Introduction: Despite pre-operative cross-sectional imaging, incidental hepatocellular carcinoma (iHCC) is sometimes diagnosed upon histological examination of the liver explant following transplantation for another indication. Whilst liver transplantation is the treatment of choice for HCC fulfilling the Milan criteria, those out-with the criteria have poor outcomes. Here we describe the characteristics and outcomes of patients diagnosed with iHCC at our centre.

Methods: Over the five year period from January 2008 to December 2012, patients in whom iHCC was diagnosed were identified and data collected from a prospectively maintained transplant database and hospital records.

Results: 329 patients underwent liver transplantation, of which 62 (18.8%) were transplanted for HCC. iHCC was diagnosed in 12 further patients transplanted for other indications (3.6%). The main indications for transplant for these individuals were alcoholic liver disease (41.7%) and Hepatitis C (33.3%).

The mean age of these patients at listing was 57 years, and the mean UKELD at time of transplant was 56.5. Regarding pre-operative investigation, the median alpha-fetoprotein level of these patients at the time of listing was 3kU/l (range <2-61); the median interval from pre-operative CT scan to transplantation was 99 days (range 0-566), and pre-operative ultrasound scan was 49.5 days (range 15-141). Median interval from placement on the waiting list to transplantation was 62.5 days (range 4-539). The mean size of the iHCC's was 16.2mm (range, 8.7-30). Of the 12 patients with iHCC, two did not fulfil the Milan criteria for liver transplantation: one had 5 small tumors (20, 15, 12, 9 and 5 mm) and 1 had small caliber vascular invasion. Median follow-up of these patients is 29 months (range 12-62). There has been no recurrence of HCC or mortality during the study period. In comparison, there have been 4 recurrences (6.5%) in those transplanted for HCC, 3 of which were found to be outside the Milan criteria on explant analysis. All recurrences occurred within 2 years.

Discussion: Despite the incidence of iHCC in patients awaiting liver transplantation, outcomes of such patients appear equivalent to those in whom iHCC did not develop. These results do not support a requirement for more frequent imaging of patients whilst on the transplantation waiting list.

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