Magnitude of Change in Alpha-Fetoprotein in Response to Transarterial Chemoembolization Predicts Survival in Patients Undergoing Liver Transplantation for Hepatocellular Carcinoma

Background: Downsizing strategies are often attempted for patients with hepatocellular carcinoma (HCC) before liver transplantation (LT). The objective of the present study was to determine clinical predictors of favourable survival outcomes after transarterial chemoembolization (TACE) before LT for HCC outside the Milan criteria, so as to better select candidates for this strategy. Methods: In this retrospective study, patients with HCC tumours either beyond Milan criteria (single lesion > 5 cm, 3 lesions with 1 or more > 3 cm) or at the upper limit of Milan criteria (single lesions between 4.1 cm and 5.0 cm), with a predicted waiting time of more than 3 months, received carboplatin-based TACE treatments. Exclusion criteria for TACE included Child–Pugh C cirrhosis or the presence of portal vein invasion or extrahepatic disease on imaging. Only patients without tumour progression after TACE underwent LT. Results: Of 160 HCC patients who received liver grafts between 1997 and 2010, 35 were treated with TACE preoperatively. The median of the sum of tumour diameters was 6.7 cm (range: 4.8–8.5 cm), which decreased with TACE to 5.0 cm (range: 3.3–7.0 cm) at transplantation (p < 0.0004). The percentage drop in alpha-fetoprotein (αFP) was a positive predictor (p = 0.0051) and the time from last TACE treatment to transplantation was a negative predictor (p < 0.0001) for overall survival. Conclusions: The percentage drop in αFP and a shorter time from the final TACE treatment to transplantation significantly predicted improved overall survival after LT for HCC downsized with TACE. As a serum marker, αFP should be followed when TACE is used as a strategy to stabilize or downsize HCC lesions before LT.