Metastatic recurrent hepatocellular carcinoma post liver transplant with marked pretransplant elevation of alpha fetoprotein and no evidence of primary neoplasm

Determinants of hepatocellular carcinoma recurrence posttransplant include hepatic tumor burden, presence of vascular invasion, and serum alpha-feto-protein level. However, the significance of marked alpha-fetoprotein elevation in cirrhosis, in the absence of a hepatic mass lesion on imaging studies, is unclear and no longer qualifies for a Model for End-Stage Liver disease exception for transplant listing in the United States. We report a case of posttransplant metastatic recurrent hepatocellular carcinoma in a patient with marked elevation of alpha-fetoprotein pretransplant without imaging evidence of primary hepatic tumor before or after transplant or histopathologic evidence of neoplasm in the explant. This report underscores the significance of marked alpha-fetoprotein elevation in the setting of cirrhosis, even in the absence of a liver lesion, as it may identify a subset of patients with microvascular invasion and microscopic tumor cell dissemination placing them at high risk of post-transplant recurrence. Longer follow-up may be considered in these patients pretransplant to optimize outcomes by lowering posttransplant recurrence risk.