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Page 6 of 11 Fatourou et al. Hepatoma Res 2018;4:63 I http://dx.doi.org/10.20517/2394-5079.2018.62

Table 2. The AFP score for the prediction of HCC recurrence
AFP model*
Variables Points
Largest tumour diameter (cm)
≤ 3 0
3-6 1
> 6 4
Number of nodules
1-3 0
≥ 4 2
AFP level (ng/mL)
≤ 100 0
100-1000 2
> 1000 3
*The score is calculated by adding the individual points for each variable. A cut-off value of 2 discriminates between patients with low
and high risk of recurrence. AFP: alpha-fetoprotein; HCC: hepatocellular carcinoma

Table 3. The proposed AFP-UTS criteria for the prediction of HCC recurrence
AFP-UTS criteria
HCC at pre-transplantation radiology within up to 7 criteria*, if AFP < 200 ng/mL
HCC at pre-transplantation radiology within up to 5 criteria*, if AFP 200-400 ng/mL
HCC at pre-transplantation radiology within up to 4 criteria*, if AFP 400-1000 ng/mL
*Considering as up to 7, 5, or 4 the maximum allowed sum of size (in cm) and number of tumours on the last radiology assessment prior
to transplantation. AFP: alpha-fetoprotein; HCC: hepatocellular carcinoma

[26]
listing, an AFP score ≤ 2 was associated with an excellent 5 year survival and reduced risk of recurrence .
Another validation study which included 327 patients from Latin America has also demonstrated the
superiority of the AFP score compared to Milan criteria in predicting post LT recurrence, even in patients who
were downstaged in order to fulfil the listing criteria .
[27]
In a study that aimed to examine the survival benefit and cost-utility in order to better allocate medical
[28]
resources, the AFP score was proven to be a useful tool for cost-effectiveness . LT was a cost-effective
treatment in patients with AFP score ≤ 3 and was proven to be cost-ineffective in patients with AFP score > 7.
Although cost-effectiveness should not directly determine eligibility for transplantation, it should be taken into
consideration in order to improve organ allocation. Finally, as previously mentioned, in 2013 the AFP model
was adopted by the French Organisation for Organ Sharing as the official national listing criteria.

Metroticket 2.0
In a study by Mazzaferro et al. which included in the training set 1018 patients who underwent LT in 3
[7]
different centres in Italy, and in the validation set, 341 patients transplanted for HCC in China, a model that
consists of the sum of tumour size and number preoperatively and log10AFP, has shown better predictability
of recurrence and survival compared to Milan criteria. By using three different cut-off AFP values the authors
defined the AFP-adjusted-to-HCC size (AFP-UTS) criteria as shown in Table 3. Patients within compared to
beyond the AFP-UTS criteria showed a 5-year overall, HCC-specific and recurrence-free survival of 79.7%
vs. 51.2% (P < 0.0001), 93.5% vs. 55.6% (P < 0.0001), and 89.6% vs. 46.8% (P < 0.0001), respectively. An online
calculator was also developed (www.hcc-olt-metroticket.org) which provides a 5-year post-transplantation
prediction of HCC specific survival based on the pre-operative radiological tumour assessment and the last
AFP value. The prediction value can also be refined based on the presence or not of HCV infection, as this can
have a negative impact on overall post-transplant survival.