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Review
. 2022 Oct 8;29(10):7537-7551.
doi: 10.3390/curroncol29100593.

Hepatocellular Carcinoma, Alpha Fetoprotein, and Liver Allocation for Transplantation: Past, Present and Future

Brianna Ruch  1 , Josiah Wagler  1 , Kayla Kumm  1 , Chi Zhang  2   3 , Nitin N Katariya  1 , Mauricio Garcia-Saenz-de-Sicilia  4 , Emmanouil Giorgakis  5 , Amit K Mathur  1
Affiliations
Review

Hepatocellular Carcinoma, Alpha Fetoprotein, and Liver Allocation for Transplantation: Past, Present and Future

Brianna Ruch et al. Curr Oncol. .

Abstract

Hepatocellular carcinoma (HCC) is one of the leading indications for liver transplantation and has been the treatment of choice due to the oncologic benefit for patients with advanced chronic liver disease (AdvCLD) and small tumors for the last 25 years. For HCC patients undergoing liver transplantation, alpha fetoprotein (AFP) has increasingly been applied as an independent predictor for overall survival, disease free recurrence, and waitlist drop out. In addition to static AFP, newer studies evaluating the AFP dynamic response to downstaging therapy show enhanced prognostication compared to static AFP alone. While AFP has been utilized to select HCC patients for transplant, despite years of allocation policy changes, the US allocation system continues to take a uniform approach to HCC patients, without discriminating between those with favorable or unfavorable tumor biology. We aim to review the history of liver allocation for HCC in the US, the utility of AFP in liver transplantation, the implications of weaving AFP as a biomarker into policy. Based on this review, we encourage the US transplant community to revisit its HCC organ allocation model, to incorporate more precise oncologic principles for patient selection, and to adopt AFP dynamics to better stratify waitlist dropout risk.

Keywords: alpha fetoprotein; hepatocellular carcinoma; liver allocation; liver transplantation.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
AFP structure model. Copyright© 2022 Mingyue Zhu et al. is licensed under CC BY 3.0 [11].
Figure 2
Figure 2
US Liver Allocation Policy and Changes.
Figure 3
Figure 3
HCC Prediction Models over time. As time has progressed, a greater focus on AFP inclusion is noted in developing prediction models for recurrence-free survival in the setting of liver transplantation.
See this image and copyright information in PMC

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This research received no external funding.
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