Hepatocellular carcinoma recurrence after liver transplantation: Risk factors, screening and clinical presentation

Table 1 Factors possibly associated with the recurrence of hepatocellular carcinoma after liver transplantation

Related to the tumor	Related to the patient	Related to the treatment
Tumor staging	Obesity	Pretransplantation:
Vascular invasion	Viral etiology	Percutaneous tumor biopsy
	HCV treatment
Differentiation’s grade		Waiting time
	NAFLD	Bridging therapy
		Peri-transplantation:
Alpha-fetoprotein		Donor’s age
Neutrophil-lymphocyte ratio		Ischemia time
		Surgical technique
		Posttransplantation:
Enhanced uptake in PET scan		Immunosuppression
		Adjuvant sorafenib
MRI findings with gadoxetic acid
Response to LRT

MRI: Magnetic resonance imaging; LRT: Locoregional therapy; HCV: Hepatitis C virus; NAFLD: Non-alcoholic fatty liver disease.

Table 2 RETREAT score to estimate the risk of tumor recurrence after liver transplantation in patients with tumors within the Milan criteria and proposed protocol for tumor recurrence screening[74]

Risk factor	Score
Alpha-fetoprotein level before LT
0–20 ng/mL	0
21–99 ng/mL	1
0–999 ng/mL	2
> 1000 ng/mL	3
Microvascular invasion	2
Sum of the diameter of the largest viable tumor and the number of viable nodules
0	0
1.1–4.9	1
5.0–9.9	2
≥ 10	3
RETREAT Score	Screening Protocol
0 points	Screening not needed
1-3 points	Screening every 6/6 mo for 2 yr
4 points	Screening every 6/6 mo for 5 yr
≥5 points	Screening every 3-4 mo for 2 yr Exams every 6 mo between the 2nd and 5th year

TR: Tumor recurrence; LT: Liver transplantation.

Table 3 Prognostic score for the prediction of survival after hepatocellular carcinoma recurrence after liver transplantation[77]

Poor prognostic variables
Early tumor recurrence (during the first year after transplantation)
AFP ≥ 100 ng/mL at the time of the TR
Tumor not susceptible to curative therapy
Score	Prognostic score	1st year survival after TR
No variable	Good prognosis	73%
1 or 2 variables	Moderate prognosis	55%
3 variables	Poor prognosis	17%

TR: Tumor recurrence.