The aim of the present study was to investigate the role of different alpha-foetoprotein (AFP) determinations in order to propose a new model aimed at predicting intention-to-treat (ITT) death and post- liver transplantation (LT) recurrence in a cohort of patients with hepatocellular cancer (HCC) enlisted for LT.

Recent studies have increasingly focused on the role of AFP as a useful tool for patient selection in the setting of LT for HCC. However, no definitive AFP model has been definitively validated.

A retrospective analysis was performed on 124 consecutive patients enlisted for LT in a UCL Brussels LT centre during the period January 2004 to March 2012. The median follow-up was 3.3 years (ranges: 1.7-6.3).

The area under the receiver-operating characteristic (AUROC) analysis showed the ability of the AFP delta-slope as a useful prognosticator of tumour-related drop-out and post-LT recurrence. In multivariate analyses, the delta-slope was an independent predictor of ITT death [hazard ratio (HR) = 1.014, P < 0.017] and post-LT tumour recurrence (HR = 1.020, P = 0.027). The 5-year ITT survival and disease-free survival rates were 66.0% versus 36.7% and 92.3% versus 53.8%, for patients meeting and exceeding the delta-slope cut-off value of 15 ng/ml/month, respectively.

Integration of the AFP delta-slope with conventional criteria may further improve patient selection and post-LT outcomes; prospective studies are needed to validate the present proposed model.

Alpha-fetoprotein (AFP) behavior in patients with hepatocellular carcinoma (HCC) waiting for liver transplant (LT) represents a perfect biological example of a fractal model in which its progressive modification and possible future prediction of its values are very hard to capture. As a consequence, AFP represents a useful but poorly manageable tool to increase the ability to better select HCC patients waiting for LT. Trying to find a "fil-rouge" in the recent literature, no definitive answers can be done to several open questions: (1) the best AFP value to adopt; (2) the best cut-off measurement; and (3) the best way to comfortably capture the effective, time-related, fluctuations of this biological marker. More, structured and prospective, studies using serial determination of AFP values within and without the context of locoregional therapies are needed in order to find the "ideal" (static and dynamic) cut-off values allowing to respond to all the still open questions in this field of transplant oncology.