Introduction: Liver resection for early-stage hepatocellular carcinoma (HCC) is limited by high surgical risk in cirrhotics and high rates of intrahepatic recurrence. We postulated that many intrahepatic recurrences after resection represent residual macroscopic HCC not initially identified. To test this hypothesis, we examined hepatectomy specimens from orthotopic liver transplant (OLT) patients with known HCC and compared the extent of tumor on pathology with pre-operative imaging.

Methods: 299 patients underwent OLT for known HCC between March 1, 2002 and December 31, 2011 at our center and were included in this study. Incidentally identified HCC was not included.

Results: 47.7% of patients had additional HCC lesions on explant pathology with a mean of 2.2±2.6 additional lesions. Patients with additional lesions had similar tumor characteristics as those without additional tumor (Table 1). Patients considered resection candidates (MELD≤12 and single lesion on pre-operative imaging) had a similar incidence of additional HCC lesions (43.4%, p=0.25). The frequency of NASH was significantly higher in resection candidates with additional lesions than in those without (10.9% vs. 1.3%, p=0.03). Rates of HCC recurrence did not significantly differ between patients with and without additional lesions on pathology (13.4% vs. 10.3%, p=0.40).

Conclusion: Early-stage HCC in OLT recipients is associated with a 40-50% incidence of unrecognized synchronous lesions despite aggressive systematic screening. Intrahepatic recurrence after resection in cirrhotics may not be attributable to a “field defect” but rather unidentified residual macroscopic synchronous disease.

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