New score helps predict HCC recurrence after liver transplant

Reuters Health Information: New score helps predict HCC recurrence after liver transplant

New score helps predict HCC recurrence after liver transplant

Last Updated: 2016-11-18

By Joan Stephenson

NEW YORK (Reuters Health) - A new scoring system based on tumor characteristics can help predict the risk of recurrence of hepatocellular carcinoma (HCC) after liver transplantation, new research shows.

Having a better way to predict recurrence risk may help clinicians "determine appropriate surveillance strategies for tumor recurrence in HCC patients undergoing transplant and . . . help determine appropriate patients for future adjuvant therapies," first author Dr. Neil Mehta, of the University of California, San Francisco, told Reuters Health by email.

For the past 20 years, the "Milan criteria" - the presence on imaging of a single HCC lesion of no greater than 5 cm or two to three lesions of no more than 3 cm - have been used to select which patients with HCC are candidates for liver transplantation.

However, despite physician adherence to the Milan criteria, tumor recurrence after liver transplant "is still a significant problem, as it is the most common cause of death in this population, occurring in up to 15% of transplant recipients," noted Dr. Mehta.

Although there are known risk factors for HCC recurrence after transplant, including tumor burden and microvascular invasion, no reliable model for estimating post-transplant recurrence exists, the authors say.

To address this issue, they tested predictors of recurrence in a "development cohort" of 721 patients (75% men, median age of 58 at the time of HCC diagnosis) who underwent liver transplantation at three centers between 2002 and 2012.

Three variables - microvascular invasion, median alpha-fetoprotein (AFP) level at the time of transplantation, and tumor burden (the sum of the largest viable tumor diameter and number of viable tumors on explant) - were independently associated with HCC recurrence, the researchers report in JAMA Oncology, online November 13.

They used these three variables to create the risk estimation of tumor recurrence after transplant (RETREAT) score.

The RETREAT score is the sum of points for each of the three variables (2 points for any microvascular invasion, plus 0 to 3 points for increasing levels of AFP, plus 0 to 3 points for increasing tumor burden). The scores, which ranged from 0 to 5 or greater, were highly predictive of HCC recurrence, with higher scores indicating a higher probability of recurrence after liver transplantation.

The RETREAT scoring system was able to stratify five-year post-transplantation recurrence risk from less than 3% for those with a score of 0 to greater than 75% for a score of 5 or more, which "significantly outperformed the Milan criteria by explant," Dr. Mehta said.

The approach was then tested in a validation cohort of 340 patients (83% men, median age of 56 at the time of HCC diagnosis) at a fourth center.

"Despite higher rates of microvascular invasion, explant tumor burden, and overall HCC recurrence in the validation cohort, the RETREAT score still performed well," the researchers report.

Additional validation of the RETREAT score in another cohort was presented on November 13 during a session at the annual meeting of the American Association for the Study of Liver Diseases (AASLD), noted Dr. Mehta.

"The presentation at the AASLD meeting was a validation of the RETREAT score in the United Network for Organ Sharing (UNOS) database of over 3,300 liver transplant recipients," he said.

Patients meeting the Milan criteria generally have an 80% chance of long-term cancer-free survival after liver transplantation, and the RETREAT score "has a higher predictive value than Milan," noted Dr. Jean C. Emond, of Columbia University and The New York Presbyterian Hospital.

Most importantly, he told Reuters Health by email, the RETREAT score identifies a subset of patients with a recurrence rate greater than 29% and up to 75%.

"The value of this study is the identification of a subset of patients who could be enrolled in adjuvant therapeutic trials with a measurable risk of recurrence that could readily identify an effective therapy," explained Dr. Emond, who was not involved with the study.

The score's limitation "is that it can only be applied after the transplant and can therefore not inform either selection or prioritization of patients on the waiting list," he said.

The study had no commercial funding and the authors reported no disclosures.


JAMA Oncol 2016.

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