Hepatocellular Carcinoma Staging: Differences Between Radiologic and Pathologic Systems and Relevance to Patient Selection and Outcomes in Liver Transplantation

Cunha, Guilherme Moura; Hosseini, Mojgan; Furlan, Alessandro; Fowler, Kathryn J.

doi:10.2214/ajr.21.26436

Cited by 10 publications

(8 citation statements)

References 56 publications

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“…Cunha et al, attributed discordance to dissimilarity between T2 lesions in radiology in correlation to T2 in histopathology. Linking explant histopathology to pre‐LT radiology is challenging as histopathological T2 staging includes vascular invasion (microvascular or small vessel) or multiple lesions up to 5 cm 15 . Another report by Ecker, et al described multifocality of the tumor and multiplicity of lesions as predictors for discordance between MRI pre‐LT and explant 16 .…”

Section: Discussionmentioning

confidence: 99%

“…Linking explant histopathology to pre-LT radiology is challenging as histopathological T2 staging includes vascular invasion (microvascular or small vessel) or multiple lesions up to 5 cm. 15 Another report by Ecker, et al described multifocality of the tumor and multiplicity of lesions as predictors for discordance between MRI pre-LT and explant. 16 A recently published T A B L E 3 Agreement between the explant histopathology and pre-LT imaging in the study population of 6994 patients.…”

Section: Discussionmentioning

confidence: 99%

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Radiological‐histopathological discordance in patients transplanted for HCC and its impact on post‐transplant outcomes

et al. 2023

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Background and AimsContrast‐enhanced cross‐sectional imaging is the cornerstone in the diagnosis, staging, and management of HCC, including eligibility for liver transplantation (LT). Radiological‐histopathological discordance may lead to improper staging and may impact patient outcomes. We aimed to assess the radiological‐histopathological discordance at the time of LT in HCC patients and its impact on the post‐LT outcomes.MethodsWe analyzed further the effect of 6‐month waiting policy on the discordance. Using United Network for Organ Sharing—Organ Procurement and Transplantation Network (UNOS‐OPTN) database, we examined the discordance between pre‐LT imaging and explant histopathology for all adult HCC patients who received liver transplants from deceased donors between April 2012 and December 2017. Kaplan–Meier methods and Cox regression analyses were used to evaluate the impact of discordance on 3‐year HCC recurrence and mortality.ResultsOf 6842 patients included in the study, 66.7% were within Milan criteria on both imaging and explant histopathology, and 33.3% were within the Milan based on imaging but extended beyond Milan on explant histopathology. Male gender, increasing numbers of tumors, bilobar distribution, larger tumor size, and increasing AFP are associated with increased discordance. Post‐LT HCC recurrence and death were significantly higher in patients who were discordant, with histopathology beyond Milan (adj HR 1.86, 95% CI 1.32–2.63 for mortality and 1.32, 95% CI 1.03–1.70 for recurrence). Graft allocation policy with 6‐month waiting time led to increased discordance (OR 1.19, CI 1.01–1.41), although it did not impact post‐LT outcome.ConclusionCurrent practice for staging of HCC based on radiological imaging features alone results in underestimation of HCC burden in one out of three patients with HCC. This discordance is associated with a higher risk of post‐LT HCC recurrence and mortality. These patients will need enhanced surveillance to optimize patient selection and aggressive LRT to reduce post‐LT recurrence and increase survival.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Radiological‐histopathological discordance in patients transplanted for HCC and its impact on post‐transplant outcomes

et al. 2023

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“…As with the OPTN-driven initiative that standardized radiologic reporting and diagnosis of HCC in 2011, [5] a similar movement may be beneficial in the pathology realm to standardize and assimilate staging systems and improve risk assessment of posttransplantation recurrence. [47] Predicting post-LT HCC recurrence…”

Section: Prognostic Hcc Imaging Featuresmentioning

confidence: 99%

“…These differences cause challenges in radiologic–explant–pathologic correlation, impeding the ability to assess true radiopathologic concordance. As with the OPTN‐driven initiative that standardized radiologic reporting and diagnosis of HCC in 2011,5 a similar movement may be beneficial in the pathology realm to standardize and assimilate staging systems and improve risk assessment of posttransplantation recurrence 47…”

Section: Future Directionsmentioning

confidence: 99%

The Organ Procurement and Transplantation Network hepatocellular carcinoma classification: Alignment with Liver Imaging Reporting and Data System, current gaps, and future direction

Kierans¹,

Chernyak

Mendiratta‐Lala

et al. 2022

Liver Transpl

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The Organ Procurement and Transplantation Network (OPTN) updated its allocation policy for liver transplantation to align with the Liver Imaging Reporting and Data System (LI-RADS) for the diagnosis of hepatocellular carcinoma (HCC). LI-RADS computed tomography/magnetic resonance imaging algorithm had achieved congruency with the American Association for the Study of Liver Diseases (AASLD) HCC Practice Guidance in 2018, and therefore, alignment of OPTN, LI-RADS, and AASLD unifies HCC diagnostic approaches. The two changes to the OPTN HCC classification are adoption of LI-RADS terminology or lexicon for HCC major imaging features as well as the modification of OPTN Class-5A through the adoption of LI-RADS-5 criteria. However, despite this significant milestone, the OPTN allocation policy may benefit from further refinements such as adoption of treatment response assessment criteria after locoregional therapy and categorization criteria for lesions with atypical imaging appearances that are not specific for HCC. In this review, we detail the changes to the OPTN HCC classification to achieve alignment with LI-RADS, discuss current limitations of the OPTN classification, and explore future directions.

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“…Risk factors for HCC are significant in cirrhotic patients due to high levels of alcohol consumption. Other risk factors include non-alcohol-associated steatohepatitis (NASH), or patients with chronic hepatitis B and C virus infection [ 2 , 3 , 4 ]. HCC comprises 75% of primary liver tumors with cholangiocarcinoma accounting for the remaining cases [ 1 , 5 , 6 , 7 ].…”

Section: Introductionmentioning

confidence: 99%

Immunotherapy as a Neoadjuvant Therapy for a Patient with Hepatocellular Carcinoma in the Pretransplant Setting: A Case Report

et al. 2022

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Systemic combination therapy of immune checkpoint inhibitors and vascular endothelial growth factors have provided the basis for improved outcomes in select patients with unresectable or metastatic hepatocellular carcinoma. However, for patients with resectable disease, surgery alone or an orthotopic liver transplant remains the standard of care. Within the realms of transplant oncology, neoadjuvant systemic therapy is currently being evaluated as a potential strategy to improve outcomes in patients with HCC. Here, we report excellent response with significant downstaging in a safe manner after neoadjuvant treatment with atezolizumab and bevacizumab in a patient diagnosed with poorly differentiated HCC. As a result of the significant response observed with safe outcomes, the patient was listed for orthotopic liver transplant (OLT) evaluation and transplanted successfully.

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Hepatocellular Carcinoma Staging: Differences Between Radiologic and Pathologic Systems and Relevance to Patient Selection and Outcomes in Liver Transplantation

Cited by 10 publications

References 56 publications

Radiological‐histopathological discordance in patients transplanted for HCC and its impact on post‐transplant outcomes

Radiological‐histopathological discordance in patients transplanted for HCC and its impact on post‐transplant outcomes

The Organ Procurement and Transplantation Network hepatocellular carcinoma classification: Alignment with Liver Imaging Reporting and Data System, current gaps, and future direction

Immunotherapy as a Neoadjuvant Therapy for a Patient with Hepatocellular Carcinoma in the Pretransplant Setting: A Case Report

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