Model combining pre-transplant tumor biomarkers and tumor size shows more utility in predicting hepatocellular carcinoma recurrence and survival than the BALAD models

Table 1 BALAD score calculation

	0 point	1 point	2 points	3 points
Bilirubin (mg/dL)	< 1.0	1.0-2.0	> 2.0
Albumin (g/dL)	> 3.5	2.8-3.5	< 2.8
Summation of these 2 points, then classified as A (0-1), B (2-3), C (4)
Albumin-Bilirubin	A	B	C	-
No. of elevated markers1	0	1	2	3
Summation of these 2 points for BALAD score (0-5)

¹Defined by AFP > 400 ng/mL, AFP-L3 > 15%, and DCP > 100 ng/mL.

Table 2 BALAD-2 class calculation

Linear predictor = 0.02 × (AFP - 2.57) + 0.012 × [(AFP-L3) - 14.19] + 0.19 × [ln(DCP) - 1.93] + 0.17 × [(bilirubin)1/2- 4.50] - 0.09 × (albumin - 35.11)

AFP capped at 50000 units. AFP and DCP modeled as /1000 units.

Units: Bilirubin (μmol/L), albumin (g/L), AFP and DCP (ng/mL), AFP-L3 (%).

class 1 (≤ -1.74), class 2 (> -1.74 to -0.91), class 3 (> -0.91 to 0.24), class 4 (> 0.24)

Table 3 GALAD-z and GALAD score calculation

GALAD-z = -10.08 + 0.09 × (Age) + 1.67 × (sex) + 2.34 × log(AFP) + 0.04 × (AFP-L3) + 1.33 × log(DCP)

GALAD score = exp (GALAD-z)/[1 + exp(GALAD-z)]

Sex = 1 for male and 0 for female.

Table 4 Baseline characteristics of 113 hepatocellular carcinoma patients who underwent liver transplant with available biomarker results n (%)

Variables	Value
Age, yr, mean ± SD	58.2 ± 8.3
Male sex	86 (76)
Race
White	91 (80)
Asian	11 (10)
Others	7 (6)
Unknown	4 (4)
Etiology
Hepatitis virus C	66 (58)
Hepatitis virus B	11 (10)
Alcohol	14 (12)
Non-alcoholic fatty liver disease or cryptogenic	14 (12)
Others	8 (7)
Cirrhosis	104 (92)
CTP class
A	13 (12)
B	76 (67)
C	24 (21)
MELD score, median (range)	14.2 (6.4–38.6)
ECOG status
0	57 (50)
1	34 (30)
2	19 (17)
3	3 (3)
Diameter of the largest tumor at the time of transplant by imaging, cm, mean ± SD	2.7 ± 1.6
Tumor number at the time of transplant
1	73 (64.6)
2	26 (23.0)
3	7 (6.2)
≥ 4	7 (6.2)
BCLC staging
Stage 0	1 (1)
Stage A	39 (35)
Stage B	7 (6)
Stage C	40 (35)
Stage D	26 (23)
Within Milan criteria at diagnosis	87 (77)
Within UCSF criteria at diagnosis	96 (85)
Within Milan criteria at transplant	88 (78)
Within UCSF criteria at transplant	105 (93)
AFP model score > 2	26 (23)
Total bilirubin, mg/dL, median (range)	2.3 (0.2-29.5)
Albumin, g/dL, median (range)	3.2 (2.1-5.2)
AFP, ng/mL, median (range)	25.3 (0.8-27800)
AFP > 400 ng/mL	18 (16)
AFP-L3, %, median (range)	12 (1-86.5)
AFP-L3 > 15%	45 (40)
DCP, ng/mL, median (range)	1.2 (0.2-1480)
DCP > 1.2 ng/mL	56 (50)

AFP: Alpha-fetoprotein; AFP-L3: Lens culinaris agglutinin-reactive alpha-fetoprotein; CTP: Child-Turcotte-Pugh; DCP: Des-gamma-carboxyprothrombin.

Table 5 Univariate models for recurrence and death outcome

Variable	Hazard ratio for recurrence		Hazard ratio for death
	HR (95%CI)	P value	HR (95%CI)	P value
MELD score (per point)	1.03 (0.98-1.09)	0.26	1.05 (1.003-1.09)	0.04a
Diameter of the largest tumor at time of transplant (per cm)	1.27 (1.04-1.56)	0.02a	1.21 (1.03-1.41)	0.02
Tumor number at time of transplant	1.001 (0.73-1.37)	1.00	0.93 (0.72-1.20)	0.57
Neutrophil lymphocyte ratio > 4	2.24 (1.17-4.26)	0.02a	1.66 (1.004-2.73)	0.048a
Hypothyroidism	1.26 (0.55-2.85)	0.59	1.54 (0.82-2.90)	0.18
BALAD components
Albumin (per g/dL)	0.75 (0.41-1.38)	0.36	0.69 (0.43-1.13)	0.14
Bilirubin (per mg/dL)	1.03 (0.98-1.09)	0.21	1.04 (0.995-1.08)	0.08
AFP: > 400 ng/mL	2.42 (1.18-5.00)	0.02a	3.27 (1.84-5.80)	< 0.001b
AFP-L3 > 15%	1.86 (0.98-3.52)	0.056	1.88 (1.14-3.09)	0.01a
DCP > 1.2 ng/mL	2.83 (1.42-5.61)	0.003b	2.40 (1.43-4.04)	< 0001b
BALAD Score
0	Reference		Reference
1	0.70 (0.20-2.47)	0.58	1.14 (0.40-3.23)	0.81
2	1.18 (0.37-3.75)	0.78	2.01 (0.75-5.38)	0.17
3	1.99 (0.62-6.36)	0.24	2.73 (0.99-7.51)	0.052
4	2.97 (0.84-10.58)	0.09	4.68 (1.52-14.36)	0.007b
5	5.02 (0.92-27.54)	0.06	17.40 (3.81-79.47)	< 0.001b
BALAD Score (per increase of 1)	1.48 (1.15-1.91)	0.002b	1.59 (1.28-1.97)	< 0.001b
BALAD-2 Score
1	Reference		Reference
2	0.41 (0.12-1.32)	0.13	1.07 (0.50-2.28)	0.86
3	1.53 (0.66-3.54)	0.32	1.76 (0.87-3.54)	0.11
4	2.17 (0.90-5.25)	0.09	2.45 (1.16-5.17)	0.02a
BALAD-2 Score (per increase of 1)	1.45 (1.06-1.98)	0.02a	1.38 (1.09-1.76)	0.008b
Within Milan criteria at diagnosis	1.69 (0.84-3.41)	0.14	2.17 (1.25-3.78)	0.006b
Within UCSF criteria at diagnosis	1.85 (0.85-4.05)	0.12	3.19 (1.75-5.84)	< 0.001b
Within Milan criteria at transplant	1.24 (0.59-2.62)	0.57	1.06 (0.57-1.95)	0.86
Within UCSF criteria at transplant	0.33 (0.05-2.43)	0.28	0.68 (0.21-2.17)	0.51
z-GALAD	1.12 (1.03-1.21)	0.006b	1.12 (1.06-1.19)	< 0.001b
GALAD score	3.01 (1.14-7.91)	0.03a	3.22 (1.48-7.00)	0.003b
AFP model cutoff > 2 (explant)	2.82 (1.47-5.41)	0.002b	2.83 (1.67-4.82)	< 0.001b
AFP model (per increase of 1, explant)	1.42 (1.20-1.68)	< 0.001b	1.34 (1.16-1.54)	< 0.001b

^aP < 0.05,

^bP < 0.01, statistical difference. AFP: Alpha-fetoprotein; AFP-L3: Lens culinaris agglutinin-reactive alpha-fetoprotein; DCP: Des-gamma-carboxyprothrombin.

Table 6 Multivariate model for recurrence outcome with BALAD and BALAD-2

Variable	Hazard ratio with BALAD		Hazard ratio with BALAD-2
	HR (95%CI)	P value	HR (95%CI)	P value
Diameter of the largest tumor at time of transplant (per cm)	1.33 (1.07-1.66)	0.02b	1.30 (1.05-1.59)	0.014a
Neutrophil-lymphocyte ratio	1.55 (0.78-3.14)	0.21	1.76 (0.90-3.49)	0.10
BALAD (per increase of 1)	1.53 (1.17-2.01)	0.002b	-	-
BALAD-2 (per increase of 1)	-	-	1.45 (1.05-2.03)	0.02a

^aP < 0.05,

^bP < 0.01, statistical difference.

Table 7 Multivariate model for death outcome with BALAD and BALAD-2

Variable	Hazard ratio with BALAD		Hazard ratio with BALAD-2
	HR (95%CI)	P value	HR (95%CI)	P value
Diameter of the largest tumor at time of transplant (per cm)	1.24 (1.04-1.48)	0.016a	1.20 (1.02-1.42)	0.03a
Neutrophil-lymphocyte ratio	1.13 (0.67-1.92)	0.64	1.31 (0.78-2.19)	0.31
BALAD (per increase of 1)	1.57 (1.27-1.96)	< 0.0001	-	-
BALAD-2 (per increase of 1)	-	-	1.37 (1.07-1.76)	0.013a

^aP < 0.05, ^bP < 0.01, statistical difference.

Table 8 Multivariate model of biomarkers and tumor size at time of transplant (S-LAD)

Variable	Hazard ratio for recurrence		Hazard ratio for death
	HR (95%CI)	P value	HR (95%CI)	P value
Diameter of the largest tumor at time of transplant (per cm)	1.30 (1.05-1.61)	0.02a	1.29 (1.08-1.55)	0.006b
AFP: > 400 ng/mL	1.63 (0.70-3.83)	0.26	2.40 (1.19-4.83)	0.02a
AFP-L3 > 15%	0.995 (0.46-2.18)	0.99	1.01 (0.54-1.88)	0.98
DCP > 1.2 ng/mL	2.69 (1.28-5.64)	0.009b	2.33 (1.31-4.13)	0.004b
c-statistic (95%CI)	0.71 (0.62-0.81)		0.69 (0.61-0.77)

^aP < 0.05,

^bP < 0.01, statistical difference. AFP: Alpha-fetoprotein; AFP-L3: Lens culinaris agglutinin-reactive alpha-fetoprotein; DCP: Des-gamma-carboxyprothrombin.

Table 9 Comparison of models to predict outcome of liver transplant patients

Variable	c-statistic (95%CI)
	For recurrence	For death
Number of elevated biomarkers	0.66 (0.57-0.75)	0.66 (0.59-0.73)
BALAD Score (per increase of 1)	0.64 (0.55-0.73)	0.65 (0.58-0.73)
BALAD-2 Score (per increase of 1)	0.61 (0.52-0.70)	0.61 (0.54-0.68)
Within Milan criteria at diagnosis	0.56 (0.49-0.62)	0.58 (0.54-0.63)
Within UCSF criteria at diagnosis	0.55 (0.49-0.60)	0.59 (0.55-0.63)
Within Milan criteria at transplant	0.53 (0.46-0.59)	0.52 (0.47-0.57)
Within UCSF criteria at transplant	0.53 (0.48-0.58)	0.50 (0.47-0.54)
z-GALAD	0.63 (0.53-0.72)	0.64 (0.56-0.72)
GALAD score	0.63 (0.53-0.72)	0.64 (0.56-0.72)
AFP model (explant model)	0.59 (0.51-0.67)	0.58 (0.51-0.65)