Is recurrence rate of incidental hepatocellular carcinoma after liver transplantation similar to previously known HCC? Towards a predictive recurrence score

Incidental Hepatocellular Carcinoma after Liver Transplantation: Clinicopathologic Features and Prognosis

Background: The prognostic impact and clinicopathologic features of incidental hepatocellular carcinoma (iHCC) detected in explanted livers of patients undergoing liver transplantation (LT) has been a controversial issue in previous studies when compared with patients who are diagnosed with hepatocellular carcinoma (pdHCC) before LT. We aimed to review and compare these patient groups in a high-volume LT center. Methods: The present study involves a retrospective analysis of 406 HCC patients who received LT between January 2002 and April 2022. Among these patients, demographic data, histopathologic features and prognosis for iHCC and pdHCC were evaluated. Results: In our series, 406 patients’ final diagnosis was HCC after they had received LT, nevertheless 54 patients in this HCC group were diagnosed incidentally after the pathological evaluation of the explanted livers. The etiology of the underlying liver disease between pdHCC (n = 352) and iHCC (n = 54) groups had some differences in our study population. Most of the patients in the pdHCC group had moderately differentiated tumors (45.7%). On the other hand, most of the patients in the iHCC group had well differentiated tumors (79.6%). There were 158 (44%) patients who met the Milan criteria in the pdHCC group while there were 48 (92%) patients in the iHCC group (p < 0.001). IHCC patients had statistically better 1, 3, 5 and 10 years disease-free and overall survival rates when compared with pdHCC patients. There was only 1 (1.8%) patient who had tumor recurrence in the iHCC group while 76 (21%) patients had tumor recurrence in the pdHCC group (p = 0.001). There is no disease free and overall survival difference when iHCC patients are compared with pdHCC patients who met the Milan criteria. Conclusion: It is the first study to show that iHCC patients may differ from pdHCC patients in terms of etiological features. IHCC tumors show better histopathologic features than pdHCC with low recurrence rate and iHCC patients have better survival rates than pdHCC patients.

Recurrent Hepatocellular Carcinoma After Liver Transplantation: Validation of a Pathologic Risk Score on Explanted Livers to Predict Recurrence

BACKGROUND

Recurrence of hepatocellular carcinoma (HCC) after liver transplantation is a major cause of morbidity and mortality. To date, there is no widely accepted pathologic assessment tool to predict HCC recurrence. In 2007, we developed a pathologic risk score that stratified patients into low, intermediate, or high risk for recurrence based on explant pathology. The aim of this study was to externally validate this risk score.

METHODS

We retrospectively evaluated 124 patients over a 10-year period who underwent liver transplantation for HCC. Using explanted pathology reports, each patient was stratified according to the pathologic risk score and followed over time for HCC recurrence.

RESULTS

Recurrence occurred in 15 patients (12%) after a mean follow-up of 25 months. Using the pathologic risk score, 10 (8%), 21 (17%), and 93 (75%) patients were stratified into high, intermediate, and low risk of recurrence, respectively. Among these risk groups, recurrence occurred in 50%, 28.5%, and 4.3% (P < .01) of patients, respectively. Using the optimal cutoff value ≤3.5, our risk score had a sensitivity of 80% and specificity of 79% with an area under the receiver operator characteristic curve of 0.8. Those with lower risk scores had higher recurrence-free survival (P < .0001).

CONCLUSIONS

Our pathologic risk score accurately risks stratified patients for HCC recurrence after liver transplant. It can be used to tailor surveillance strategies for those deemed to be at elevated risk for recurrence.

Characteristics and outcome of incidental hepatocellular carcinoma after liver transplantation: a cohort study

INTRODUCTION

Despite advances in imaging diagnostic modalities, hepatocellular carcinoma is sometimes incidentally diagnosed on histological examination of the liver explant. Our objectives were: 1) To compare the characteristics between incidental and known hepatocellular carcinoma and 2) To estimate survival and tumor recurrence after liver transplantation.

MATERIAL AND METHODS

Retrospective, single-center study. The inclusion criteria were 1) cirrhotic patients, age≥18 years, 2) Liver transplantation between 1998 and 2018, and 3) hepatocellular carcinoma diagnosed on the histopathologic examination of the explanted liver. Cholangiocarcinoma and patients with early retransplantation were excluded. Multivariate analysis was performed using binomial logistic regression to assess the factors associated incidental hepatocellular carcinoma. Kaplan-Meier curves were plotted to explore the impact on overall survival and recurrence free survival.

RESULTS

269 patients were enrolled. The prevalence of incidental hepatocellular carcinoma was 4.18% (95% CI: 2.89-6.01%) of all liver transplants performed in cirrhotic patients. The median diameter of the main nodule was smaller in incidental hepatocellular carcinoma (20 vs 27 mm, p=0.004) although they were more likely to be beyond the Up-to-Seven criteria on explant examination (22.2% vs 7.5%, p=0.001), showing no differences in any other histological features. No differences were found in overall survival rates (incidental 70.2% vs 70.4%, p=0.87) nor recurrence-free survival (incidental 100% vs 83.8%, p=0.07) at 5 years.

CONCLUSION

Incidental hepatocellular carcinoma has a smaller size and is more frequently found to be beyond the Up-to-Seven criteria. However, no differences were found in overall survival rates nor recurrence-free survival, although there was no tumor recurrence in incidental hepatocellular carcinoma group.

Results of Liver Transplantation for Hepatocellular Carcinoma in a Multicenter Latin American Cohort Study

BACKGROUND AND AIMS

Heterogeneous data has been reported regarding liver transplantation (LT) for hepatocellular carcinoma (HCC) in Latin America. We aimed to describe treatment during waiting list, survival and recurrence of HCC after LT in a multicenter study from Latin America.

MATERIAL AND METHODS

Patients with HCC diagnosed prior to transplant (cHCC) and incidentally found in the explanted liver (iHCC) were included. Imaging-explanted features were compared in cHCC (non-discordant if pre and post-LT were within Milan, discordant if pre-LT was within and post-LT exceeding Milan).

RESULTS

Overall, 435 patients with cHCC and 92 with iHCC were included. At listing, 81% and 91% of cHCC patients were within Milan and San Francisco criteria (UCSF), respectively. Five-year survival and recurrence rates for cHCC within Milan, exceeding Milan/within UCSF and beyond UCSF were 71% and 16%; 66% and 26%; 46% and 55%, respectively. Locoregional treatment prior to LT was performed in 39% of cHCC within Milan, in 53% beyond Milan/within UCSF and in 83% exceeding UCSF (p &lt; 0.0001). This treatment difference was not observed according to AFP values (≤100, 44%; 101-1,000, 39%, and &gt; 1,000 ng/mL 64%; p = 0.12). Discordant imaging-explanted data was observed in 29% of cHCC, showing lower survival HR 2.02 (CI 1.29; 3.15) and higher recurrence rates HR 2.34 when compared to AFP &lt;100 ng/mL. Serum AFP &gt; 1,000 ng/mL at listing was independently associated with a higher 5-year recurrence rate and a HR of 3.24 when compared to AFP &lt;100 ng/mL.

CONCLUSION

Although overall results are comparable to other regions worldwide, pre-LT treatment not only considering imaging data but also AFP values should be contemplated during the next years.

Human immunodeficiency virus-infected liver transplant recipients with incidental hepatocellular carcinoma: A prospective multicenter nationwide cohort study

There is a lack of data on incidental hepatocellular carcinoma (iHCC) in the setting of liver transplantation (LT) in human immunodeficiency virus (HIV)-infected patients. This study aims to describe the frequency, histopathological characteristics, and outcomes of HIV+ LT recipients with iHCC from a Spanish multicenter cohort in comparison with a matched cohort of LT patients without HIV infection. A total of 15 (6%) out of 271 patients with HIV infection who received LT in Spain from 2002 to 2012 and 38 (5%) out of the 811 HIV- counterparts presented iHCC in liver explants (P = 0.58). Patients with iHCC constitute the present study population. All patients also had hepatitis C virus (HCV)-related cirrhosis. There were no significant differences in histopathological features of iHCC between the 2 groups. Most patients showed a small number and size of tumoral nodules, and few patients had satellite nodules, microvascular invasion, or poorly differentiated tumors. After a median follow-up of 49 months, no patient developed hepatocellular carcinoma (HCC) recurrence after LT. HIV+ LT recipients tended to have lower survival than their HIV- counterparts at 1 (73% versus 92%), 3 (67% versus 84%), and 5 years (50% versus 80%; P = 0.06). There was also a trend to a higher frequency of HCV recurrence as a cause of death in the former (33% versus 10%; P = 0.097). In conclusion, among LT recipients for HCV-related cirrhosis, the incidence and histopathological features of iHCC in HIV+ and HIV- patients were similar. However, post-LT survival was lower in HIV+ patients probably because of a more aggressive HCV recurrence. Liver Transplantation 23 645-651 2017 AASLD.

Incidental hepatocellular carcinoma after liver transplantation: Prevalence, histopathological features and prognostic impact

Background

Incidental hepatocellular carcinoma (iHCC) is a histological finding after liver transplantation (LT) which relevance has been scarcely studied.

Aims

to describe the histopathological features of iHCC and to determine its prognostic impact in terms of tumor recurrence and overall survival.

Methods

Observational study including 451 consecutive adult LT patients (2000–2013). Patients aged<18, retransplanted or with early postoperative death were excluded. Median follow-up after LT was 58 months. Multiple Cox’s regression was used to assess the prognostic impact of iHCC on tumor recurrence and mortality while controlling for potential confounders.

Results

141 patients had known HCC before LT (31.3%). Among the remaining 310 patients, the prevalence of iHCC was 8.7% (n = 27). In the explanted liver, 36.2% of patients with known HCC and 25.9% of patients with iHCC trespassed Milan criteria (p = 0.30). Patients with known and iHCC had similar rates of multinodular disease (50.4% vs 55.6%; p = 0.62), macrovascular invasion (6.5% vs 3.7%; p = 0.58), microvascular invasion (12.9% vs 14.8%; p = 0.76) and moderate-poor tumor differentiation (53.9% vs 70.4%; p = 0.09). In the multivariate analysis, iHCC and known HCC had identical recurrence-free survival after controlling for histological features (RR = 1.06, 95%CI 0.36–3.14; p = 0.90). Cumulative 5-year overall survival rates were similar between patients with known and iHCC (65% vs 52.8% respectively; log rank p = 0.44), but significantly inferior as compared with patients without HCC (77.8%) (p = 0.002 and p = 0.007 respectively). Indeed, in the overall cohort, iHCC was an independent predictor of mortality (RR = 3.02; 95%CI 1.62–5.65; p = 0.001).

Conclusion

The risk of tumor recurrence after LT is similar in patients with iHCC and known HCC. A close imaging surveillance is strongly recommended for patients awaiting LT in order to detect HCC prior to LT, thus allowing for an adequate selection of candidates, prioritization and indication of bridging therapies.