An Evidence-Based Strategy for Hcc Surveillance after Liver Transplantationv

Background: Liver transplantation (LT) has been accepted as the treatment of choice for early, unresectable hepatocellular carcinoma (HCC) in cirrhotic patients. Still, HCC recurrence after transplant remains a serious problem. Currently, there are no evidence-based guidelines for post-transplant surveillance for HCC recurrence. In this study we review our experience with LT for HCC and determine the characteristics and patterns of recurrence. Our purpose is to generate a surveillance strategy for HCC recurrence after LT. Methods: We retrospectively reviewed our experience with LT for HCC, focusing on those patients that experienced HCC recurrence. The setting was a single, high volume center in the US operating under the MELD allocation system. The risk factors that predicted recurrence and the incidence of recurrence were determined. Data regarding the timing and first site of recurrence, alpha-fetoprotein (AFP) level, treatment, and survival after the diagnosis of recurrent HCC were collected and analyzed. With this information we propose surveillance guidelines. Results: Between March 2002 and December 2010, 275 adults underwent primary LT for cirrhosis and HCC including 53 with incidental tumors. The 5 year recurrence-free survival for the cohort was 83.4%. At a median follow-up of 44.0 months, 42 patients developed recurrent HCC for an actual recurrence rate of 15.2%. The factors most predictive of HCC recurrence included an elevated peak AFP prior to transplant (>50 ng/ml) and unfavorable explant pathology (poorly differentiated tumors and/or presence of lymphovascular invasion-LVI). Nine (21%) patients that recurred had none of these factors while 5 (11.9%) of patients that recurred originally had incidental tumors. The median time to recurrence was 20.5 months (n=42), with the presence of LVI predicting earlier recurrence (median 7.5 months, n=24). Nineteen patients (46%) experienced recurrence more than 2 years after LT. The site of first recurrence was the lung (38%) followed by the liver (33%). Serum AFP was elevated (>50 ng/ml) at the time of recurrence diagnosis in 26 patients (61.9%). Median survival after recurrence was 10.0 months; 11 patients are currently alive with recurrent HCC. Patients with recurrent tumors able to undergo resection or loco-regional therapy experienced improved survival. Conclusions: These data suggest that surveillance for HCC recurrence after LT is warranted, including patients thought to be at low risk for recurrence. Surveillance imaging should include the chest and abdomen. Surveillance should be more rigorous for those patients that had HCC with LVI, especially during the first year after LT. The duration of surveillance for HCC recurrence should extend at least 4 years. AFP is a useful adjunct for surveillance. Early detection of HCC recurrence may allow for aggressive treatment and improved survival.