liver transplantation (LT) for hepatocellular carcinoma (HCC).
• A national policy now mandates AFP reduction to < 500 ng/mL before LT for HCC, but optimal thresholds require further investigation.

Purpose of the Study:

• To assess the impact of reducing AFP levels from > 1,000 ng/mL to various thresholds on patient survival and HCC recurrence after LT.
• To evaluate the efficacy of different AFP reduction targets in the context of current LT policies for HCC.

Main Methods:

• Analysis of 407 patients undergoing LT between 2005-2015 with pre-LT AFP > 1,000 ng/mL, using the United Network for Organ Sharing database.
• Comparison of post-LT survival and HCC recurrence rates based on the last pre-LT AFP measurement: > 1,000 ng/mL, 101-499 ng/mL, or ≤ 100 ng/mL.

Main Results:

• Patients with last pre-LT AFP of 101-499 ng/mL (9.6%) and ≤ 100 ng/mL (14.3%) had significantly better 5-year survival (67.0% and 88.4%) and lower HCC recurrence (13.3% and 7.2%) compared to those with AFP > 1,000 ng/mL (48.8% survival, 35.0% recurrence).
• Reduction to 101-499 ng/mL was associated with a >2-fold decrease in post-LT mortality and a nearly 3-fold decrease in HCC recurrence.
• Fewer patients with reduced AFP levels (101-499 ng/mL or ≤ 100 ng/mL) received local-regional therapy prior to LT compared to those with AFP > 1,000 ng/mL.

Conclusions:

• Reducing AFP levels from > 1,000 ng/mL to < 500 ng/mL before LT significantly improves post-transplant survival and reduces HCC recurrence.
• These findings support the current national policy of requiring AFP reduction to < 500 ng/mL for HCC patients undergoing LT.