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Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jul 28, 2016; 8(21): 881-890
Published online Jul 28, 2016. doi: 10.4254/wjh.v8.i21.881
Contribution of alpha-fetoprotein in liver transplantation for hepatocellular carcinoma
Bérénice Charrière, Charlotte Maulat, Bertrand Suc, Fabrice Muscari
Bérénice Charrière, Charlotte Maulat, Bertrand Suc, Fabrice Muscari, Department of Visceral Surgery, Toulouse-Rangueil University Hospital, 31059 Toulouse, France
Fabrice Muscari, Service de Chirurgie Digestive, CHU Toulouse Rangueil, 31059 Toulouse, France
Author contributions: Charrière B, Maulat C and Muscari F performed the research and wrote the paper; Suc B revised the manuscript for important intellectual content.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Fabrice Muscari, Professor, Service de Chirurgie Digestive, CHU Toulouse Rangueil, 1 Avenue du Pr. Jean Poulhès, Cedex 9, 31059 Toulouse, France. muscari.f@chu-toulouse.fr
Telephone: +33-561-322088 Fax: +33-561-322936
Received: March 27, 2016
Peer-review started: March 28, 2016
First decision: May 17, 2016
Revised: May 30, 2016
Accepted: June 27, 2016
Article in press: June 29, 2016
Published online: July 28, 2016
Abstract

Alpha-fetoprotein (AFP) is the main tumor biomarker available for the management of hepatocellular carcinoma (HCC). Although it is neither a good screening test nor an accurate diagnostic tool for HCC, it seems to be a possible prognostic marker. However, its contribution in liver transplantation for HCC has not been fully determined, although its use to predict recurrence after liver transplantation has been underlined by international societies. In an era of organ shortages, it could also have a key role in the selection of patients eligible for liver transplantation. Yet unanswered questions remain. First, the cut-off value of serum AFP above which liver transplantation should not be performed is still a subject of debate. We show that a concentration of 1000 ng/mL could be an exclusion criterion, whereas values of < 15 ng/mL indicate patients with an excellent prognosis whatever the size and number of tumors. Monitoring the dynamics of AFP could also prove useful. However, evidence is lacking regarding the values that should be used. Today, the real input of AFP seems to be its integration into new criteria to select patients eligible for a liver transplantation. These recent tools have associated AFP values with morphological criteria, thus refining pre-existing criteria, such as Milan, University of California, San Francisco, or “up-to-seven”. We provide a review of the different criteria submitted within the past years. Finally, AFP can be used to monitor recurrence after transplantation, although there is little evidence to support this claim. Future challenges will be to draft new international guidelines to implement the use of AFP as a selection tool, and to determine a clear cut-off value above which liver transplantation should not be performed.

Keywords: Hepatocellular carcinoma, Downstaging, Alpha-fetoprotein, Liver transplantation, Selection criteria

Core tip: Alpha-fetoprotein (AFP) is the main biomarker available for the management of hepatocellular carcinoma (HCC). Yet, its contribution in liver transplantation for HCC has not been fully determined. We discuss the interest of AFP as a prognostic factor to predict tumor recurrence after liver transplantation, and as a selection tool to assess the best candidates to receive a graft. We also provide an overview of the different ways that AFP could be included in decisional algorithms before liver transplantation, through its static and dynamic values.