# Predicting and Managing Hepatocellular Carcinoma Recurrence After Liver Transplant: A Single-Center Experience 2012–2024

## TL;DR

This study examines HCC recurrence after liver transplants and finds that current risk scores may not reliably identify low-risk patients.

## Contribution

The study evaluates the effectiveness of the RETREAT score in predicting HCC recurrence and suggests broader surveillance may be needed.

## Key findings

- The observed HCC recurrence rate after liver transplant was 11%.
- One-third of patients with recurrence had low RETREAT scores (0 or 1).
- Systemic therapy for recurrence was challenging due to adverse effects in many patients.

## Abstract

Liver transplant can cure hepatocellular carcinoma (HCC), but recurrence can be expected in 10–15% of cases. There is interest in identifying subgroups of patients with particularly low risk for post-transplant recurrence in whom an abbreviated protocol of surveillance for post-transplant HCC recurrence may be acceptable, for example, based on RETREAT scores. We analyzed the outcomes of 923 patients undergoing liver transplant at our center between 2012 and 2024, of which 329 were for HCC. Our observed recurrence rate was 11%. We found that the RETREAT score had limited sensitivity in predicting HCC recurrence, with one-third of patients with post-transplant HCC recurrence having RETREAT scores of 0 or 1. Due to unique challenges in the post-transplant population regarding the provision of systemic therapy for recurrent HCC, early detection is a priority. Our findings suggest that a broad surveillance strategy may be justified.

Background: Hepatocellular carcinoma (HCC) is a major cause of mortality in the United States, but it can be cured with orthotopic liver transplant (OLT) in selected patients. Despite curative intent, post-OLT recurrence can occur in up to 15% of patients. The need for a program of post-OLT surveillance is widely accepted but the specifics of an optimal program have not been established. There is interest in identifying lower-risk cohorts of patients in whom an abbreviated strategy of surveillance may prove adequate, utilizing tools such as the RETREAT score. Unique challenges are posed in the post-transplant population regarding safety and tolerability of systemic therapy for HCC recurrence, suggesting early detection is beneficial. Methods: This was a single-center retrospective analysis of characteristics and outcomes for all patients undergoing transplant at our center between 1 January 2012 and 31 December 2024. Diagnosis of HCC was determined by histological confirmation or Liver Imaging and Reporting Data System (LI-RADS) 5 findings on contrast-enhanced cross-sectional imaging. RETREAT scores were calculated for all patients. Results: During the study period, 923 transplants were performed, of which 329 (35.6%) were for HCC. Post-OLT recurrence occurred in 36 (10.9%) of these. Recurrence was associated with the presence of any viable tumor on explant surgical pathology, the presence of a viable tumor beyond Milan Criteria, the presence of microvascular invasion, a larger diameter of viable tumor on explant, and a higher RETREAT score. Although higher RETREAT scores were associated with post-OLT recurrence, one-third of patients who experienced post-OLT recurrence had RETREAT scores of 0 or 1. RETREAT scores did not correlate with the time interval between transplant and HCC recurrence. Systemic therapy proved challenging, with 10/25 patients receiving systemic therapy for post-OLT recurrence having to stop or alter regimens due to the severity of adverse effects. Conclusions: The rates of post-transplant recurrence and the experience of patients managed with systemic therapy for post-OLT recurrence in our experience were in line with previously published data. Due to the overall low RETREAT scores, the sensitivity of the RETREAT score in identifying patients at risk for post-OLT recurrence was limited, and the low RETREAT score had very limited incremental negative predictive value for identifying a low-risk population. This suggested that a broad screening strategy for post-OLT recurrence may be better than a personalized strategy in which patients with low RETREAT scores receive abbreviated surveillance.