LIVER TRANSPLANTATION (LT) FOR HEPATOCELLULAR CARCINOMA (HCC): RELATIONSHIP BETWEEN ALPHA-FETOPROTEIN (AFP) AND OUTCOME.Room: Hall C
RT Stravitz, DM Heuman, N Chand, ML Shiffman, DG Maluf, AH Cotterell, MP Posner, BE Williams, RK Sterling, VA Luketic, AJ Sanyal, A Habib, AA Mihas, E Gavis, RA Fisher. Liver Transplant Program, Virginia Commonwaelth University, Richmond, VA; GI Section, McGuire Veterans Administration Medical Center, Richmond, VA.
In patients with cirrhosis (Cx), surveillance (Srv) programs including AFP and ultrasound have been advocated to detect earlier stage HCC. Our objective was to determine whether the AFP and AFP kinetics at and preceding diagnosis of HCC were useful as predictors of outcome. Methods. We reviewed records of 296 patients with Cx and HCC from our academic center and its VA affiliate seen between 1997 and 2005. Of these, 286 had AFP determined at the time HCC was diagnosed, and 182 had 1 additional AFP determination 3 months before diagnosis. Results. The median AFP at HCC diagnosis was 60 ng/ml, with 1/3 less than 17 (AFP-L), 1/3 between 17 and 248 (AFP-M) and 1/3 greater than 248 (AFP-H). 3-Year survival (Kaplan-Meier) from diagnosis of HCC was strongly associated with AFP at diagnosis (AFP-L=50%, AFP-M=31%, AFP-H=18%, all p<0.01 by Cox regression). AFP-H patients were more likely to be stage 3-4 at diagnosis (75% vs. 37 and 34% for AFP-M and AFP-L, respectively), even in patients who had undergone regular HCC Srv (49% vs. 30 and 21%, respectively). 83 patients (28%) underwent LT, of whom 73 (88%) had stage 1-2 HCC at diagnosis. The probability of receiving LT declined with increasing AFP at diagnosis (AFP-L=42%, AFP-M=26%, AFP-H=11%), including sub-analysis restricted to patients with stage 1-2 disease at diagnosis (57%, 37% and 26%, respectively). Increasingly rapid AFP doubling times (DT) of > 360 d, 180-360 d, and <180 d during the months preceding diagnosis were associated with increasing risk of stage 3-4 at diagnosis (20%, 40%, and 49% respectively; p < 0.01), and patients with DT < 180 d were less likely to undergo LT than patients with DT > 180 d (32 vs. 58%; p < 0.05). In patients receiving LT, survival was not related to AFP at diagnosis nor to DT; however, all 5 HCC recurrences post-LT were in patients with AFP > 100 at diagnosis. Conclusion. Both the absolute level and rate of increase of AFP are markers of biological aggressiveness of HCC. Even with careful Srv, tumors associated with elevated AFP were diagnosed at a more advanced stage and had poorer outcomes. These considerations should be taken into account in designing HCC Srv programs and in selecting patients for LT.
Keywords: Hepatocellular carcinoma; Liver cirrhosis; Screening
Wednesday, July 26, 2006 12:30 PM
Poster Session: Malignancy (12:30 PM-2:00 PM)