Hepatocellular carcinoma (HCC) is one of the leading causes of liver transplantation. In an attempt to predict their recurrence after liver transplantation, evaluation of tumor number and size, degree of histologic differentiation, and the presence of vascular invasion already have their importance established. In this context, the role of biologic markers such as alpha-fetoprotein (AFP) is still not clear. This retrospective cross-sectional study analyzed the AFP relationship with recurrence of HCC after orthotopic liver transplantation.The current study retrospectively analyzed data from 206 patients with a histopathologic confirmed HCC between 1997 and 2010.The overall survival rates at 1, 3, 5, and 14 years were 78.6%, 65.4%, 60.5%, and 38.7%, respectively. The frequency of recurrence was 15.5%, and recurrence was significantly associated with a lower survival rate (P < 0.001). No association was observed between survival and AFP level (P = 0.153). A correlation, however, was found between tumor recurrence and AFP level (P = 0.002). Univariate analysis of risk factors for recurrence revealed that an AFP level greater than 200 ng/mL, the number of tumors, the degree of cellular differentiation, and the presence of vascular invasion or satellite nodules were associated with relapse. By multivariate analysis, only an AFP level greater than 200 ng/mL remained as a risk factor.Although an elevated AFP level did not correlate with survival in HCC patients undergoing orthotopic liver transplantation, a high AFP level was associated with a 3.32-folds increase in the probability of HCC recurrence.

Post-transplant lymphoproliferative disorder (PTLD) is a major and potentially life-threatening complication after solid-organ transplantation. The aim of this study was to describe the disease characteristics, clinical practices, and survival related to PTLD in adult orthotopic liver transplant (OLT) recipients in South America. We conducted a survey at four different transplant groups from Argentina, Brazil, and Chile. Among 1621 OLT recipients, 27 developed PTLD (1.7%); the mean age at diagnosis was 53.7 (± 14) yr with a mean time of 39.7 (± 35.2) months from OLT to PTLD diagnosis. Initial therapy included reduction in immunosuppression alone in 23.1% of the patients. Either rituximab or chemotherapy was employed as initial or second-line therapy in 76.9% of the patients. PTLD location was frequently extranodal (80.7%) and mostly involving the transplanted liver (59.3%). The overall survival at one and five yr post-PTLD diagnosis was 53.8% and 46.2%, respectively. Significant univariate risk factors for post-PTLD mortality included lactate dehydrogenase ≥ 250 U/L (HR 9.66, p = 0.02), stage III/IV PTLD (HR 5.34, p = 0.004), and HCV infection (HR 7.68, p = 0.01). In conclusion, PTLD in OLT adult recipients is predominantly extranodal, and although mortality is high, long-term survival is possible.

TO THE EDITORS:Hameed et al.1 published a study on a-fetoprotein (AFP) as an exclusion criterion for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). We believe that they used a very high cutoff for AFP (>1000 ng/mL). Because of the retrospective nature of the study and the small sample with elevated AFP levels, we believe that it is difficult to take this value as definitive.We conducted a retrospective study of 768 patients undergoing LT between 1997 and 2010 (206 with a histological diagnosis of HCC). The leading cause of cirrhosis was also hepatitis C. Patients were followed for up to 173 months (mean 5 49.8 months). The survival of LT recipients at 1, 3, 5, and 14 years was 78.6%, 65.4%, 60.5%, and 38.7%, respectively. Survival was higher in the recurrence-free group versus patients with HCC recurrence (P < 0.001), and AFP levels correlated with tumor recurrence. At the 5-year posttransplant follow-up, the rate of HCC recurrence in patients with AFP levels < 50 ng/mL was 13.1%, whereas the rates were 29.4% for AFP levels of 50 to 200 ng/mL and 36.8% for AFP levels >200 ng/mL (P 5 0.002). A univariate analysis of risk factors for HCC recurrence revealed a hazard ratio (HR) of 3.85 [95% confidence interval (CI) 5 1.66-8.93, P 5 0.002] for AFP levels 200 ng/mL. Other risk factors for recurrence were the number of tumors (HR 5 1.37, 95% CI 5 1.20-1.56, P < 0.001), the degree of differentiation (HR 5 2.28, 95% CI 5 1.18-4.39, P 5 0.014), vascular invasion (HR 5 4.82, 95% CI 5 2.08-11.17, P < 0.001), and the presence of satellite nodules (HR 5 3.33, 95% CI 5 1.66-6.68, P 5 0.001). In a multivariate analysis, only AFP levels > 200 ng/mL remained a risk factor with an HR of 3.32 (95% CI 5 1.40-7.91, P 5 0.007).Despite the diversity of values reported in the literature, 2-4 we believe that very high levels of AFP (>1000 ng/mL) are restrictive because of the small number of patients who meet this criterion and the need for a better standard for organ allocation.