Research ArticleThe impact of waiting list alpha-fetoprotein changes on the outcome of liver transplant for hepatocellular carcinoma

Background & AimsLiver transplantation is a recognized treatment for selected patients with hepatocellular carcinoma (HCC), but transplant criteria still need to be refined, especially in the case of more advanced or downstaged tumors.MethodsThe present study investigated alpha-fetoprotein (AFP) as a predictor of outcome in 6817 patients listed with a diagnosis of HCC in the Scientific Registry of Transplant Recipients.ResultsLocal pre-transplant HCC treatment was used in 41% of patients on the waiting list. Patients with AFP levels >400 ng/ml at the time of listing who were downstaged to AFP ⩽400 ng/ml had better intent-to-treat survival than patients failing to reduce AFP to ⩽400 (81% vs. 48% at 3 years, p ⩽ 0.001) and comparable survival to patients with stable AFP ⩽400 ng/ml (74%, p = 0.14). Patients with AFP levels decreased ⩽400 ng/ml and patients with levels persistently ⩽400 ng/ml also had similar drop-out rates from the list (10% in both groups) and post-transplant survival rates (89% vs. 78% at 3 years, p = 0.11). Such an AFP downstaging was associated with good survivals whatever the level of the original AFP (even if originally >1000 ng/ml). Only the last pre-transplant AFP independently predicted survival (p ⩽0.001), unlike AFP at listing or AFP changes.ConclusionsOverall, downstaging HCC patients with high AFP is feasible and leads to similar intent-to-treat and post-transplant survivals to those of patients with AFP persistently low. Only last AFP appears relevant for patient selection before transplantation and should be used in combination with morphological variables.