Liver transplantation for hepatocellular carcinoma and cirrhosis in candidates with undetectable or very low alpha-fetoprotein levels: is an expansion of the listing criteria justified?

Background: Liver transplantation (LT) is the optimal therapy for hepatocellular carcinoma (HCC) in the setting of cirrhosis. The purpose of this study was to evaluate the results after LT for HCC patients with very low alpha fetoprotein (AFP) values both in our series and in literature reports.

Methodology: Data obtained prospectively on 51 transplanted patients with HCC having AFP values < 30 ng/mL preoperatively were analyzed.

Results: Four-year overall and recurrence-free survival was 81% and 79%, respectively (median follow up of 35 months). Twenty nine patients (57%) were within the Milan criteria. Thirteen patients (25%) demonstrated advanced tumor stages. Ablative bridging treatments were attempted in 27 instances, and were associated with significantly worse overall and recurrence-free survivals (p=0.0209 and p=0.0111, respectively). Patients with AFP values < 30 ng/mL and no bridging treatments experienced 4-year overall and recurrence-free survivals of 96% and 95%, respectively.

Conclusions: HCC patients with AFP values < 30 ng/mL who undergo LT with no bridging treatments experience excellent overall and recurrence-free survival rates, even with advanced tumor stages, independent of the Milan listing criteria.