Division of Transplant Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PATable.
Division of Hepatology, Department of Gastroenterology, University of Pennsylvania, Philadelphia, PA.
Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, Philadelphia, PA.
Department of Pathology & Laboratory Medicine, University of Pennsylvania, Philadelphia, PA.
Department of Radiology, University of Pennsylvania, Philadelphia, PA.
Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA.
Patients with hepatocellular carcinoma (HCC) exceeding Milan criteria on explant pathology are at increased risk of recurrence and death. Discordance between contemporary magnetic resonance imaging (MRI) and explant pathology, and preoperative characteristics predictive of discordance are not well understood.
Patients who underwent orthotopic liver transplantation (OLT) for HCC following preoperative MRI were identified in a prospectively collected institutional database (1/2003-12/2013). Patients were dichotomized to "within" or "outside" Milan criteria by both imaging and explant pathologic evaluation. Binary logistic regression and Kaplan-Meier methodology were utilized to identify independent predictors of imaging/pathologic discordance and its impact on posttransplant survival.
Of 318 patients with HCC meeting Milan criteria by MRI at the time of OLT, 248 (78.0%) remained within a pathological correlate of Milan criteria on explant examination. Understaging was associated with worse median recurrence-free survival (64.0 vs. 140.0 months, p=0.002) and overall survival (96.0 vs. 143.0 months, p=0.005), and did not vary between patients exceeding criteria due to tumor explant >5 cm, >3 tumor foci, or a tumor >3 cm in the setting of multifocality. Discordance was independently associated with an increasing serum AFP level (OR 2.82, 95% CI 1.37-5.79, p=0.005).
Underestimating HCC burden prior to liver transplant remains frequent despite contemporary imaging technologies. Patients with an increasing AFP prior to transplantation may benefit from more frequent testing or novel neoadjuvant therapies.