External Validation of the RETREAT Score for Prediction of Hepatocellular Carcinoma Recurrence after Liver Transplantation

Abstract

Background. We aimed to externally validate the performance of the RETREAT score in a European population. Methods. This single center retrospective cohort study enrolled all consecutive patients with HCC who underwent LT between 1989 and 2019. The performance of RETREAT was assessed in the overall population and after stratification between being within or beyond the Milan criteria based on the explant pathology report. Recurrence probabilities were estimated by using the Kaplan–Meier method and compared by log-rank test. Results. We studied 203 patients; 42 patients were beyond the Milan criteria based on explant pathology. The median follow-up was 26.8 months (IQR 7.2–60.7). Overall cumulative HCC recurrence rates were 10.6%, 21.3%, and 23.0% at 2, 5, and 10 years, with the majority of recurrences extrahepatic and at multiple sites. Higher RETREAT scores were associated with higher recurrence rates, with a 10-year recurrence rate of 60.5% in patients with RETREAT ≥ 3 (n = 65), compared to 6.2% in those with RETREAT ≤2 (n = 138; p < 0.001). HCC recurrence rates were even lower in patients within the Milan criteria who also had a low RETREAT score (n = 122; 2.7% at 10 years). Conclusion. Low RETREAT scores identify patients at low risk of HCC recurrence after LT in patients within the Milan criteria based on explant pathology.

Transplant oncology – Current indications and strategies to advance the field

“… 57 In contrast, a RETREAT score ≥5 points carries a 1- and 5-year recurrence risk close to 40% and 75%, respectively. 57 , 59 While not helpful for patient selection, as it only becomes available after LT, the RETREAT score may help to guide postoperative surveillance as well as to select recipients for adjuvant therapy. At UCSF, surveillance intervals are guided by the recipient’s RETREAT score.…”

“… Predictor Points AFP levels, ng/ml 0–20 0 21–99 1 100–999 2 ≥1,000 3 Microvascular invasion Absent 0 Present 2 Largest viable tumour diameter (cm) + number of viable tumours 0 ∗ 0 1.1–4.9 1 5.0–9.9 2 ≥10 3 Modified from van Hooff et al. 59 AFP, alpha-fetoprotein. ∗ No viable tumour on explant pathology.…”

The Role of PIVKA-II as a Predictor of Early Hepatocellular Carcinoma Recurrence-Free Survival after Liver Transplantation in a Low Alpha-Fetoprotein Population

“…In this study, all consecutive HCC patients receiving LT between October 1989 and October 2019 in our center were included, and the data were retrospectively evaluated. For a more detailed description of this cohort, see Van Hooff et al [ 7 ]. Before LT, all patients provided written informed consent, approving the use of their data and biomaterial for research purposes.…”

“…Recently, the RETREAT score was validated in our cohort of patients who underwent LT for HCC at the Erasmus University Medical Center, Rotterdam, the Netherlands [ 7 ]. Since the average AFP in our population is low, the addition of other biomarkers or characteristics might strengthen the predictive value of the RETREAT score in our population [ 3 , 8 ].…”

Different Models to Predict the Risk of Recurrent Hepatocellular Carcinoma in the Setting of Liver Transplantation

“…However, the score was designed in a cohort who were mostly within the Milan criteria during their time on the waiting list. The score has been validated outside the USA in an European setting [ 58 , 59 ], but in this study, the prognosis of the patients after recurrence could not by differentiated with the RETREAT score [ 58 ]. Agopian et al used these same clinicopathological variables combined with total cholesterol to develop a prognostic nomogram based on the data of 865 patients transplanted for HCC and reported the same excellent predictive value for recurrence after LT [ 55 ].…”