Optimal Tailored Screening Protocol after Living Donor Liver Transplantation for Hepatocellular Carcinoma

Abstract

The indication for hepatocellular carcinoma (HCC) is expanding in living donor livertransplantation (LDLT). Early detection and effective management of recurrence hasbecome an important issue in LDLT for HCC. This study aimed to find an optimal screeningprotocol in terms of screening interval and screening tools by analyzing recurrence patternafter LDLT for HCC. A total of 205 LDLT patients in two centers from February 1999 toOctober 2010 was reviewed. Recurrence appeared in 55 cases. Six risk factors forrecurrence were identified: preoperative alpha-fetoprotein > 400, Edmonson grade 3 or 4,tumor size > 7 cm, tumor number ≥ 7, minimal tumor necrosis in the transarterialchemoembolization group and positive micro-vascular invasion. Four groups with differentranges of index scores showed different recurrence-free survival and median time torecurrence. Group I showed low and late recurrence. Groups II and III showed linearlyincreased rate of recurrence until 18 months. Group IV showed very early recurrence within6 months. Across the groups, extra-hepatic recurrence developed in more than 40% ofcases and multi-organ recurrence rate was 20%. The screening interval should be differentbased on the risk of recurrence. Screening should include work-up for extra-hepaticrecurrence as well as intra-hepatic recurrence.