Post-resection Prognosis of Combined Hepatocellular Carcinoma-Cholangiocarcinoma According to the 2010 WHO Classification

Leveraging radiomics and AI for precision diagnosis and prognostication of liver malignancies

Liver tumors, whether primary or metastatic, have emerged as a growing concern with substantial global health implications. Timely identification and characterization of liver tumors are pivotal factors in order to provide optimum treatment. Imaging is a crucial part of the detection of liver tumors; however, conventional imaging has shortcomings in the proper characterization of these tumors which leads to the need for tissue biopsy. Artificial intelligence (AI) and radiomics have recently emerged as investigational opportunities with the potential to enhance the detection and characterization of liver lesions. These advancements offer opportunities for better diagnostic accuracy, prognostication, and thereby improving patient care. In particular, these techniques have the potential to predict the histopathology, genotype, and immunophenotype of tumors based on imaging data, hence providing guidance for personalized treatment of such tumors. In this review, we outline the progression and potential of AI in the field of liver oncology imaging, specifically emphasizing manual radiomic techniques and deep learning-based representations. We discuss how these tools can aid in clinical decision-making challenges. These challenges encompass a broad range of tasks, from prognosticating patient outcomes, differentiating benign treatment-related factors and actual disease progression, recognizing uncommon response patterns, and even predicting the genetic and molecular characteristics of the tumors. Lastly, we discuss the pitfalls, technical limitations and future direction of these AI-based techniques.

Long‐term outcomes of laparoscopic versus open liver resection for intrahepatic combined hepatocellular: Cholangiocarcinoma with propensity score matching

Background

Combined hepatocellular‐cholangiocarcinoma (cHCC‐CCA) is a rare primary hepatic neoplasm. Currently, there are no well‐structured studies that analyze the feasibility of laparoscopic liver resection in cHCC‐CCA alone. This retrospective cohort study aimed to compare the long‐term survival of laparoscopic liver resection with open liver resection in cHCC‐CCA.

Methods

Patients with a postoperative pathologic report of cHCC‐CCA who underwent liver resection from August 2004 to December 2017 were included in this study. Kaplan–Meier survival analysis was performed to analyze the 3‐y disease‐free survival and 3‐y overall survival. Propensity score matching was done to reduce the influence of confounding variables.

Results

A total of 145 patients were pathologically confirmed to have cHCC‐CCA, of which 10 patients were excluded due to having received palliative surgery. Of the remaining 135 patients, 43 underwent laparoscopic and 92 underwent open liver resection; propensity score matching yielded 30 patients for each group. The 3‐y overall survival was 38 (88.4%) in the laparoscopic group and 84 (91.3%) in the open group before propensity score matching (P = .678), and 25 (83.3%) and 28 (93.3%), respectively, after matching (P = .257). The 3‐y disease‐free survival was 24 (55.8%) in the laparoscopic group and 32 (34.8%) in the open group before matching (P = .040), and 17 (56.7%) and 16 (53.3%), respectively, after matching (P = .958). The hospital stay was shorter in the laparoscopic group before and after matching, while other operative outcomes were similar in both groups.

Conclusion

Laparoscopic liver resection for cHCC‐CCA is technically feasible and safe, having a shorter hospital stay without compromising oncological outcomes.

MRI-based radiomics distinguish different pathological types of hepatocellular carcinoma

OBJECT

To distinguish combined hepatocellular cholangiocarcinoma (cHCC-CC), hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) before operation using MRI radiomics.

METHOD

This study retrospectively analyzed 196 liver cancers: 33 cHCC-CC, 88 HCC and 75 CC. They had confirmed by pathological analysis in the Affiliated Hospital of Hebei University. MRI lesions were manually segmented by a radiologist.1316 features were extracted from MRI lesions by Pyradiomics. Useful features were retained through two-level feature selection to establish a classification model. Receiver operating characteristic (ROC), area under curve (AUC) and F1-score were used to evaluate the performance of the model.

RESULTS

Compared with low-order image features, the performance of the model based on high-order features was improved by about 10%. The model showed better performance in identifying HCC tumors during the delay phase (AUC = 0.91, sensitivity = 0.88, specificity = 0.89, accuracy = 0.89, F1-Score = 0.88).

CONCLUSION

The classification ability of cHCC-CC, HCC and CC can be further improved by extracting MRI high-order features and using a two-level feature selection method.

Postresection prognosis of combined hepatocellular carcinoma-cholangiocarcinoma according to the 2010 World Health Organization classification: single-center experience of 168 patients

Purpose

Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) has wide histologic diversity. This study investigated the effects of cHCC-CC histology, according to the 2010 World Health Organization (WHO) classification, on patient prognosis.

Methods

The medical records of patients who underwent surgical resection for cHCC-CC at our institution between July 2012 and June 2019 were retrospectively evaluated.

Results

During the study period, 168 patients, 122 males (72.6%) and 46 females (27.4%), underwent surgical resection for cHCC-CC, including 159 patients (94.6%) who underwent R0 resection. Mean tumor diameter was 4.4 ± 2.8 cm, and 161 patients (95.8%) had solitary tumors. Histologically, 86 patients (51.2%) had classical type, and 82 (48.8%) had tumors with stem cell (SC) features, including 33 (19.6%) with intermediate-cell and 23 (13.7%) each with typical SC and cholangiolocellular features; 3 tumors (1.8%) were unclassifiable. At 1, 3, and 5 years, tumor recurrence rates were 31.9%, 49.6%, and 58.1%, respectively, and patient survival rates were 91.0%, 70.2%, and 60.3%, respectively. Univariate analysis showed that tumor size of >5 cm, microscopic and macroscopic vascular invasion, lymph node metastasis, 8th edition of the American Joint Committee on Cancer (AJCC) tumor stage, and 2010 WHO classification were significantly prognostic. Multivariate analysis showed that the 8th AJCC tumor stage and 2010 WHO histologic classification were independently prognostic for tumor recurrence and patient survival. There were no significant prognostic differences among the 3 SC subtypes.

Conclusion

Postresection outcomes are better in patients with SC-type than with classical-type cHCC-CC.

Post-resection prognosis of combined hepatocellular carcinoma-cholangiocarcinoma cannot be predicted by the 2019 World Health Organization classification

BACKGROUND

Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CCA) has wide histologic diversity. This study investigated the prognostic impacts of cHCC-CCA histology according to the 2019 World Health Organization (WHO) classification.

METHODS

This retrospective observational study included 153 patients who underwent surgical resection for cHCC-CCA at Asan Medical Center between August 2012 and July 2019.

RESULTS

During the study period, 153 patients, 112 (73.2%) men and 41 (26.8%) women with a mean age of 56.4 ± 10.8 years, underwent R0 resection for cHCC-CCA. Mean tumor diameter was 4.2 ± 2.6 cm, and 147 (96.1%) patients had solitary tumors. According to 2019 WHO classification, 111 (72.5%) patients had cHCC-CCA alone, and 29 of them (26.1%) showed stem cell features. cHCC-CCA-intermediate cell carcinoma and cHCC-CCA-cholangiolocellular carcinoma were identified in 27 (17.6%) and 15 (9.8%), respectively. The 1-, 3-, and 5-year tumor recurrence and patient survival rates were 31.8% and 92.1%, 49.8% and 70.9%, and 59.0% and 61.7%, respectively. Univariate analyses revealed that significant prognostic factors were tumor size >5 cm, microscopic and macroscopic vascular invasion, lymph node metastasis, 8th American Joint Committee on Cancer (AJCC) tumor stage, and status of stem cell features. Multivariate analysis revealed 8th AJCC tumor stage and status of stem cell features as independent prognostic factors. 2019 WHO classification was not associated with post-resection prognosis.

CONCLUSIONS

2019 WHO classification was not associated with post-resection prognosis, thus was considered as simplified histologic classification requiring prognostic validation. We suggest that stem cell features should be included as an essential component of the pathology report for cHCC-CCA.

Do the existing staging systems for primary liver cancer apply to combined hepatocellular carcinoma-intrahepatic cholangiocarcinoma?

BACKGROUND

The incidence of combined hepatocellular carcinoma-intrahepatic cholangiocarcinoma (cHCC-ICC) is relatively low, and the knowledge about the prognosis of cHCC-ICC remains obscure. In the study, we aimed to screen existing primary liver cancer staging systems and shed light on the prognosis and risk factors for cHCC-ICC.

METHODS

We retrospectively reviewed 206 cHCC-ICC patients who received curative surgical resection from April 1999 to March 2017. The correlation of survival measures with the histological types or with tumor staging systems was determined and predictive values of tumor staging systems with cHCC-ICC prognosis were compared.

RESULTS

The histological type was not associated with overall survival (OS) (P = 0.338) or disease-free survival (DFS) (P = 0.843) of patients after curative surgical resection. BCLC, TNM for HCC, and TNM for ICC stages correlated with both OS and DFS in cHCC-ICC (all P < 0.05). The predictive values of TNM for HCC and TNM for ICC stages were similar in terms of predicting postoperative OS (P = 0.798) and DFS (P = 0.191) in cHCC-ICC. TNM for HCC was superior to BCLC for predicting postoperative OS (P = 0.022) in cHCC-ICC.

CONCLUSION

The TNM for HCC staging system should be prioritized for clinical applications in predicting cHCC-ICC prognosis.

Clinical features and diagnostic imaging of cholangiolocellular carcinoma compared with other primary liver cancers: a surgical perspective

Background and Objectives:

Although cholangiolocellular carcinoma is considered a combined hepatocellular and cholangiocarcinoma, we feel that this classification is not appropriate. Therefore, we compared the diagnostic imaging findings, surgical prognosis, and pathological features of cholangiolocellular carcinoma with those of other combined hepatocellular and cholangiocarcinoma subtypes, hepatocellular carcinoma, and cholangiocarcinoma.

Methods:

The study patients included 7 with classical type combined hepatocellular and cholangiocarcinoma; 8 with stem cell feature, intermediate type combined hepatocellular and cholangiocarcinoma; 13 with cholangiolocellular carcinoma; 58 with cholangiocarcinoma; and 359 with hepatocellular carcinoma. All patients underwent hepatectomy or living-related donor liver transplantation from 2001 to 2014.

Results:

cholangiolocellular carcinoma could be distinguished from hepatocellular carcinom, other combined hepatocellular and cholangiocarcinoma subtypes, and cholangiocarcinoma by the presence of intratumoral Glisson’s pedicle, hepatic vein penetration, and tumor-staining pattern on angiography-assisted CT. Cholangiolocellular carcinoma was associated with a significantly lower SUV-max than that of cholangiocarcinoma on FDG-PET. Hepatocellular carcinoma, classical type, and cholangiolocellular carcinoma had significantly better prognoses than stem cell feature, intermediate type and cholangiocarcinoma. A cholangiocarcinoma component was detected in cholangiolocellular carcinoma that progressed to the hepatic hilum, and the cholangiocarcinoma component was found in perineural invasion and lymph node metastases.

Conclusions:

From the viewpoint of surgeon, cholangiolocellular carcinoma should be classified as a good-prognosis subtype of biliary tract carcinoma because of its tendency to differentiate into cholangiocarcinoma during its progression, and its distinctive imaging and few recurrence rates different from other combined hepatocellular and cholangiocarcinoma subtypes.

Combined hepatocellular-cholangiocarcinoma: which preoperative clinical data and conventional MRI characteristics have value for the prediction of microvascular invasion and clinical significance?

Objectives

To explore which preoperative clinical data and conventional MRI findings may indicate microvascular invasion (MVI) of combined hepatocellular-cholangiocarcinoma (cHCC-CCA) and have clinical significance.

Methods

The study enrolled 113 patients with histopathologically confirmed cHCC-CCA (MVI-positive group [n = 56], MVI-negative group [n = 57]). Two radiologists retrospectively assessed the preoperative MRI features (qualitative analysis of morphology and dynamic enhancement features), and each lesion was assigned according to the LI-RADS. Preoperative clinical data were also evaluated. Logistic regression analyses were used to assess the relative value of these parameters as potential predictors of MVI. Recurrence-free survival (RFS) rates after hepatectomy in the two groups were estimated using Kaplan–Meier survival curves and compared using the log-rank test.

Results

The majority of cHCC-CCAs were categorized as LR-M. On multivariate analysis, a higher serum AFP level (OR, 0.523; 95% CI, 0.282–0.971; p = 0.040), intratumoral fat deposition (OR, 14.368; 95% CI, 2.749–75.098; p = 0.002), and irregular arterial peritumoral enhancement (OR, 0.322; 95% CI, 0.164–0.631; p = 0.001) were independent variables associated with the MVI of cHCC-CCA. After hepatectomy, patients with MVI of cHCC-CCA showed earlier recurrence than those without MVI (hazard ratio [HR], 0.402; 95% CI, 0.189–0.854, p = 0.013).

Conclusion

A higher serum AFP level and irregular arterial peritumoral enhancement are potential predictive biomarkers for the MVI of cHCC-CCA, while intratumoral fat detected on MRI suggests a low risk of MVI. Furthermore, cHCC-CCAs with MVI may have worse surgical outcomes with regard to early recurrence than those without MVI.

Key Points

• Higher serum levels of AFP combined with irregular arterial peritumoral enhancement are independent risk factors for the MVI of cHCC-CCA, while fat deposition might be a protective factor.

• cHCC-CCA with MVI may have a higher risk of early recurrence after surgery.

• Most cHCC-CCAs were categorized as LR-M in this study, and no significant difference was found in MVI based on LI-RADS category.

Differentiation combined hepatocellular and cholangiocarcinoma from intrahepatic cholangiocarcinoma based on radiomics machine learning

BACKGROUND

Combined hepatocellular and cholangiocarcinoma (CHC) and intrahepatic cholangiocarcinoma (ICC) are hard to identify in clinical practice preoperatively. This study looked to develop and confirm a radiomics-based model for preoperative differentiation CHC from ICC.

METHODS

The model was developed in 86 patients with ICC and 46 CHC, confirmed in 37 ICC and 20 CHC, and data were collected from January 2014 to December 2018. The radiomics scores (Radscores) were built from radiomics features of contrast-enhanced computed tomography in 12 regions of interest (ROI). The Radscore and clinical-radiologic factors were integrated into the combined model using multivariable logistic regression. The best-combined model constructed the radiomics-based nomogram, and the performance was assessed concerning its calibration, discrimination, and clinical usefulness.

RESULTS

The radiomics features extracted from tumor ROI in the arterial phase (AP) with preprocessing were selected to build Radscore and yielded an area under the curve (AUC) of 0.800 and 0.789 in training and validation cohorts, respectively. The radiomics-based model contained Radscore and 4 clinical-radiologic factors showed the best performance (training cohort, AUC =0.942; validation cohort, AUC =0.942) and good calibration (training cohort, AUC =0.935; validation cohort, AUC =0.931).

CONCLUSIONS

The proposed radiomics-based model may be used conveniently to the preoperatively differentiate CHC from ICC.

Risk Factors of Tumor Recurrence After Liver Transplantation for Combined Hepatocellular Carcinoma and Cholangiocarcinoma

BACKGROUND

Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is commonly diagnosed as hepatocellular carcinoma (HCC) preoperatively. Therefore, unexpected recurrence occurs in some patients after liver transplantation (LT). The aim of this study was to identify the risk factors of recurrence.

METHODS

We retrospectively reviewed the data of 20 patients who underwent LT for cHCC-CC from January 2005 to December 2015.

RESULTS

Of the 20 patients, 11 (55%) had concurrent HCC and 10 (50%) had multiple cHCC-CCs. Before LT, 13 patients had undergone transarterial chemoembolization (TACE, n = 9), radiofrequency ablation, and TACE (n = 3) or surgical resection (n = 1). Four of the patients (20%) had the classical type, whereas 16 (80%) had subtypes with stem cell features. Six of the 16 patients (37.5%) with subtypes with stem cell features and 3 of the 4 patients (75%) with the classical type showed recurrence after LT. In multivariate analysis, the classical type was significantly associated with poorer recurrence-free survival (RFS) (hazard ratio [HR]: 8.65, confidence interval [CI]: 1.25-60.05, P = .03) and poorer overall survival (HR: 8.89, CI: 1.37-57.84, P = .02). Spontaneous tumor necrosis also showed significance on RFS (P = .03) among 11 patients with nontreated lesions.

CONCLUSION

In cHCC-CC, the classical type and spontaneous tumor necrosis were associated with recurrence. If these risk factors are found after LT, short-interval follow-up and strategies such as chemotherapy and/or use of mammalian target of rapamycin inhibitors to prevent recurrence are needed.

Imaging features of combined hepatocellular and cholangiocarcinoma compared with those of hepatocellular carcinoma and intrahepatic cholangiocellular carcinoma in a Chinese population

AIM

To determine the enhanced computed tomography (CT) and magnetic resonance imaging (MRI) characteristics of combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) in Chinese patients.

MATERIALS AND METHODS

Patients with histopathologically proven cHCC-CC (n=54) were compared with hepatocellular carcinoma (HCC; n=41) and cholangiocellular carcinoma (CCC; n=41) patients. Clinical information was measured in all patients. Tumour size, tumour margins, signs of cirrhosis, pseudocapsule, capsular retraction, rim enhancement, intrahepatic biliary dilatation, portal vein thrombosis, upper abdominal lymphadenopathy, were assessed on CT and/or MRI. The dynamic pattern of enhancement was also assessed.

RESULTS

The majority (81.5%) of cHCC-CC patients had positive hepatitis B serology. The presence of cirrhosis and tumour blood vessels was comparable in cHCC-CC and HCC, but significantly lower in CCC (p>0.05). The presence of ill-defined margin and regional lymphadenopathy was comparable in cHCC-CC and CCC, but significantly lower in HCC (p>0.05). The pseudocapsule, capsular retraction, biliary dilatation, rim enhancement, and abnormal perfusion were significantly different between the three types of lesions, with cHCC-CC being intermediate between HCC and CCC. Nearly half of the cHCC-CC tumours (25; 46.3%) showed the wash-in and wash-out enhancement pattern; the gradual, persistent, and mixed patterns were seen in 12 (22.2%), 5 (9.3%), and 12 (22.2%) tumours, respectively.

CONCLUSION

The majority of cHCC-CC tumours occur against a background of positive hepatitis B serology and cirrhosis. Imaging findings vary widely between cHCC-CC tumours. In the present series, the enhancement pattern of cHCC-CC tumours was HCC-like in most cases.

Response to Loco-Regional Therapy Predicts Outcomes After Liver Transplantation for Combined Hepatocellular-Cholangiocarcinoma

INTRODUCTION AND AIM

Combined hepatocellular-cholangiocarcinoma (HCC-CCA) is a rare liver malignancy distinct from either hepatocellular carcinoma (HCC) or cholangiocarcinoma. Liver transplantation (LT) is not recommended for HCC-CCA because of suboptimal outcomes. Non-invasive diagnosis of HCC-CCA is extremely challenging; thus, some HCC-CCAs are presumed as HCC on imaging and listed for LT with the correct diagnosis ultimately made on explant pathology. We compared HCC-CCA with HCC to determine the utility of response to pre-transplant loco-regional therapy (LRT) in predicting outcomes for HCC-CCA after LT as a potential means of identifying appropriate HCC-CCA patients for LT.

MATERIAL AND METHODS

Retrospective review of 19 patients with pathologically confirmed HCC-CCA were individually matched to 38 HCC patients (1:2) based on age, sex, and Milan criteria at listing was performed. The modified response evaluation criteria in solid tumors was used to categorize patients as responders or non-responders to pre-transplant LRT based on imaging performed before and after LRT. Overall survival (OS) and recurrence-free survival (RFS) were examined.

RESULTS

OS at 3 years post-transplant was 74% for HCC-CCA and 87% for HCC. RFS at 3 years was 74% for HCC-CCA, and 87% for HCC. Among responders to LRT, the 3-year OS was 92% for HCC-CCA and 88% for HCC; among non-responders, 3-year OS was 43% for HCC-CCA and 83% for HCC. Higher 3-year OS was observed among HCC-CCA responders (77%) compared with HCC-CCA non-responders (23%).

CONCLUSIONS

OS was similarly high among.

The Predictive Value of Staging Systems and Inflammation Scores for Patients with Combined Hepatocellular Cholangiocarcinoma After Surgical Resection: a Retrospective Study

BACKGROUND

Combined hepatocellular cholangiocarcinoma (cHCC-CC) is a rare form of primary liver tumor. A specific staging system for predicting survival in patients with cHCC-CC is not available. The aim of the present study was to evaluate the ability of staging systems and inflammation-based scores to predict overall survival (OS) and progression-free survival (PFS) of patients with cHCC-CC after surgical resection.

METHODS

The data from 99 patients with cHCC-CC after surgical resection from June 2000 and January 2017 were retrospectively collected. Patients were allocated into HCC (hepatocellular carcinoma)-dominant (IHD) group and ICC (intrahepatic cholangiocarcinoma)-dominant (IID) group based on radiological characteristics. Similarly, patients were also divided into HCC-dominant (PHD) group and ICC-dominant (PID) group based on pathological characteristics. Univariate and multivariate analyses were performed to identify variables associated with OS and PFS. The prognostic value of staging systems and inflammation-based scores were analyzed and compared using receiver operating characteristic (ROC) curves.

RESULTS

The 1-, 2-, and 3-year OS rates were 82.6, 66.3, and 59.6%, respectively. The 1-, 2-, and 3-year PFS rates were 52.2, 38.1, and 31.5%, respectively. Independent prognostic factors identified by multivariate analyses included HCC-TNM staging system and tumor diameter both for OS and PFS analyses. HCC-TNM staging system displayed higher area under ROC curve (AUC) values than the other staging systems or inflammation-based scores.

CONCLUSIONS

HCC-TNM staging system was able to adequately predict prognosis of patients with cHCC-CC after surgical resection, especially for patients with HCC-dominant characteristics in clinical practice.

A Case of Cholangiolocellular Carcinoma Preoperatively Diagnosed With Typical Imaging Findings

Introduction:

Cholangiolocellular carcinoma (CoCC) is a rare primary liver neoplasm. A recent integrative genomic analysis has revealed that CoCC represents a distinct biliary-derived molecular entity. Several cases of CoCC have been reported so far, but accurate preoperative diagnosis was difficult in most cases.

Case presentation:

We report a case of 70-year-old woman with CoCC. Preoperative imaging findings revealed several typical signs of CoCC (i.e., thick early ring enhancement in the peripheral area of the tumor and its prolongation, vessel penetration through the tumor, no dilatation of the peripheral bile ducts, and dot-/band-like internal enhancement or a target appearance on contrast-enhanced magnetic resonance imaging). We strongly suspected CoCC from these preoperative imaging findings of the tumor and performed extended left hepatectomy. Pathologic diagnosis was CoCC, and the histologic findings such as peripheral highly cellular areas, central abundant hyalinized/edematous fibrotic stroma, and retained Glisson's sheath structures in the tumor, corresponded closely to each preoperative imaging finding. Immunohistochemical study revealed the tumor cells were positive for cytokeratin 7 and epithelial membrane antigen. The postoperative course was uneventful, and the patient is alive without recurrence for 15 months. The prognosis of CoCC is known to be better than that of cholangiocellular carcinoma, indicating the importance of preoperative differential diagnosis of these tumors.

Conclusion:

Even though preoperative diagnosis of CoCC is difficult because of its rarity, cautious investigation of preoperative typical imaging findings can possibly lead to accurate diagnosis of CoCC.

Longterm prognosis of combined hepatocellular carcinoma-cholangiocarcinoma following liver transplantation and resection

Combined hepatocellular carcinoma-cholangiocarcinoma (cHCC-CC) is a rare disease. We investigated the clinicopathological features of cHCC-CC and compared the longterm outcomes following liver transplantation (LT) and hepatic resection (HR). We identified 32 LT patients with cHCC-CC through an institutional database search. The HR control group (n = 100) was selected through propensity score-matching. The incidence of cHCC-CC among all adult LT patients was 1.0%. Mean patient age was 53.4 ± 6.7 years, and 26 patients were male. Thirty patients had hepatitis B virus infection. All patients of cHCC-CC were diagnosed incidentally in the explanted livers. Mean tumor diameter was 2.5 ± 1.3 cm, and 28 patients had single tumors. Tumor stage was stage I in 23 and II in 9. Concurrent hepatocellular carcinoma (HCC) was detected in 12 patients with stage I in 5 and II in 7. Mean tumor diameter was 1.9 ± 1.2 cm, and 5 had single tumors. Tumor recurrence and survival rates were 15.6% and 84.4% at 1 year and 32.2% and 65.8% at 5 years, respectively. Patients with very early stage cHCC-CC (1 or 2 tumors ≤ 2.0 cm) showed 13.3% tumor recurrence and 93.3% patient survival rates at 5 years, which were significantly improved than those with advanced tumors (P = 0.002). Tumor recurrence and survival rates did not differ significantly between the LT and HR control groups (P = 0.22 and P = 0.91, respectively); however, postrecurrence patient survival did (P = 0.016). In conclusion, cHCC-CC is rarely diagnosed following LT, and one-third of such patients have concurrent HCC. The longterm posttransplant prognosis was similar following LT and HR. Very early cHCC-CC resulted in favorable posttransplant prognosis, thus this selection condition can be prudently considered for LT indication. Liver Transplantation 23 330-341 2017 AASLD.