Background: The risk of hepatocellular carcinoma (HCC) is increased in patients with cirrhosis as a result of any chronic liver disease. Current guidelines recommend HCC surveillance for at risk patients with imaging and alpha feto-protein levels (AFP). HCC can be diagnosed based on imaging characteristics, without the need for histological analysis. Small HCCs, as defined by Milan criteria have good outcomes following liver transplantation (LT).

Incidental HCC is defined as an HCC which is detected on explant analysis, without known radiographic evidence prior to LT, regardless of AFP levels. All patients with known and incidental HCC routinely undergo surveillance post LT for recurrence. The protocol for surveillance is not standard across transplant centers, but usually involves a CT scan or MRI at periodic intervals.

There is limited data on incidental HCC, outcomes and recurrence.

Methods: We conducted a retrospective review of patients with incidental HCC who underwent LT between 1988-2010. Patients who had no evidence of focal hepatic lesions on pre-transplant imaging and whose explant pathology revealed hepatocellular carcinoma were included. Patients with incidental HCC were followed post LT with serial imaging and AFP per protocol: 6, 12, 18, 24 months and then yearly.

Results: A total of 139 patients met the inclusion criteria. The mean age of the patients was 56 years with 80% being male. The median AFP pre-transplant was 4. Most of the patients had alcoholic cirrhosis (30.9%) followed by hepatitis C (29.5%). While NASH comprised only a small number (2.9%), hepatitis B represented 8.6%, cryptogenic 7.9% and others (including PSC/PBC/Autoimmune and metabolic etiologies) comprised 15.8% of the cohort. All patients had pre-transplant imaging before the transplant with a US or a CT abdomen/ MRI abdomen with or without contrast. While the tumor size was less than 2 cm in majority of the cases (70.4%), it was multifocal in 6.5%. Vascular invasion was present on explant in 10 %.

Mean follow-up was 7 years post LT. Recurrent HCC was seen in 3 patients (2.2%). The one and five year patient survival in patients with incidental HCC was 84.2 and 59.7% respectively.

Conclusions: This is the largest reported series on incidental HCC. The recurrence rate of incidental HCC is less than 2.5%. Rigorous post LT surveillance is likely not indicated in this group of patients.

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