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Research Article Volume 11 Issue 1
Incidental versus preoperatively diagnosed hepatocellular carcinoma in liver transplantation: a clinicopathologic comparison
Amna Anzar, Cindy Qian Xue, Jennifer Rytych, Akram Shalaby
Received: May 30, 2026 | Published: June 12, 2026
Citation: Anzar A, Xue CQ, Rytych J, et al. Incidental versus preoperatively diagnosed hepatocellular carcinoma in liver transplantation: a clinicopathologic comparison. Int Clin Pathol J. 2026;11(1):27-31. DOI: 10.15406/icpjl.2026.11.00224
Abstract
Background: Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. Despite advances in diagnostic imaging, incidental HCC (iHCC) continues to be detected on histopathologic evaluation of liver explants. The clinicopathologic features and outcomes of iHCC compared with preoperatively diagnosed (known) HCC (kHCC) remain incompletely characterized. Methods: A retrospective search of pathology databases at two academic institutions (University Hospitals Cleveland Medical Center and Northwestern Memorial Hospital) identified liver explants containing HCC from 2011 to 2025. Clinicopathologic features and follow-up data were collected. Cases were classified as kHCC (detected on preoperative imaging) or iHCC (identified only on explant pathology). Comparisons were performed using chi-square tests for categorical variables and t-tests for continuous variables, with statistical significance defined as p < 0.05. Results: Of 134 HCC cases identified, 120 (89.6%) were kHCC and 14 (10.4%) were iHCC. Patients with iHCC were slightly younger (mean 57.6 vs. 62.1 years, p = 0.06) and included a higher proportion of females (35.7% vs. 19.2%, p = 0.12). No iHCC patient had multiple underlying liver diseases, compared with 10.0% of kHCC patients ( p < 0.001). Fatty liver disease was significantly more prevalent in the iHCC group (78.6% vs. 56.7%, p = 0.04), whereas hepatitis C virus infection was more common in kHCC (41.7% vs. 7.1%, p < 0.001). Alpha-fetoprotein levels at diagnosis and transplantation did not differ significantly between groups. Magnetic resonance imaging was the predominant preoperative modality in kHCC (92.5%) but was used in only 28.6% of iHCC cases. Tumors in the iHCC group were significantly smaller (mean 1.4 cm vs. 3.1 cm, p < 0.001), and poorly differentiated morphology was observed exclusively in kHCC. On follow-up, 92.9% of iHCC patients were alive without evidence of disease, with no recurrence, metastasis, or disease-related death. Conclusions: Incidental HCC represents a distinct subset of small, early-stage, welldifferentiated tumors with favorable post-transplant outcomes. Differences in underlying liver disease etiology and preoperative imaging modality may contribute to radiologicpathologic discordance.
Keywords: hepatocellular carcinoma, incidental hepatocellular carcinoma, liver transplantation, liver explant, radiologic-pathologic discordance, fatty liver disease
©2026 Anzar, et al. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.