Monitoring for post-transplant hepatocellular carcinoma recurrence

Sir,

In identifying the risks for recurrent hepatocellular carcinoma (HCC) after liver transplantation, Nissen and colleagues propose that this group of patients can be monitored with less rigidity.¹ We believe that this conclusion is not well supported. Roayaie et al.² and Sotiropoulos et al.³ have reported tumour recurrence rates in the range of 8–18%. Amongst the last 28 transplants performed at this centre for HCC, we encountered five instances (17.9%) of rapid recurrence (within 15 months). One patient was initially considered to be outside the Milan criteria, but was downstaged. Two patients were outside Milan criteria following examination of the explanted liver. Four patients had a moderately elevated alphafetoprotein (AFP) level (54.0–114.5 U) and one patient had a poorly differentiated tumour.

In the HCC Clinical Practice Guidelines,⁴ the authors propose that patients should be followed monthly for 6 months, then once every 3 months up to 1 year, twice per year up to 2 years and once every year thereafter for life. We think that accepting non-rigid follow-up for patients whose disease characteristics fall within the Milan criteria is not justified. Other factors, such as vascular invasion, tumour differentiation⁵ and AFP slope,⁶ play various roles. The early detection of recurrence and the surgical management of affected patients is related to increased survival.² We support the view of Kneteman et al.,⁶ who recommend that follow-up should be defined according to the risk of each patient, based on AFP levels at transplant, status regarding Milan criteria at listing and explant, and pathology features such as microvascular invasion, tumour grade and microsatellitosis.