Abstract
In hepatocellular carcinoma (HCC), there is a need for novel tumor markers to enhance patient selection for liver transplantation. This study evaluates the prognostic value of Prothrombin Induced by Vitamin K Absence-II (PIVKA-II) in predicting microvascular invasion (MVI) and post-transplant recurrence, either alone or in combination with alpha-fetoprotein (AFP), following living donor liver transplantation (LDLT). We reviewed 400 patients who underwent LDLT under expanded criteria (largest tumor diameter ≤ 10 cm, any tumor number, AFP < 1000 ng/ml). PIVKAII outperformed AFP and tumor size in predicting MVI, with a C-statistic of 0.777 compared to 0.579 and 0.631. On multivariate analysis, AFP > 20 ng/ml [HR 3.3, P = 0.003] and PIVKAII > 1000 mAU/ml [HR 3.5, P = 0.001] were predictors of recurrence. PIVKAII > 1000 mAU/ml was associated with MVI (21.6% vs. 65.7%, P < 0.001) and lower 5-year RFS (79% vs. 50%, P < 0.001). A combination of AFP > 20 ng/ml and PIVKAII > 1000 mAU/ml predicted 47.1% of recurrences, whereas HCC recurred in 6.1% of patients not meeting this threshold. The 5-year RFS was 45% for dual tumor marker positive HCC versus 77% for all others (P < 0.001). PIVKAII is a strong predictor of MVI and post-transplant recurrence. Dual tumor marker-positive HCC can serve as an exclusion criterion for upfront LDLT.