DOES HEPATOCELLULAR CARCINOMA SECONDARY TO NASH HAVE A BETTER PROGNOSIS AFTER LIVER TRANSPLANT?

Background:The number of Non-alcoholic steatohepatitis (NASH) cases has been increasing in Western countries as Hepatocellular carcinomas (HCC) etiology. However, patients with NASH cirrhosis seems to undertake less intensive screening for HCC than the rest of other cirrhosis etiologies. Although discovering more advanced tumors at diagnosis is intuitively expected, retrospective studies suggest more indolent biological behavior of HCC in this subpopulation. Objectives: To evaluate the association between NASHHCC, histopathological findings of the explant and risk of tumor recurrence (TR) after liver transplantation (LT), comparing them with patients with HCC secondary to other etiologies. Methods: Retrospective cohort study of 212 patients submitted to LT for HCC at a reference center between 2000 and 2016 and followed up to 12/31/2018. Patients with NASH were considered those with compatible clinical and laboratory characteristics, suggestive histological findings of the explant and absence of other risk factors. Results: Among HCC etiologies, 15% of the sample were NASH patients. Dividing the follow-up period into three times, an upward trend was observed in NASH-HCC cases (8.9% up to 2008, 13.6% between 2008-2012 and 19.8% between 2013- 2016, p = 0.15). Median age in NASH group was 6.5 years higher than non-NASH group. Significant associations between cases of NASH-HCC and females (p = 0.01), age > 60 years old (p = 0.001), BMI > 30 kg/m2 (p = 0.004) and alpha-fetoprotein (AFP) levels < 10 ng/mL (p = 0.003) were found. Regarding tumor characteristics of the explant, there was no association with staging according to the Milan criteria or with histological grade. A lower frequency of vascular invasion was observed in NASH cases (p = 0.07). None of NASH patients had TR after a median follow-up of 29.2 (IQR 4.47-66.22) months post-LT (p = 0.006). Conclusion: In this sample, we found an association with data of lower tumor aggressiveness and lower expression of AFP, besides a tendency to less vascular invasion in the explant. In spite of being a population with greater median age and more comorbidities due to metabolic syndrome, there were no cases of TR within two years, being consistent with the hypothesis that NASH defines a more indolent HCC subtype. Nevertheless, screening for HCC should be more intensive, in regards to the clinical frailty of these patients due to more advanced age and multiple conditions, difficulting surgical treatment, when needed.