Background: Because of unfavorable recurrence rates and donor organ unavailability, the use of orthotopic liver transplantation (OLTX) for the treatment of hepatocellular carcinoma (HCC) has generally become restricted to carefully selected cases of small, oligocentric tumors. However, it is not uncommon to find previously undetected HCC within native cirrhotic livers at the time of pathologic examination. The impact of unsuspected HCC on graft and patient outcomes remains unclear.
Method: A retrospective analysis was performed comparing our institutional experience with adult primary OLTX performed for recipients with incidental HCC (Group 1), recipients with known or radiographically suspected HCC (Group 2), and recipients with pathologically confirmed tumor-free cirrhosis (Group 3). 30 day operative mortalities were excluded from survival analyses.
Results: Between 1984 and 2000, 27 Group 1, 12 Group 2, and 612 Group 3 patients underwent primary OLTX. Tumors were smaller (p=0.022), more unifocal (p=0.053), and histologically more well-differentiated (p=0.031) in Group 1 than in Group 2. Incidence of bilobar involvement, vascular invasion, lymphatic spread, portal vein tumor thrombus, or distant metastasis at the time of OLTX was not significantly different between these groups. 5 year graft survival was lower in Group 1 patients (66%) than in Group 3 patients (78%), although this difference did not reach full statistical significance (p=0.051); however, 5 year graft survival was significantly worse for Group 2 (35%) than for Group 3 patients (p=0.005). Similarly, the difference in 5 year patient survival between Group 1 (71%) and Group 3 (81%) did not reach statistical significance (p=0.071), but survival was significantly lower in Group 2 (35%) than in Group 3 patients (p=0.001).
Conclusion: Despite increasing sensitivity of preoperative radiographic imaging studies, HCC continues to be discovered unexpectedly in the explanted livers of cirrhotic patients undergoing OLTX. In our experience, tumor size, number and histology are generally favorable from an oncologic perspective among incidentally diagnosed cases of HCC. Indeed, graft and patient survival are not significantly worse in these patients than in those whose native livers are pathologically free of HCC. In contrast, both graft and patient survival are significantly lower for patients transplanted with known or suspected HCC than in tumor-free recipients.