Incidence and Risk Factors of Hepatocellular Carcinoma Recurrence After Liver Transplantation in the MELD Era

Abstract

Deceased donor liver transplantation (DDLT) rates for candidates with hepatocellular carcinoma (HCC) have significantly increased in the MELD era because of the extra priority given to these candidates. We examined the incidence and pre-DDLT radiological and donor factors associated with post-DDLT HCC recurrence in the MELD era. Outcomes of HCC candidates aged ≥18 years that underwent DDLT between 2/28/02 and 6/30/08 (n = 94) were reviewed. The primary outcome was biopsy-proven post-LT HCC recurrence at any site. Kaplan-Meier analysis was used to calculate the cumulative incidence and Cox regression was used to identify the predictors of post-LT HCC recurrence. The median age of the 94 candidates who met the study criteria was 54 years, 64% had hepatitis C, median lab MELD was 13, and median pre-LT AFP was 47 ng/dl. Based upon pre-DDLT imaging, 94% candidates met the Milan criteria. The median waiting time to transplant was 47 days and 27% received pre-DDLT loco-regional therapy. Seventeen (18%) developed HCC recurrence after 2.1 median years with a cumulative incidence of 6.8, 12, and 19% at 1, 2, and 3 years post-DDLT. The pre-DDLT number of lesions (p = 0.015), largest lesion diameter (p = 0.008), and higher donor age (p = 0.002) were the significant predictors of HCC recurrence after adjusting for pre-LT loco-regional therapy and waiting time. Post-LT HCC recurrence (p < 0.0001) and higher donor age (p = 0.029) were associated with lower post-LT survival. Post-LT HCC recurrence is higher in our MELD era cohort than the reported rate of 8% at 4 years in Mazzaferro et al.'s study. The risk of HCC recurrence was significantly associated with the number of lesions and size of the largest lesion at the time of DDLT as well as with older donor age. Risk stratification using a predictive model for post-LT HCC recurrence based on pre-LT imaging and donor factors may help guide candidate selection and tailoring of HCC surveillance strategies after LT.