LIVER TRANSPLANTATION 20:1285, 2014
LETTER TO THE EDITORS
Response to Letter to the Editors Received July 23, 2014; accepted July 24, 2014.
TO THE EDITORS: We thank dos Santos Schraiber et al.1 and Lai and Lerut2 for their interest and comments regarding our study on applying alpha-fetoprotein (AFP) >1000 ng/ mL as an exclusion criterion for liver transplantation (LT) for hepatocellular carcinoma (HCC).3 dos Santos Schraiber et al.1 reported their experience with 206 patients receiving transplants for HCC and found that an AFP threshold of 200 ng/mL was predictive of HCC recurrence. They believed that the higher AFP >1000 ng/mL used in our study was restrictive and that our results were based on a small number of patients. We recognize the small number of patients with AFP >1000 ng/mL to be a limitation, but our results are entirely consistent with those reported from a recent large study published by the Liver Transplantation French Study Group in the subgroup of patients meeting Milan criteria.4 The key question of our study is how many patients would have to be excluded from LT at a specific AFP threshold to prevent 1 HCC recurrence. We found that applying an AFP level >1000 ng/mL as the cutoff would have resulted in the exclusion of approximately 5% of patients for LT and a 20% reduction in the rate of HCC recurrence. The 5-year survival without HCC recurrence was 80% after excluding those with pre-LT AFP >1000 ng/mL. Applying a lower AFP threshold (>300 ng/mL to >500 ng/mL) would have resulted in a slightly greater reduction in the HCC recurrence rate but at the expense of excluding more patients from LT who did not have tumor recurrence and would have benefited from LT. We also found AFP >1000 ng/mL to have the highest specificity in predicting vascular invasion as well as post-LT HCC recurrence compared with a lower AFP. We agree with Lai and Lerut’s2 comments about the complexity of using AFP as a variable in exclusion of candidates for LT. We should point out that, among the 211 patients in our study cohort, 12 patients had an initial AFP >1000 ng/mL at LT listing who showed a decrease in AFP to 1000 ng/ mL are required to show a decrease in AFP to 1000 ng/mL as an exclusion criterion for liver transplantation in patients with hepatocellular carcinoma meeting the Milan criteria. Liver Transpl 2014;20:945-951. 4. Duvoux C, Roudot-Thoraval F, Decaens T, Pessione F, Badran H, Piardi T, et al.; for Liver Transplantation French Study Group. Liver transplantation for hepatocellular carcinoma: a model including a-fetoprotein improves the performance of Milan criteria. Gastroenterology 2012;143:986-994. 5. Lai Q, Avolio AW, Graziadei I, Otto G, Rossi M, Tisone G, et al.; for European Hepatocellular Cancer Liver Transplant Study Group. Alpha-fetoprotein and modified response evaluation criteria in solid tumors progression after locoregional therapy as predictors of hepatocellular cancer recurrence and death after transplantation. Liver Transpl 2013;19:1108-1118.
Address reprint requests to Francis Y. Yao, M.D., University of California, San Francisco, 513 Parnassus Avenue, Room S-357, San Francisco, CA 94143-0538. Telephone: 415-514-0332; FAX: 415-476-0659; E-mail: [email protected] DOI 10.1002/lt.23982 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
LETTER TO THE EDITORS
Response to Letter to the Editors Received July 23, 2014; accepted July 24, 2014.
TO THE EDITORS: We thank dos Santos Schraiber et al.1 and Lai and Lerut2 for their interest and comments regarding our study on applying alpha-fetoprotein (AFP) >1000 ng/ mL as an exclusion criterion for liver transplantation (LT) for hepatocellular carcinoma (HCC).3 dos Santos Schraiber et al.1 reported their experience with 206 patients receiving transplants for HCC and found that an AFP threshold of 200 ng/mL was predictive of HCC recurrence. They believed that the higher AFP >1000 ng/mL used in our study was restrictive and that our results were based on a small number of patients. We recognize the small number of patients with AFP >1000 ng/mL to be a limitation, but our results are entirely consistent with those reported from a recent large study published by the Liver Transplantation French Study Group in the subgroup of patients meeting Milan criteria.4 The key question of our study is how many patients would have to be excluded from LT at a specific AFP threshold to prevent 1 HCC recurrence. We found that applying an AFP level >1000 ng/mL as the cutoff would have resulted in the exclusion of approximately 5% of patients for LT and a 20% reduction in the rate of HCC recurrence. The 5-year survival without HCC recurrence was 80% after excluding those with pre-LT AFP >1000 ng/mL. Applying a lower AFP threshold (>300 ng/mL to >500 ng/mL) would have resulted in a slightly greater reduction in the HCC recurrence rate but at the expense of excluding more patients from LT who did not have tumor recurrence and would have benefited from LT. We also found AFP >1000 ng/mL to have the highest specificity in predicting vascular invasion as well as post-LT HCC recurrence compared with a lower AFP. We agree with Lai and Lerut’s2 comments about the complexity of using AFP as a variable in exclusion of candidates for LT. We should point out that, among the 211 patients in our study cohort, 12 patients had an initial AFP >1000 ng/mL at LT listing who showed a decrease in AFP to 1000 ng/ mL are required to show a decrease in AFP to 1000 ng/mL as an exclusion criterion for liver transplantation in patients with hepatocellular carcinoma meeting the Milan criteria. Liver Transpl 2014;20:945-951. 4. Duvoux C, Roudot-Thoraval F, Decaens T, Pessione F, Badran H, Piardi T, et al.; for Liver Transplantation French Study Group. Liver transplantation for hepatocellular carcinoma: a model including a-fetoprotein improves the performance of Milan criteria. Gastroenterology 2012;143:986-994. 5. Lai Q, Avolio AW, Graziadei I, Otto G, Rossi M, Tisone G, et al.; for European Hepatocellular Cancer Liver Transplant Study Group. Alpha-fetoprotein and modified response evaluation criteria in solid tumors progression after locoregional therapy as predictors of hepatocellular cancer recurrence and death after transplantation. Liver Transpl 2013;19:1108-1118.
Address reprint requests to Francis Y. Yao, M.D., University of California, San Francisco, 513 Parnassus Avenue, Room S-357, San Francisco, CA 94143-0538. Telephone: 415-514-0332; FAX: 415-476-0659; E-mail: [email protected] DOI 10.1002/lt.23982 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
