The development ofde novohepatocellular carcinoma in patients on a liver transplant list: Frequency, size, and assessment of current screening methods

Abstract

Chronic end stage liver disease is the most frequent indication for liver transplantation. Individuals with end stage cirrhosis, and therefore individuals on liver transplant lists, are at increased risk of developing a hepatic cancer. Those individuals on liver transplant lists also may represent the best group available for evaluating the current methods for screening and surveillance for the development of hepatic cancer as an examination of the explant liver provides a gold standard for tumor assessment. Assuming that only tumor free individuals were screened at the onset of this study, the data obtained enables one to determine the frequency of new hepatic cancers since listing and evaluate the positive and negative predictive values of each assessment method over the surveillance interval. All patients listed for liver transplantation with end stage chronic liver disease, who did not have a hepatoma at the time of transplant listing, were followed and assessed for the development of a hepatic cancer while on the waiting list. The screening techniques utilized included quarterly ␣ fetoprotein (␣FP) determinations and ultrasound (US) studies as well as semi-annual triple phase computed tomography (CT) scans of the liver. ␣FP failed to identify any cases of de novo hepatic cancer in patients waiting for a liver transplant. In contrast, US and especially CT scanning with intravenous contrast identified new hepatic masses. The later method, which identified early enhancing mass lesions, was the more valuable method at identifying masses that subsequently were shown by pathologic examination of the explant liver to be hepatic cancers. However, only 14 of 20 individuals found to have a de novo tumor were identified by this method. Once identified however, the treatments utilized for hepatic tumor ablation while waiting for a transplant appear to be effective with a mean of 57.8؎8.3% necrosis of the treated masses being identified at the time of explant examination. In conclusion these data suggest that: T he major etiologic agents identified for the development of hepatocellular carcinoma (HCC) in the western world are chronic hepatitis C virus (HCV) infection and chronic alcohol abuse. 1 -16 Worldwide, particularly in Asia and Africa, the leading etiologic agent for the development of HCC is the presence of a chronic hepatitis B infection. 3,4,7,8,12,13 Chronic hepatitis C appears to be responsible for the recent increase in prevalence of HCC in the United States 5,6 and in other unique groups. 9 -11 HCC is also a well-recognized complication of cirrhosis in individuals with the various toxin exposures particularly alcohol but also other environmental toxins. 1,2,9,16,17 Finally, HCC occurs in cases of advanced endstage liver disease regardless of the etiology. 1,2,9,10,14,15 Thus, candidates for liver transplantation on a waiting list are a unique population at risk for the development of HCC. Despite this fact, the rate of de novo HCC development in liver transplant candidates listed for transplantation is cu...

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

“…However, CT and MRI are not appropriate surveillance tests because they are too expensive, invasive (radiation with CT or intravenous injection), and have limited availability in community setting [194]. Additional use of dynamic CT or dynamic MRI is recommended in patients undergoing HCC screening while awaiting liver transplantation because it may be associated with the greatest gain in life expectancy [195][196][197].…”

Hepatocellular Carcinoma in Liver Transplantation Candidates: Detection with Gadobenate Dimeglumine–Enhanced MRI

“…Therefore, CT and MRI aided by technologic advances that afford improved spatial, temporal, and contrast resolution are regarded as promising alternative surveillance tools for detecting HCC [4,5]. Contrast-enhanced dynamic multiphasic imaging has substantial performance benefits because most HCCs are hypervascular lesions that typically become enhanced during the hepatic arterydominant phase of imaging [6].…”

Differentially Expressed Genes between Early and Advanced Hepatocellular Carcinoma (HCC) as a Potential Tool for Selecting Liver Transplant Recipients

“…So far, size of tumor by CT scan or MRI has been used for preoperative staging because size has been reported to correlate with vascular invasion, progression of tumor, and recurrence rate after transplantation (6)(7)(8)(9)(10)(11)(12). TNM staging is limited by the need to obtain pathologic information, and imagebased tumor assessment can be misleading given the difficulty in visualizing HCCs in the cirrhotic liver (6)(7)(8)(9)(10)(11)(12).…”

“…The diagnostic sensitivity of AFP for HCC is reported to range from 39% to 64% and specificity from 76% to 91% (3)(4)(5)(6)(7). The sensitivity of US for the detection of HCC is directly related to tumor size.…”

“…The sensitivity of US for the detection of HCC is directly related to tumor size. Its diagnostic sensitivity for tumors smaller than 1 cm is about 42% (7,8) and reaches 95% for tumors of larger size (9). To confirm the suspicion of HCC by US in a patient with cirrhosis of the liver, the use of computed tomography (CT) is suggested (9).…”