Page 123 - Read Online

Simsek et al. Hepatoma Res 2020;6:11 I http://dx.doi.org/10.20517/2394-5079.2019.51 Page 9 of 10

HCC recurrence following LT is an unfortunate event and associated with poor outcomes. In a recent
meta-analysis, the median overall survival was 13 months following the diagnosis of HCC recurrence post-
[8]
[8]
LT . Herein, supportive care was associated with the lowest survival rate of 3.3 months . There is no
standardized protocol regarding the type and frequency of post-LT cross-sectional imaging in surveillance
of HCC LT recipients. It is important to note that more than 50% of patients develop tumor recurrences
that are outside of liver (extrahepatic), therefore imaging limited to the liver may not be sufficient for
the diagnosis of majority of HCC recurrences. We also note that AFP is a useful marker in post-LT HCC
surveillance only for high-AFP-secreting tumors. Four patients in our study had pre-AFP levels of > 1000
ng/mL. It is well known that patients with high AFP producing tumors have worse tumor biology and have
worse outcomes [12,25] . HCC candidates need to have AFP of ≤ 1000 ng/mL to receive extra points to shorten
[25]
the waiting period for liver transplantation . The overall prognosis of HCC recurrence following LT is
poor in the majority of cases and there are no available studies evaluating cost-effectiveness of surveillance
protocols specific to this group of patients.

In conclusion, HCC recurrence post liver transplant is an unfortunate event associated with extremely poor
survival. The majority of the cases are early recurrence occurring 1-2 years following liver transplantation.
More than 50% of HCC recurrences are extrahepatic. Therefore, post-liver transplant imaging confined
to the liver may not be enough to detect all of the recurrences. In patients with AFP producing tumors,
this marker may also be helpful to diagnose the HCC recurrence. There is no general consensus on the
treatment for post liver transplant hepatocellular carcinoma recurrence. The current reports are mainly
based on single-center retrospective experience.

DECLARATIONS
Authors’ contributions
Acquisition of data, analysis and interpretation of data, drafting of the manuscript: Simsek C
Interpretation of the data, Final Editing and Critical Review of the manuscript for important intellectual
content: Kim A
Acquisition of data, analysis and interpretation of data, drafting of the manuscript: Ma M
Review of the data, drafting of the manuscript and editing: Danis N
Analysis and interpretation of data, statistical analysis: Gurakar M
Study concept and design, interpretation of data, critical revision manuscript for important intellectual
content: Cameron AM
Study concept and design, interpretation of data, critical revision of the manuscript for important
intellectual content: Philosophe B
Study concept and design, interpretation of data, statistical analysis, critical revision of the manuscript for
important intellectual content: Garonzik-Wang J
Study concept and design, critical revision of the manuscript for important intellectual content: Ottmann S
Study concept and design, acquisition of data, drafting of the manuscript, analysis and interpretation of
data, revision of the manuscript for important intellectual content study supervision: Gurakar A
Study concept and design, acquisition of data, drafting of the manuscript, analysis and interpretation of
data, critical revision of the manuscript for important intellectual content, study supervision: Saberi B

Availability of data and materials
Data source has been the Electronic Medical System. Please contact the corresponding author for
unidentified data availability.

Financial support and sponsorship
This Research is partially supported by NIH Grants: R44 CA165312 - Development of a urine test for the
early detection of liver cancer. U01 CA230690 - Pathway Specific Functional Biomarkers for the Early
Detection of Liver Cancer.