Incidental hepatocellular carcinoma in explanted livers: Prevalence, prognosis and features

• Prevalence of iHCC is not rare among LT candidates (12 %). • iHCC patients show worse 5-year survival rate than tumor-free ESLD recipients. • Using MRI HCC screening in ESLD patients awaiting LT could improve their prognosis. • Histopathologic risk factors for tumor recurrence were similar in iHCC and pkHCC. • iHCC patients should have similar postoperative follow-up as pkHCC patients. Incidental hepatocellular carcinoma (iHCC) on cirrhotic liver specimens is not rare. The aim of this study was to evaluate prevalence and outcomes of liver transplant recipients (LTRs) with iHCC. We compared this group to cirrhotic patients who underwent liver transplantation (LT) for previously known hepatocellular carcinoma (pkHCC) or tumor-free end-stage liver disease (ESLD). We retrospectively reviewed 268 cirrhotic patients who underwent LT at our center between 2010 and 2020 . Patient selection was made according to the indication for LT and histopathological analyses of surgical specimens (tumor-free ESLD, hepatocellular carcinoma (HCC)). Results were compared using Fisher's exact or Mann-Whitney U tests as appropriate. We used the Kaplan-Meier method to analyze the rate of death and log-rank tests to compare survival curves. The prevalence of iHCC was 12 %. Alcohol-related liver disease was more frequent in iHCC LTRs than in the other groups ( p = 0.046). iHCC patients spent more time on the waiting list than patients with tumor-free ESLD cirrhosis (Ci) (12.2 months vs. 3.5 months; p = 0.04). Five-year overall survival of iHCC LTRs was significantly reduced compared to the survival of Ci LTRs (44 % vs. 87 %, p = 0.028). The prevalence of iHCC within LT candidates is significant. iHCC LTRs show a lower survival rate than Ci LTRs, but a reduced rate of tumor recurrence compared to pkHCC LTRs. HCC screening protocol of ESLD LT candidates might include a larger use of high-resolution imaging techniques and iHCC LTRs should be approached as pkHCC LTRs with regards to postoperative imaging follow-up. Prevalence of incidental hepatocellular carcinoma is considerable among LT candidates. These patients have a lower survival rate than recipients with tumor-free ESLD cirrhosis. Optimizing screening methods for hepatocellular carcinoma in cirrhotic patients awaiting liver transplantation could improve their prognosis.