α-Fetoprotein and Hepatocellular Cancer Recurrence: A Paradigm of the Chaos Theory

Lai, Quirino; Lerut, Jan

doi:10.1002/lt.23962

Cited by 3 publications

(6 citation statements)

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“…The threshold value of 400 ng/ml was considered in the last static AFP examination . A threshold value of 15 ng/ml/month was considered in the AFP slope, as previously reported . For AFP delta‐slopes, we arbitrarily decided a similar cut‐off of 15 ng/ml/month, corresponding to an 85th centile of the cohort.…”

Section: Patients and Materialsmentioning

confidence: 99%

“…The area under the receiver‐operating characteristic (AUROC) curve was calculated with the intent to evaluate the prognostic ability of the variables. Different cut‐offs of these variables were also investigated, as previously reported. The diagnostic odds ratio (DOR), which measures the overall accuracy of a diagnostic test, was calculated for each cut‐off value.…”

Section: Patients and Materialsmentioning

confidence: 99%

“…Unfortunately, AFP modifications present a chaotic behaviour. Consequently, the creation of an equation able to predict the evolution of its casual oscillations and to capture its trend represents a mathematical challenge …”

Section: Introductionmentioning

confidence: 99%

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Delta‐slope of alpha‐fetoprotein improves the ability to select liver transplant patients with hepatocellular cancer

Lai

Inostroza

Juri³

et al. 2015

HPB

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Section: Patients and Materialsmentioning

confidence: 99%

Section: Patients and Materialsmentioning

confidence: 99%

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Delta‐slope of alpha‐fetoprotein improves the ability to select liver transplant patients with hepatocellular cancer

Lai

Inostroza

Juri³

et al. 2015

HPB

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“…The behavior of alpha-fetoprotein (AFP) in patients having hepatocellular carcinoma (HCC) awaiting for liver transplant (LT) represents a perfect biological example of a fractal model in which its progressive modification and possible future prediction of its values are very hard to capture [1] .…”

Section: Sciencesmentioning

confidence: 99%

“…Several questions are thus still open in relation to the Han et al [22] 2007 48 Canada 50 Vibert et al [23] 2010 153 France 15 Dumitra et al [24] 2013 92 Canada 0.1 1 Lai et al [25] 2013 increase the ability to better select HCC patients waiting for LT. More, structured and prospective, studies using serial determination of AFP values within and without the context of locoregional therapies are needed in order to find the "ideal" (static and dynamic) cut-off values allowing to respond to all the still open questions in this field of transplant oncology.…”

Section: Modelmentioning

confidence: 99%

Selection tool alpha-fetoprotein for patients waiting for liver transplantation: How to easily manage a fractal algorithm

Lai

Sandri

Lerut

2015

WJH

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Alpha-fetoprotein (AFP) behavior in patients with hepatocellular carcinoma (HCC) waiting for liver transplant (LT) represents a perfect biological example of a fractal model in which its progressive modification and possible future prediction of its values are very hard to capture. As a consequence, AFP represents a useful but poorly manageable tool to increase the ability to better select HCC patients waiting for LT. Trying to find a "filrouge" in the recent literature, no definitive answers can be done to several open questions: (1) the best AFP value to adopt; (2) the best cut-off measurement; and (3) the best way to comfortably capture the effective, time-related, fluctuations of this biological marker. More, structured and prospective, studies using serial determination of AFP values within and without the context of locoregional therapies are needed in order to find the "ideal" (static and dynamic) cut-off values allowing to respond to all the still open questions in this field of transplant oncology. Core tip: Alpha-fetoprotein (AFP) behavior in patients with hepatocellular carcinoma waiting for liver transplant (LT) represents a perfect example of a fractal model. Consequently, AFP represents a useful but poorly manageable selection tool for patients waiting for LT. Looking at the recent literature, we can assume that: (1) last AFP value seem to be the best values to adopt; (2) different cut-offs may be adopted in the two different scenarios of Milan Criteria (MC) IN and MC OUT status; (3) AFP cut-off of 1000 ng/mL represent EDITORIAL Submit a

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Response to Letter to the Editors

Yao

Hameed²,

Mehta³

et al. 2014

Liver Transpl

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TO THE EDITORS:We thank dos Santos Schraiber et al. 1 and Lai and Lerut 2 for their interest and comments regarding our study on applying alpha-fetoprotein (AFP) >1000 ng/ mL as an exclusion criterion for liver transplantation (LT) for hepatocellular carcinoma (HCC).3 dos Santos Schraiber et al.1 reported their experience with 206 patients receiving transplants for HCC and found that an AFP threshold of 200 ng/mL was predictive of HCC recurrence. They believed that the higher AFP >1000 ng/mL used in our study was restrictive and that our results were based on a small number of patients. We recognize the small number of patients with AFP >1000 ng/mL to be a limitation, but our results are entirely consistent with those reported from a recent large study published by the Liver Transplantation French Study Group in the subgroup of patients meeting Milan criteria. 4 The key question of our study is how many patients would have to be excluded from LT at a specific AFP threshold to prevent 1 HCC recurrence. We found that applying an AFP level >1000 ng/mL as the cutoff would have resulted in the exclusion of approximately 5% of patients for LT and a 20% reduction in the rate of HCC recurrence. The 5-year survival without HCC recurrence was 80% after excluding those with pre-LT AFP >1000 ng/mL. Applying a lower AFP threshold (>300 ng/mL to >500 ng/mL) would have resulted in a slightly greater reduction in the HCC recurrence rate but at the expense of excluding more patients from LT who did not have tumor recurrence and would have benefited from LT. We also found AFP >1000 ng/mL to have the highest specificity in predicting vascular invasion as well as post-LT HCC recurrence compared with a lower AFP.We agree with Lai and Lerut's 2 comments about the complexity of using AFP as a variable in exclusion of candidates for LT. We should point out that, among the 211 patients in our study cohort, 12 patients had an initial AFP >1000 ng/mL at LT listing who showed a decrease in AFP to <1000 ng/mL by the time of LT as a result of local regional therapy (LRT), and only 1 of these 12 patients suffered from HCC recurrence after LT. Although the numbers are small, this observation highlights the importance of change in AFP in the context of LRT while on the LT waiting list as Lai et al. 5 have indicated from their recent multicenter study. We agree that there should be a "dynamic" approach to using AFP in the selection guidelines for LT that are readily adoptable in clinical practice. At our center, we have implemented a policy in which those with an initial AFP >1000 ng/ mL are required to show a decrease in AFP to <500 ng/ mL with LRT before they can undergo LT.

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α-Fetoprotein and Hepatocellular Cancer Recurrence: A Paradigm of the Chaos Theory

Cited by 3 publications

References 4 publications

Delta‐slope of alpha‐fetoprotein improves the ability to select liver transplant patients with hepatocellular cancer

Delta‐slope of alpha‐fetoprotein improves the ability to select liver transplant patients with hepatocellular cancer

Selection tool alpha-fetoprotein for patients waiting for liver transplantation: How to easily manage a fractal algorithm

Response to Letter to the Editors

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