Adult cirrhotic liver explants: Precancerous lesions and undetected small hepatocellular carcinomas

Mion, François; Grozel, L; Boillot, Olivier; Paliard, P; Berger, Françoise

doi:10.1016/s0016-5085(96)70021-5

Cited by 97 publications

(59 citation statements)

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“…Furthermore, the indication of OLT should be based in the findings of the preoperative imaging techniques and it has been repeatedly shown that, despite significant technological improvements, the stage of HCC will be underestimated in a relevant proportion of the patients: Rizzi et al were able to detect only 62% of the multicentric tumors 32 ; Gores et al observed than only 50% of the patients with TNM II were confirmed to be in that stage 33 screening. 34 Similarly, in our study we failed to identify the presence of additional nodules in up to 50% of the multicentric tumors and the pTNM classification disclosed understaging in 43% of the cases. Interestingly, the prevalence of multi-centric tumors decreased with time, representing 51% of the HCC transplanted from 1989 to 1993 and only 24% of the cases from 1994 to 1995.…”

Section: Discussioncontrasting

confidence: 53%

Liver transplantation for small hepatocellular carcinoma: The tumor-node-metastasis classification does not have prognostic power

et al. 1998

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From a theoretical point of view, orthotopic liver transplantation (OLT) should be considered the ideal therapeutic option for patients with hepatocellular carcinoma (HCC).This neoplasm usually appears in the setting of liver cirrhosis, 1,2 and thus, OLT would eliminate the tumor and the oncogenic underlying liver. However, the first series of OLT for HCC showed disappointing results. [3][4][5][6] The inclusion of patients with advanced HCC prompted a high recurrence rate (higher than 50% at 3 years) whereas the survival rate (20%-50% at 5 years) was clearly less than that of non-HCC patients. Subsequent reports showed that HCC stage is a key point in determining the success of OLT in these patients and suggested that patients with early HCC could benefit from OLT both in terms of recurrence and survival. 5,7-10 Thereby, the recurrence rate of patients with incidental tumors which were discovered at the time of the pathological examination of the explanted liver is negligible. 3,7 Finally, two recent studies have shown that if OLT is restricted only to patients with early HCC (some years ago these tumors would have been identified only in the explanted livers), the risk of recurrence is minimal and the survival is identical to that of patients without HCC. 11,12 These encouraging data would favor OLT as the first therapeutic option to be considered in patients with HCC 13 as surgical resection is hampered by a higher recurrence rate during follow up [14][15][16][17] ; however, OLT is a highly invasive procedure with potentially severe complications in the early, medium, and long-term follow up. In addition, it must be stressed that HCC in most of the patients arises on liver cirrhosis caused by infection with HBV or HCV, 2,18 which frequently infects the graft, 19,20 and that the progression of the liver disease may be faster than in immunologically competent individuals. 21 As previously reported, 22-25 the treatment schedule applied in our Liver Unit in patients with HCC considered OLT only for those patients with solitary tumors smaller than 5 cm in whom resection was contraindicated, whereas the stage according to the TNM staging system was not taken into account. The present study analyzes the outcome of the cohort of the first 58 HCC patients submitted to OLT following this pre-established treatment algorithm, describing the accuracy of the preoperative staging, the recurrence and survival data, and also the rate of viral infection of the new liver. PATIENTS AND METHODS PatientsBetween January 1989 and December 1995, 877 patients with HCC were diagnosed, staged, and treated in our Liver Unit according to a previously published schedule. [22][23][24][25] Patients with HCC were Abbreviations: HCC, hepatocellular carcinoma; OLT, orthotopic liver transplantation; TNM, tumor-node-metastasis classification system; pTNM, pathological tumor-nodemetastasis classification.From the

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Section: Discussioncontrasting

confidence: 53%

Liver transplantation for small hepatocellular carcinoma: The tumor-node-metastasis classification does not have prognostic power

et al. 1998

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“…The prevalence of incidental hepatoma has been reported to be 1.3% to 17.5%. [20][21][22] Although the number of patients studied was small, our findings support other reports of the high risk for hepatocellular carcinoma among patients with HBV and HCV coinfection compared with those with HBV or HCV infection alone. [5][6][7] We have shown that among liver transplant recipients with HBV and HCV coinfection, HDV infection is associated with the suppression of HCV replication after OLT.…”

Section: Discussionsupporting

confidence: 88%

Clinical and virologic outcomes of hepatitis B and C viral coinfection after liver transplantation: Effect of viral hepatitis D

et al. 2000

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Hepatitis B (HBV) and C viral (HCV) dual-infectionassociated liver disease is an uncommon indication for liver transplantation. The clinical and virologic outcomes in such patients have not been well studied. We retrospectively studied 13 patients with hepatitis B surface antigen (HBsAg) and antibody to HCV positivity who underwent orthotopic liver transplantation (OLT) and survived at least 30 days post-OLT. Antibody to hepatitis delta virus (HDV) was negative in 8 patients (group I) and positive in 5 patients (group II). Eleven of the 13 patients received standard hepatitis B immune prophylaxis, and they all remained HBsAg negative. All group I patients were HCV RNA positive after transplantation; in contrast, all group II patients were HCV RNA negative. Serum alanine aminotransferase levels were elevated in 88% (7 of 8) of the patients in group I compared with 20% (1 of 5 patients) in group II. None of the patients had graft loss from chronic rejection or recurrent hepatitis. Three patients had unsuspected hepatocellular carcinoma in the explant. We conclude that among liver transplant recipients with HBV and HCV coinfection, HDV infection is associated with the suppression of HCV replication and mild inflammatory activity after OLT.

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“…A small HCC can be misdiagnosed as a regenerative or dysplastic nodule, especially when ultrasonography is used alone. 7 Radiographic diagnostic tools have low sensitivity in differentiating HCC lesions between 1 to 2 cm and < 1 cm (21% and 0%); therefore, sensitivity of pretransplant screening for such tumor sizes is limited. 8 In our study, there were only 3 lesions detected ≥ 4 cm; 2 of them were screened with CT scan, but no focal lesions were discovered.…”

Section: Discussionmentioning

confidence: 99%

“…7 In 2002, Molmenti and coworkers updated the previous study of the International Tumor Registry and observed an advantage in survival and recurrence-free survival in 324 patients with iHCC compared with 466 patients with kHCC. 1 Castillo and associates showed no difference in survival rates, and the 5-year overall survival was not significantly different between iHCC and kHCC patients (51 [58%] vs 143 [70%]; P = .086).…”

Section: Discussionmentioning

confidence: 99%

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2015

Exp Clin Transplant

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Objectives: Orthotopic liver transplant is the treatment of choice for hepatocellular carcinoma in cirrhotic patients with satisfactory oncologic and survival outcomes. Incidental hepatocellular carcinoma is frequently a reported finding in the explant pathology after orthotopic liver transplant. Material and Methods:The present study retrospectively analyzed the tumor characteristics and outcomes of 50 incidental hepatocellular carcinomas compared with 252 transplants for known hepatocellular carcinoma. Results: Patients with incidental hepatocellular carcinoma had lower peak alpha-fetoprotein level (P = .001), lower pretransplant alpha-fetoprotein level (P = .002), smaller total tumor size (P = .0001), fewer tumor numbers (P = .0001), lower level of microvascular invasion (P = .001), more cases within Milan criteria (P = .005), and more well-differentiated tumors (P = .017). However, no difference in survival rates was observed between the 2 groups. In 35 patients (70%) who had incidental hepatocellular carcinoma, pretransplant imaging studies were normal; ultrasonography was used as the only screening tool in 25 of 35 patients (71%) who had incidental hepatocellular carcinoma, and 15 patients (30%) who had incidental hepatocellular carcinoma had regenerative or dysplastic nodules. The accuracy of ultrasonography in our unit for diagnosing hepatocellular carcinoma was 97.5%. A quarter of hepatitis B recipients had incidental hepatocellular carcinoma with a younger median recipient age. Tumor recurrence was higher with incidental hepatocellular carcinoma in hepatitis C recipients (22%). However, the overall recurrence was similar between all hepatitis and nonhepatitis recipients who were transplanted for incidental or known hepatocellular carcinoma. Conclusions: Incidental hepatocellular carcinoma has similar outcome as known hepatocellular carcinoma. Early screening of hepatitis B patients is recommended, and cross-sectional imaging is not mandatory for hepatocellular carcinoma screening in patients who are on the waiting list. The pretransplant diagnosis of HCC in nodular cirrhotic livers is difficult despite improvements in diagnostic tools. These results in a variable degree of incidental HCC (iHCC), which is undetected HCC in explanted hepatic specimens. 2 The frequency of iHCC varies widely in reported series between 4.2% and 40%. [1][2][3] Imaging is important in the diagnosis of HCC and posttransplant follow-up. Many investigators claim that HCC lesions < 2 cm are difficult to diagnose with conventional diagnostic imaging studies, and recommend that an additional diagnostic evaluation should be undertaken in the screening process of cirrhotic patients who are on waiting lists. 4 Many studies have shown that long-term outcome and survival are similar in patients who have iHCC or known HCC (kHCC) before transplant. The iHCC has lower recurrence rate than kHCC, and this has raised the question about the need for cross-sectional imaging screening for HCC in all cirrhotic patients, especially while w...

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Adult cirrhotic liver explants: Precancerous lesions and undetected small hepatocellular carcinomas

Cited by 97 publications

References 0 publications

Liver transplantation for small hepatocellular carcinoma: The tumor-node-metastasis classification does not have prognostic power

Liver transplantation for small hepatocellular carcinoma: The tumor-node-metastasis classification does not have prognostic power

Clinical and virologic outcomes of hepatitis B and C viral coinfection after liver transplantation: Effect of viral hepatitis D

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