Abstract
Background and Aims: Several models have been developed to predict tumor the recurrence of hepatocellular carcinoma (HCC) after liver transplantation besides the conventional Milan criteria (MC), including the MoRAL score. This study aimed to compare the prognostication power of the MoRAL score to most models designed so far in the Eastern and Western countries. Methods: This study included 564 patients who underwent living donor liver transplantation (LDLT) in three large-volume hospitals in Korea. The primary and secondary endpoints were time-to-recurrence, and overall survival (OS), respectively. The performance of the MoRAL score was compared with those of other various Liver transplantation (LT) criteria, including the Milan criteria, University of California San Francisco (UCSF) criteria, up-to-seven criteria, Kyoto criteria, AFP model, total tumor volume/AFP criteria, Metroticket 2.0 model, and Weill Cornell Medical College group model. Results: The median follow-up duration was 78.1 months. Among all models assessed, the MoRAL score showed the best discrimination function for predicting the risk of tumor recurrence after LT, with c-index of 0.78, compared to other models (all p < 0.001). The MoRAL score also represented the best calibration function by Hosmer-Lemeshow test (p = 0.15). Especially in the beyond-MC sub-cohort, the MoRAL score predicted tumor recurrence (c-index, 0.80) and overall survival (OS) (c-index, 0.70) significantly better than any other models (all p < 0.001). When the MoRAL score was low (<314.8), the five-year cumulative risks of tumor recurrence and death were excellent in beyond-MC (27.8%, and 20.5%, respectively) and within-MC (16.3%, and 21.1%, respectively) sub-cohorts. Conclusions: The MoRAL score provides the most refined prognostication for predicting HCC recurrence after LDLT.
Highlights
Liver transplantation (LT) has been widely accepted as the treatment of choice for early-stage hepatocellular carcinoma (HCC) and end-stage liver disease [1,2]
The MoRAL score showed the best calibration function with a non-significant p value (p = 0.15) by the Hosmer-Lemeshow test; the Weill Cornell Medical College (WCM) model and the AFP model, the second and third best models evaluated by c-index, were found to be less accurate with marginally significant p values (p = 0.07, and p = 0.06, respectively). These findings indicate that patients within a sub-group, that are classified by a MoRAL score, had a more homogeneous prognosis than patients within a subgroup classified by the others
We found that the MoRAL score performed better in predicting the risk of tumor recurrence after living donor liver transplantation (LDLT) among other currently available models, including the Milan criteria (MC), current standard of care, and several other risk scores, which use AFP and tumor burden, including the WCM model [13], AFP model [18], University of California San Francisco (UCSF) or up-to-seven and AFP [19], and Metroticket 2.0 model [21]
Summary
Liver transplantation (LT) has been widely accepted as the treatment of choice for early-stage hepatocellular carcinoma (HCC) and end-stage liver disease [1,2]. LT eligibility criteria has been gradually expanded, especially for living donor LT (LDLT), due to excellent overall survival (OS). LDLT provides an alternative to deceased donor LT (DDLT), allowing many centers to provide transplants to patients beyond the MC. Several models have been developed to predict tumor the recurrence of hepatocellular carcinoma (HCC) after liver transplantation besides the conventional Milan criteria (MC), including the MoRAL score. Methods: This study included 564 patients who underwent living donor liver transplantation (LDLT) in three large-volume hospitals in Korea. The performance of the MoRAL score was compared with those of other various Liver transplantation (LT) criteria, including the Milan criteria, University of California San Francisco (UCSF) criteria, up-to-seven criteria, Kyoto criteria, AFP model, total tumor volume/AFP criteria, Metroticket 2.0 model, and Weill Cornell Medical College group model
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