Liver Transplantation and Incidentally Found Hepatocellular Carcinoma in Liver Explants: Need for a New Definition?

Long-Term Outcomes of Incidental Liver Malignancies in Simultaneous Liver-Kidney Transplant Recipients

BACKGROUND

The pretransplant diagnosis of liver malignancies in nodular cirrhotic livers remains a diagnostic challenge despite current advances. Although the prognostic impact of incidental hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (iCC) in liver transplant recipients is well documented, there are no data on the impact in simultaneous liver kidney transplant (LKT) recipients.

METHODS

This is a single-center observational, retrospective study of all LKT performed from May 1993 to April 2022. Among these patients, demographic data, immunosuppressive therapy, rejection episodes, and prevalence of incidental HCC or iCC were evaluated.

RESULTS

One hundred eight LKTs were performed and 6 were excluded. There were 13 patients with incidental carcinomas in the explanted liver: one of them with both an HCC and iCC, one with an iCC, and the remaining with an HCC. One case of iCC died. No other recurrences occurred. There were no cases of incidental HCC nor iCC in patients with a hereditary or metabolic LKT indication. We found no differences in the 5-year patient survival, and death-censored kidney and liver graft survival rates for those LKT with an incidental HCC and those without it (76.9% vs 84.2%, P = .5; 100% vs 91.6%, P = .28; and 100% vs 94.7%, P = 0.39, respectively). Finally, there were no significant associations between explant carcinoma and rejections of the liver (7.7% vs 17.9%, P = .34) or kidney graft (0% vs 16.8%, P = 0.11).

CONCLUSION

Despite a high prevalence of incidental HCC or iCC, patient, kidney, and liver graft 5-year survival were unaffected by incidental HCC.

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.

Incidental Finding of Multiple Synchronous Neoplasms in Explanted Liver After Transplantation: A Case Report

Liver transplantation is the only potentially curative treatment for patients with end-stage liver disease. After the procedure, histopathologic analysis of the liver explant may reveal neoplasms that were not previously diagnosed in preoperative imaging examinations. This incidental finding of primary liver neoplasms in the explant is not an uncommon situation in liver transplant, and hepatocarcinomas and cholangiocarcinomas are the types of tumors most frequently encountered in this scenario. These are the most common primary neoplasms of the liver, and liver transplantation is often a curative treatment for these types of tumors when they are in their earlier stages. In contrast, liver plasmacytoma is a rare type of plasma cell neoplasm, consisting of a single mass of monoclonal plasma cells, which is treated primarily by radiotherapy and is seldom encountered in the setting of liver transplant. We report the case of a patient who underwent liver transplantation for the treatment of cryptogenic cirrhosis, with no preoperative diagnosis of liver tumors. Analysis of the liver explant revealed the presence of three synchronous neoplasms with different histologic origins: a 27-mm hepatocellular carcinoma, a 17-mm intrahepatic cholangiocarcinoma, and a 25-mm solitary hepatic plasmacytoma. The patient received no further adjuvant treatment and remained well and with no signs of disease recurrence over an observation period of 44 months. We found no previous report in the literature of the synchronous presence of these three types of liver neoplasms.

Blood Cell Salvage and Autotransfusion Does Not Worsen Oncologic Outcomes Following Liver Transplantation with Incidental Hepatocellular Carcinoma: A Propensity Score-Matched Analysis

BACKGROUND

Intraoperative blood cell salvage and autotransfusion (IBSA) during liver transplantation (LT) for hepatocellular carcinoma (HCC) is controversial for concern regarding adversely impacting oncologic outcomes.

OBJECTIVE

We aimed to evaluate the long-term oncologic outcomes of patients who underwent LT with incidentally discovered HCC who received IBSA compared with those who did not receive IBSA.

METHODS

Patients undergoing LT (January 2001-October 2018) with incidental HCC on explant pathology were retrospectively identified. A 1:1 propensity score matching (PSM) was performed. HCC recurrence and patient survival were compared. Kaplan-Meier survival analyses were performed, and univariable Cox proportional hazard analyses were performed for risks of recurrence and death.

RESULTS

Overall, 110 patients were identified (IBSA, n = 76 [69.1%]; non-IBSA, n = 34 [30.9%]). Before matching, the groups were similar in terms of demographics, transplant, and tumor characteristics. Overall survival was similar for IBSA and non-IBSA at 1, 3, and 5 years (96.0%, 88.4%, 83.0% vs. 97.1%, 91.1%, 87.8%, respectively; p = 0.79). Similarly, the recurrence rate at 1, 3, and 5 years was not statistically different (IBSA 0%, 1.8%, 1.8% vs. non-IBSA 0%, 3.2%, 3.2%, respectively; p = 0.55). After 1:1 matching (26 IBSA, 26 non-IBSA), Cox proportional hazard analysis demonstrated similar risk of death and recurrence between the groups (IBSA hazard ratio [HR] of death 1.26, 95% confidence interval [CI] 0.52-3.05, p = 0.61; and HR of recurrence 2.64, 95% CI 0.28-25.30, p = 0.40).

CONCLUSIONS

IBSA does not appear to adversely impact oncologic outcomes in patients undergoing LT with incidental HCC. This evidence further supports the need for randomized trials evaluating the impact of IBSA use in LT for HCC.

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.

Prognostic impact of incidentally detected hepatocellular carcinoma in explanted livers after living donor liver transplantation

BACKGROUND

The impact of incidentally detected hepatocellular carcinoma (iHCC) in explanted liver on the prognosis of the patients undergoing orthotopic liver transplantation remains controversial with several studies reporting survival worse than true non-hepatocellular carcinoma (non-HCC) recipients. Patients undergoing living donor liver transplantation (LDLT) have the benefit of a shorter waiting time to transplant which in principle should reduce the frequency of new tumors developing while waiting for transplant. We aimed to evaluate the incidence, histopathological features, and impact of iHCC on short- and long-term outcomes in adult LDLT recipients.

METHODS

The present study retrospectively analyzed the patients' demographics, tumor characteristics, and outcomes of iHCC in adult patients undergoing LDLT for non-HCC indications at our center between August 2009 and March 2018.

RESULTS

Five hundred and forty-five adults underwent LDLT in our center during the study period. iHCC was detected in the explanted livers in 28 patients (5.1%) out of 545 LDLTs. Only one patient had iHCC beyond Milan criteria. No tumor recurrence was observed in the iHCC cohort after a median follow-up of 28 months. Five-year overall and recurrence-free survival was 96.4%.

CONCLUSIONS

Incidence of iHCC in explanted livers after LDLT is low and most patients have very early-stage tumors with excellent recurrence-free survival. Hence, no specific post-transplant surveillance or treatment is necessary.

Detect or not to detect very early stage hepatocellular carcinoma? The western perspective

Very early stage hepatocellular carcinoma (HCC) is defined as a single tumor with the largest diameter of the lesion measuring 2 cm or less according to Barcelona Liver Cancer staging system. Detection of very early stage HCC is clinically important as it confers an excellent prognosis with the 5-year survival rates over 60 to 80% after patients receive curative treatments. While diagnosing HCC at a very early stage is crucial, it is technically challenging and may come with the physical or psychosocial harms related to diagnostic tests. It is further complicated by the fact that patients with very early stage HCC are not prioritized for liver transplant (LT) in the United States organ allocation system. When LT-eligible patients present with an indeterminate lesion measuring between 1 and 2 cm on the multiphasic computed tomography or magnetic resonance imaging, clinicians often observe patients carefully until the lesion grows up to 2 cm so that patients can be eligible to receive a Model for End-Stage Liver Disease (MELD) exception score for HCC in the United States. The European guideline recommends a routine biopsy of such lesion. In conclusion, attempting to detect very early stage HCC is difficult to achieve and controversial. Clinicians should take into account of the risk and the benefit of diagnostic tests, LT candidacy of patients and the local organ allocation system.

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.

Alpha-fetoprotein Level Predicts Recurrence After Transplantation in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the leading causes of liver transplantation. In an attempt to predict their recurrence after liver transplantation, evaluation of tumor number and size, degree of histologic differentiation, and the presence of vascular invasion already have their importance established. In this context, the role of biologic markers such as alpha-fetoprotein (AFP) is still not clear. This retrospective cross-sectional study analyzed the AFP relationship with recurrence of HCC after orthotopic liver transplantation.The current study retrospectively analyzed data from 206 patients with a histopathologic confirmed HCC between 1997 and 2010.The overall survival rates at 1, 3, 5, and 14 years were 78.6%, 65.4%, 60.5%, and 38.7%, respectively. The frequency of recurrence was 15.5%, and recurrence was significantly associated with a lower survival rate (P < 0.001). No association was observed between survival and AFP level (P = 0.153). A correlation, however, was found between tumor recurrence and AFP level (P = 0.002). Univariate analysis of risk factors for recurrence revealed that an AFP level greater than 200 ng/mL, the number of tumors, the degree of cellular differentiation, and the presence of vascular invasion or satellite nodules were associated with relapse. By multivariate analysis, only an AFP level greater than 200 ng/mL remained as a risk factor.Although an elevated AFP level did not correlate with survival in HCC patients undergoing orthotopic liver transplantation, a high AFP level was associated with a 3.32-folds increase in the probability of HCC recurrence.

Incidental hepatocellular carcinoma: risk factors and long-term outcome after liver transplantation

BACKGROUND

Orthotopic liver transplantation (OLT) currently represents the treatment of choice for early hepatocellular carcinoma (HCC). Preoperatively known HCC (pkHCC) is diagnosed via imaging methods before OLT or before HCC is found postoperatively in the liver explant, denoted as incidental HCC (iHCC). The aim of this study was a comprehensive analysis of the post-transplantation survival of patients with iHCC and the identification of risk factors of iHCC occurrence in cirrhotic liver.

METHODS

We retrospectively reviewed 33 adult cirrhotic patients with incidentally found HCC, comparing them with 606 tumor-free adult cirrhotic patients with end-stage liver disease (group Ci) who underwent OLT in our center from January 1995 to August 2012. Within the same period, a total of 84 patients underwent transplantation for pkHCC. We compared post-transplantation survivals of iHCC, Ci, and pkHCC patients. In the group of cirrhotic patients (Ci + iHCC), we searched for risk factors of iHCC occurrence.

RESULTS

There was no difference in sex, Model for End-Stage Liver Disease score, and time spent on the waiting list in either group. In the multivariate analysis we identified age >57 years (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.75-8.14; P < .001), hepatitis C virus or alcoholic liver disease (OR, 3.89; 95% CI, 1.42-10.7; P < .001), and alpha-fetoprotein level >6.4 μg/L (OR, 6.65; 95% CI, 2.82-15.7; P = .002) to be independent predictors of iHCC occurrence. Both the 1-, 3-, and 5-year overall survival (OS) and the 1-, 3- and 5-year recurrence-free survival (RFS) differed in iHCC patients compared with the Ci group (iHCC: OS 79%, 72%, and 68%, respectively; RFS 79%, 72%, and 63%, respectively; vs Ci: OS = RFS: 93%, 94%, and 87%, respectively; P < .001).

CONCLUSIONS

The survival of iHCC patients is worse than in tumor-free cirrhotic patients, but similar to pkHCC patients. The independent risk factors for iHCC occurrence in cirrhotic liver are age, hepatitis C virus, or alcoholic liver disease etiology of liver cirrhosis and alpha-fetoprotein level.

Long-term survival outcomes for living donor liver transplant recipients with pathologically nonviable hepatocellular carcinoma

PURPOSE

Complete necrosis of hepatocellular carcinoma (HCC) lesions has occasionally been found by explant pathology after pretransplant neoadjuvant treatment. This study sought to investigate the long-term prognostic effect of loss of tumor viability after HCC treatment in living donor liver transplant (LDLT) recipients.

METHODS

We reviewed retrospectively the 5-year records of 37 patients who demonstrated nonviable HCC on explant pathology.

RESULTS

The most common primary disease was hepatitis-B-virus-associated liver cirrhosis (n = 34). Single explant tumors were found in 29 patients; the mean maximal tumor size was 2.1 ± 0.9 cm (range: 0.8-4.0). No patients showed microvascular invasion. The median level of alpha-fetoprotein was 12 ng/mL (range: 1-1160). The 1 patient who showed a recurrence at 20 months remains alive more than 6 years after adrenalectomy and repeated pulmonary metastasectomy. The 5-year HCC recurrence rate was thus 2.1%. There were 2 late mortalities, each due to graft failure and recurrent gastric cancer. The overall patient survival rate was 97.3% at 5 and 92.7% at 10 years.

CONCLUSIONS

The results of this study revealed that the loss of tumor viability induced by pretransplant neoadjuvant treatment definitely decreased the risk of post-transplant HCC recurrence. Therefore, patients with nonviable HCC can be regarded as members of a superselect group with minimal risk for HCC recurrence, and may be exempted from routine HCC screening.

Liver transplantation for hepatocellular carcinoma--is there a risk of recurrence caused by intraoperative blood salvage autotransfusion?

BACKGROUND/AIMS

The use of intraoperative blood salvage autotransfusion (IBSA) during surgical approaches may contribute to tumour cell dissemination. Therefore, IBSA should be avoided in cases of malignancy. However, the risks of IBSA might be acceptable in liver transplantation (LT) for selected small hepatocellular carcinoma (HCC).

METHODS

In total, 136 recipients of LT with histologically proven HCC in the explanted liver were included in this analysis. With regard to tumour recurrence, 40 patients receiving IBSA despite HCC (IBSA group) were compared to 96 patients without IBSA (non-IBSA group).

RESULTS

Milan criteria as assessed in the explanted liver were fulfilled in 24 of 40 IBSA patients and 58 of 96 non-IBSA patients (p = 0.85). Five of 40 patients in the IBSA group and 18 of 96 patients in the non-IBSA group experienced tumour recurrence (p = 0.29). In spite the theoretical risk of tumour cell dissemination, the recurrence rate was not increased in the IBSA group.

CONCLUSION

Our results indicate that IBSA does not modify the risk of HCC recurrence. Therefore, in highly selected HCC patients undergoing LT, the use of IBSA appears to be justified.

Super-selection of a subgroup of hepatocellular carcinoma patients at minimal risk of recurrence for liver transplantation

BACKGROUND

A majority of patients with hepatocellular carcinoma (HCC) undergoing liver transplantation (LT) meet the Milan criteria, but these are still regarded as the narrowest criteria for transplantation. Prognostic analysis of incidentally detected HCC after LT suggests that a subgroup of HCC patients is at very low risk of recurrence. To determine the criteria defining this super-selection group, we retrospectively analyzed survival data of 593 adult living-donor LT recipients with HCC in the explanted liver

DISCUSSION

Tumor features of incidental HCC in 38 patients not showing recurrence were analyzed. Of these patients, 34 (89.5%) each had ≤2 tumors and tumors ≤2.0 cm in size. Applying these criteria to 555 patients with pretransplant known HCC (pkHCC) allowed us to identify 79 patients with untreated pkHCCs ≤2.0 cm in size. To date, only two of these patients have shown recurrence, making the conditions for super-selection the presence of tumors ≤2.0 cm in size, ≤2 tumors, alpha-fetoprotein ≤200 ng/mL, and no pretransplant treatment. In 87 patients satisfying these criteria, the 10-year recurrence and survival rates were 1.3% and 92.1%, respectively. After excluding patients meeting these criteria, the 5-year recurrence rates in patients satisfying the Milan, University of California at San Francisco, and Asan criteria were increased by 2.9-4.0%. In conclusion, this super-selection or super-Milan category may be used for validation assessment of various indication criteria and for the development of cost-effective post-transplantation HCC surveillance protocols. Further studies should be followed for deceased-donor LT and patients who have undergone pretransplant treatment.

Diffuse cirrhosis-like hepatocellular carcinoma: a clinically and radiographically undetected variant mimicking cirrhosis

A rare variant of hepatocellular carcinoma (HCC) is encountered that produces small cirrhosis-like nodules diffusely throughout the liver (CL-HCC), instead of a larger evident mass. This pattern remains undetected as carcinoma clinically and radiographically and is unexpectedly discovered after liver transplantation in the explanted native liver. We studied 10 such cases (9 males and 1 female, age 35 to 80 y) from 4 medical centers. The pretransplant clinical, laboratory, and radiographical studies were reviewed to determine the cause and stage of liver disease, alpha-fetoprotein (AFP) levels, and detectability of a mass on imaging. All 10 cases had underlying cirrhosis of varying etiology [3 hepatitis C virus (HCV), 3 alcoholic hepatitis, 1 hepatitis B virus, 1 autoimmune, and 2 mixed HCV/alcoholic hepatitis and hemochromatosis/HCV] and underwent orthotopic liver transplantation with no preoperative clinical suspicion of HCC. Ultrasound and/or dynamic imaging showed cirrhosis and no definite HCC. AFP levels were only mildly elevated in only 3 of 10 cases (144, 150, and 252 ng/mL). Grossly, there were innumerable (from about 20 to >1000) small CL-HCC nodules (0.2 to 0.6 cm) scattered among cirrhotic nodules. Histologically, these were well or moderately differentiated HCC, often with pseudoglandular pattern, perinodular sclerotic rims, cholestasis, frequent Mallory bodies, and small vessel invasion. In addition to the usual HCC immunophenotype, CL-HCC showed frequent ubiquitin and cytoplasmic and membranous CD10 positivity, relatively low Ki-67 proliferative index and absence of AFP immunohistochemically. CL-HCC warrants recognition as a unique HCC variant that evades pretransplant detection despite massive tumor burden, mimics cirrhotic nodules, and shows some uncommon pathologic and immunophenotypical characteristics.

Incidental hepatocellular carcinoma after liver transplantation: population characteristics and outcomes

We combined data from two liver transplant centers to determine the tumor characteristics and outcomes of 51 patients transplanted with incidental hepatocellular carcinoma (iHCC) compared with 143 patients transplanted for previously known HCC (pkHCC). There were no differences in age, gender, or frequency of hepatitis C infection. Patients with iHCC were more likely to be African-American (22% vs 10%; P = .016), more likely to be screened by ultrasound (38% vs 9%; P < .001), had a lower alpha-fetoprotein (83.9 +/- 258.1 vs 572.4 +/- 2376.4 ng/mL; P = .005), and had a higher model for end-stage liver disease (MELD) score (14.3 +/- 4.1 vs 11.8 +/- 4.7; P < .001). The liver explants of patients with iHCC had smaller total tumor burden than patients with pkHCC (3.1 +/- 3.5 vs 4.1 +/- 2.6 cm; P < .001), but a similar percentage of single lesions (66% vs 65%) and tumors that met Milan criteria (76% vs 65%). Patients with iHCC had 1-, 3-, and 5-year survivals of 78%, 67%, and 58%, and 1-, 3-, and 5-year recurrence-free survivals of 90%, 87%, and 87% compared with the 1-, 3-, and 5-year survivals of 90%, 82%, and 70%, and the 1-, 3-, and 5-year tumor-free survivals of 91%, 84%, and 78% in patients with pkHCC. We concluded that patients with iHCC were more likely to be African-American, to be screened by ultrasound, to have a lower alpha-fetoprotein, and a higher MELD score. Ultrasound is not a sensitive modality for screening patients for HCC. Patients with iHCC do not have an advantage in survival over those with pkHCC.

Liberal policy in living donor liver transplantation for hepatocellular carcinoma: lessons learned

BACKGROUND

Living donor liver transplantation (LDLT) in cases of hepatocellular carcinoma (HCC) that do not fulfil accepted tumor criteria continues to be a matter of controversy. The aim of this study was to evaluate survival and prognostic factors associated with a liberal exclusionary policy.

MATERIAL AND METHODS

This is an analysis of data collected prospectively on 57 HCC patients who underwent LDLT at our institution between April 1998 and January 2007.

RESULTS

Overall 3-year survival was 62%; this increased to 71% when 45-day mortality was excluded from the analysis. Age proved to be a predictor of survival irrespective of the 45-day mortality. In contrast, the Model for End stage Liver Disease (MELD) score predicted survival only when 45-day mortality was included in the analysis, while alpha fetoprotein (AFP) level predicted survival only when it was excluded. Significant cut-off values were patient age of over 60 years, MELD score above 22, and AFP level greater than 400 ng/ml. A scoring system was developed. Survival rate at 3 years--including 45-day mortality--was 72% for score =2 and 41% for score >2 (P = 0.0146). When 45-day mortality was excluded, the survival rate at 3 years was 90% for score =2 and 32% for score >2 (P = 0.00002).

CONCLUSIONS

Our results could further enhance current guidelines on age, MELD score, and AFP level for patients with HCC being evaluated to undergo LDLT.

Hepatocellular carcinoma with indeterminate or false-negative findings at initial MR imaging: effect on eligibility for curative treatment initial observations

PURPOSE

To retrospectively evaluate the effect of indeterminate or false-negative findings at magnetic resonance (MR) imaging on eligibility for curative treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This HIPAA-compliant retrospective study was approved by the institutional review board; the need for informed consent was waived. Of 166 patients with cirrhosis in whom HCC was detected with MR imaging, 21 (13 men, eight women; mean age, 60 years) had 33 proved HCCs that were not detected on previous MR images obtained 6-24 months earlier. MR imaging included T1-weighted, T2-weighted, and dynamic contrast material-enhanced T1-weighted imaging. Serial MR images and treatment records were reviewed to evaluate nodule growth and the effect of delayed diagnosis on treatment eligibility.

RESULTS

Of 33 HCCs in 21 patients, 24 corresponding nodules (73%) were described on previous MR images as benign or indeterminate. Five additional nodules were visible at retrospective evaluation, but only on arterial phase images. The diameters of these 29 visible but indeterminate nodules were initially 0.6-1.9 cm (mean, 1.1 cm) and increased to 0.9-4.5 cm (mean, 1.9 cm) at HCC diagnosis (mean follow-up, 378 days). The mean doubling time was 856 days for diameter and 285 days for volume. All nine HCCs with a delayed diagnosis of less than 1 year were smaller than 3 cm at diagnosis, and the patients had undergone liver transplantation (n=3) or technically successful ablation or embolization (n=6). All 10 subcentimeter indeterminate nodules were smaller than 2 cm at HCC diagnosis, and none progressed to untreatable HCC.

CONCLUSION

Indeterminate nodules smaller than 2 cm did not become untreatable HCC with delayed HCC diagnosis of 6-12 months.