Background: Despite new technologies and improvements in imaging diagnosis, incidental and misdiagnosed hepatocellular carcinomas (HCC) are entities that remain present and problematic in liver transplantation.

Methods: From January 1, 2006 through December 31, 2015, 921 liver transplants were performed at our center; 345 of them with diagnosis of HCC. We retrospectively identified all cases of incidental and misdiagnosed HCC in explant livers of patients without previous diagnosis of HCC (n=576). Pre-transplant imaging tests were reviewed by a single radiologist to determine the concordance between lesions observed on MRI, using LIRADSv2013 classification, and the final pathology report of each lesion.

Results: 45 patients (7.8%) presented with an incidental or misdiagnosed HCC. 20 patients presented an incidental HCC not observed on MRIs pre-transplantation (3.5% incidental HCC rate), and 25 presented misdiagnosed tumors; lesions described on MRI/CT pre-transplantation but not diagnosed as HCC (4.3% of misdiagnosed rate). Reviewing retrospectively imaging tests (MRI/CT) performed pre-transplantation, we found that 37 lesions were identified prior to surgery in these patients. 27 lesions (73%) were LR3; indeterminate for HCC. 3 lesions (8.1%) were LR4; probably HCC. 4 lesions (10.8%) were LR4/5, and 3 lesions (8.1%) were LR5; definitely HCC. 8 of these 49 patients showed elevated AFP levels (median 21.3 ng/mL, range 12.9-71 ng/mL) before transplantation; 4 of them corresponded to LR3 lesions on MRIs, 1 corresponded to LR4, and 3 were incidental HCC.

Conclusion: Incidental or misdiagnosed malignancy is a rare but reported finding at the time of liver transplantation and have been related to worse outcomes and higher rates of recurrence after transplantation. New imaging algorithms, such as LI-RADS or the OPTN classification system focus primarily on specificity rather than sensitivity and hence lesions that do not meet criteria may still represent HCC.

CITATION INFORMATION: Garcia Aroz S, Ludwig D, Fowler K, Vachharajani N, Xu M, Lin Y, Doyle M, Chapman W. Incidental Hepatocellular Carcinoma in Explanted Livers: An Assessment After LIRADS Introduction. Am J Transplant. 2017;17 (suppl 3).

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