Risk-Stratified Surveillance for Recurrent Hepatocellular Carcinoma After Liver Transplantation: A Comparison With the RETREAT-Guided Surveillance Protocol.

BACKGROUND

Hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) is uncommon but associated with poor outcomes, requiring effective surveillance. We assessed adherence to and effectiveness of a risk-stratified surveillance protocol and compared it with the RETREAT-guided surveillance protocol.

METHODS

We performed a single-center retrospective review of patients with HCC on explant after LT (2013-2023). Patients were assigned low- or high-risk surveillance based on explant pathology (AJCC tumor stage, grade, and vascular invasion). Protocol performance, modified surveillance strategies, and comparison with RETREAT across multiple cutoffs were assessed.

RESULTS

Among 480 patients, 55 (11.5%) developed recurrence; 23 (41.8%) of these died, with median post-recurrence survival of 14 months. Only 15.8% were fully adherent, with higher adherence in low-risk patients (p<0.001). The protocol appropriately stratified risk (sensitivity 80.0%, specificity 54.1%) and retained substantially higher specificity than RETREAT even at RETREAT's conventional low-risk cutoff (32.0%) despite matching sensitivity; the two systems captured different patients (McNemar's test, p<0.001). Extrahepatic disease at recurrence was more common in high-risk patients (56.8% vs. 18.2%, p = 0.040). Fully adherent patients had earlier recurrence detection (206.4 vs. 666.9 days, p = 0.015). Modified protocols improved adherence but delayed some diagnoses; most low-risk recurrences occurred within 1 year and high-risk recurrences within 2 years.

CONCLUSIONS

This protocol effectively stratifies recurrence risk and is more sensitive than the RETREAT-guided surveillance protocol. Modified strategies may improve adherence and reduce cost while maintaining effectiveness, particularly in low-risk patients.