Risk Factors and Center‐Level Variation in Hepatocellular Carcinoma Under‐Staging for Liver Transplantation

Liver transplantation (LT) is curative for most patients with hepatocellular carcinoma (HCC). However, 10%‐15% of patients experience HCC recurrence. Patients who are reported as within Milan criteria by imaging are frequently found to be outside the criteria on explant. This under‐staging of HCC worsens post‐LT outcomes. However, risk factors for under‐staging have not been elucidated. Furthermore, it is not known if there is regional or center‐level variation in under‐staging. We conducted a retrospective analysis of adult patients transplanted for HCC in the United Network for Organ Sharing (UNOS) database between 2012 and 2016. Under‐staging was determined on the basis of comparing pre‐LT imaging to explant findings. Kaplan‐Meier methods and Cox regression were used to evaluate the impact of under‐staging on HCC recurrence and post‐LT survival. Mixed effects logistic regression was used to identify risk factors for under‐staging and to study regional and center‐level variation in adjusted analyses. A total of 5424 patients were included in the cohort, of whom 24.9% (n = 1353) were under‐staged. Post‐LT HCC recurrence and death were significantly associated with under‐staging (each P