Liver Transplantation for Hepatocellular Carcinoma: A Real-Life Comparison of Milan Criteria and AFP Model

SIMPLE SUMMARY: The α-fetoprotein (AFP) model officially replaced the Milan criteria in France for liver transplantation (LT) for hepatocellular carcinoma (HCC) in January 2013. The aim of our retrospective study was to analyze the agreement of the criteria and the results of LT with an intention-to-treat design since the adoption of the AFP model and to compare them to the practice and results of LT before the adoption of the AFP model. We did not observe significant changes in practices in 523 consecutively listed patients, with a good agreement (88%) to AFP criteria on the explants before and after the adoption of the AFP model. However, the prognosis of patients listed in the most recent period was worse, maybe because of a significant increase in bridging treatments and in the waiting time. This observational study provides an insight into the real-life course of LT for HCC. ABSTRACT: Purpose: To compare the agreement for the criteria on the explant and the results of liver transplantation (LT) before and after adoption of the AFP (α-fetoprotein) model. Methods: 523 patients consecutively listed in five French centers were reviewed to compare results of the Milan criteria period (MilanCP, n = 199) (before 2013) and the AFP score period (AFPscP, n = 324) (after 2013). (NCT03156582). Results: During AFPscP, there was a significantly longer waiting time on the list (12.3 vs. 7.7 months, p < 0.001) and higher rate of bridging therapies (84 vs. 75%, p = 0.012) compared to the MilanCP. Dropout rate was slightly higher in the AFPscP (31 vs. 24%, p = 0.073). No difference was found in the histological AFP score between groups (p = 0.838) with a global agreement in 88% of patients. Post-LT recurrence was 9.2% in MilanCP vs. 13.2% in AFPscP (p = 0.239) and predictive factors were AFP > 2 on the last imaging, downstaging policy and salvage transplantation. Post-LT survival was similar (83 vs. 87% after 2 years, p = 0.100), but after propensity score analysis, the post-listing overall survival (OS) was worse in the AFPscP (HR 1.45, p = 0.045). Conclusions: Agreement for the AFP model on explant analysis (≤2) did not significantly change. AFP score > 2 was the major prognostic factor for recurrence. Graft allocation policy has a major impact on prognosis, with a post-listing OS significantly decreased, probably due to the increase in waiting time, increase in bridging therapies, downstaging policy and salvage transplantation.