Reduced exposure to calcineurin inhibitors early after liver transplantation prevents recurrence of hepatocellular carcinoma

Background & Aims: Recurrence of hepatocellular carcinoma (HCC) is a major complication after liver transplantation (LT). The initial immunosuppression protocol may influence HCC recurrence, but the optimal regimen is still unknown. Methods: 219 HCC consecutive patients under Milan criteria, who received an LT at 2 European centres between 2000 and 2010, were included. Median follow-up was 51 months (IQR 26-93). Demographic characteristics, HCC features, and immunosuppression protocol within the first month after LT were evaluated against HCC recurrence by using Cox regression. Results: In the explanted liver, 110 patients (50%) had multinodular HCC, and largest nodule diameter was 3 +/- 2.1 cm. Macrovascular invasion was incidentally detected in 11 patients (5%), and microvascular invasion was present in 41 patients (18.7%). HCC recurrence rates were 13.3% at 3 years and 17.6% at 5 years. HCC recurrence was not influenced by the use/non-use of steroids and antimetabolites (p = 0.69 and p = 0.70 respectively), and was similar with tacrolimus or cyclosporine (p = 0.25). Higher exposure to calcineurin inhibitors within the first month after LT (mean tacrolimus trough concentrations >10 ng/ml or cyclosporine trough concentrations >300 ng/ml), but not thereafter, was associated with increased risk of HCC recurrence (27.7% vs. 14.7% at 5 years; p = 0.007). The independent predictors of HCC recurrence by multivariate analysis were: high exposure to calcineurin inhibitors defined as above (RR = 2.82; p = 0.005), diameter of the largest nodule (RR = 1.31; p <0.001), microvascular invasion (RR = 2.98; p = 0.003) and macrovascular invasion (RR = 4.57; p = 0.003). Conclusions: Immunosuppression protocols with early CNI minimization should be preferred in LT patients with HCC in order to minimize tumour recurrence. (C) 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.