3A) and in the subgroup of 83 patients with a nodule 2-3 cm (Fig. 3B): again, no significant survival difference was observed among the three alpha-fetoprotein

classes (HCC ≤2 cm: χ2 = 0.6744, P = 0.714; HCC 2-3 cm: χ2 = 2.0926, P = 0.351). We also compared survival between patients with normal (≤20 ng/mL) and elevated (>20 ng/mL) alpha-fetoprotein (Fig. 4A), and between patients with an alpha-fetoprotein above or below 200 ng/mL (Fig. 4B). Even with these cutoffs, no statistically significant differences were observed. Lastly, we evaluated treatment and survival of the seven patients with extremely high alpha-fetoprotein levels (>400 ng/mL): three (42.9%) had a tumor ≤2 cm, four underwent hepatic resection, and three percutaneous ablation. Four patients Paclitaxel concentration died after a median of 56 months (range, 17-79 months) and three were alive after a median of 60 months (range, 6-100 months). Taking into account the caveat selleck such an analysis may bear, due to the very small sample size, there was no survival difference between patients with alpha-fetoprotein above and below 400 ng/mL (χ2 = 0.137, P = 0.712). The ROC curve showed that alpha-fetoprotein had inadequate accuracy to discriminate survivors and deceased patients (area under the ROC curve = 0.536, 95% confidence interval

[CI] = 0.465-0.606). A ROC curve-identified alpha-fetoprotein cutoff of 100 ng/mL had good specificity (88%, 95% CI = 81%-94%) but unacceptably low sensitivity (23%, 95% CI = 15%-33%) for discriminating survivors and deceased patients MCE (Fig. 5). Prevalence-adjusted positive and negative predictive values for death of this cutoff were 63.6% and 56.5%, respectively, whereas positive and negative likelihood ratios were 1.96 and 0.86, respectively. Moreover, there was no significant survival difference between patients with an alpha-fetoprotein below or above this cutoff (χ2 = 0.8301; P = 0.367). Lastly, we also evaluated the predictors of death in this

very homogenous population of cirrhosis patients with HCC and found that the type of curative treatment (hepatic surgery, median survival 86 months versus ablative treatment, median survival 64 months, P = 0.019) was the only predictor of survival, whereas there was no significant survival difference associated with gender, age below 65 years, etiology of liver disease (viral versus nonviral), presence of esophageal varices (datum available in 163 patients), and size of HCC (≤2 or 2-3 cm). The usefulness of serum alpha-fetoprotein as a surveillance and diagnostic test for HCC has been dramatically challenged by the impressive technical improvement of abdominal ultrasound and contrast medium-enhanced diagnostic imaging that have led to great accuracy in the early identification and noninvasive characterization of small HCCs.