title: Pulmonary nodules in liver transplant candidates with hepatocellular carcinoma: Imaging characteristics and clinical outcomes.
abstract: No guidelines exist for the management of pulmonary nodules in patients with hepatocellular carcinoma (HCC) who are being evaluated for liver transplantation. The 172 patients with HCC who were listed for liver transplant at our institution received both pretransplant chest computed tomography (CT) and follow-up CT. Pulmonary nodules on CT were characterized and followed on subsequent scans by a blinded radiologist, with a consensus review with a second radiologist being performed for equivocal cases. Nodule characteristics and outcomes were examined with chi-square tests, and the posttransplant survival of patients with different nodule outcomes was compared. Cumulative probabilities of waiting-list removal for nontransplant patients and cumulative probabilities of undergoing transplantation for all patients were also compared between patients with and without pulmonary nodules. Of all the patients, 76.2% had at least 1 pulmonary nodule on pretransplant CT, with 301 total nodules characterized; 2.7% of nodules represented HCC metastases, 1.0% represented other bronchopulmonary malignancies, and 2.7% represented infections. None of the malignant nodules exhibited a triangular/lentiform shape or calcifications. There were no statistically significant differences in pulmonary nodule outcomes between patients who underwent transplantation and those who did not undergo transplantation. No significant differences in posttransplant survival were found between patients with different nodule outcomes. There was also no significant difference between patients with and without nodules in the cumulative probabilities of waiting-list removal. However, the cumulative probability of undergoing liver transplantation was borderline significantly higher in patients without pulmonary nodules. In conclusion, despite the low prevalence of malignant nodules, all pulmonary nodules besides triangular/lentiform-shaped or calcified nodules should be followed with serial CT while the patient is on the transplant list, with biopsy performed for new and/or enlarged nodules. Both malignancy and active infection must be excluded when one is confronted with enlarged pulmonary nodules. Clinicians should also be aware of the possibility of reactivation of a granulomatous infection after transplantation.
authors.affiliation: Departments of Radiology, Keck School of Medicine, University of Southern California.
authors.forename: Christopher
authors.initials: C
authors.lastname: Lee
authors.affiliation: Departments of Radiology, Keck School of Medicine, University of Southern California.
authors.forename: Lauren
authors.initials: L
authors.lastname: Ihde
authors.affiliation: Departments of Radiology, Keck School of Medicine, University of Southern California.
authors.forename: Andrew
authors.initials: A
authors.lastname: Kim
authors.affiliation: Department of Radiology, Parc Sanitari Sant Joan de Déu, Barcelona, Spain.
authors.forename: Idoia
authors.initials: I
authors.lastname: Santos
authors.affiliation: Department of Surgery, Keck School of Medicine, University of Southern California.
authors.forename: Lea
authors.initials: L
authors.lastname: Matsuoka
authors.affiliation: Departments of Radiology, Keck School of Medicine, University of Southern California.
authors.forename: Yong
authors.initials: Y
authors.lastname: Cen
authors.affiliation: Departments of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Wallman
authors.affiliation: Departments of Radiology, Keck School of Medicine, University of Southern California.
authors.forename: Edward
authors.initials: E
authors.lastname: Grant
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000000981:diagnostic imaging / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D016009:Chi-Square Distribution; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000000981:diagnostic imaging / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality; D008175:Lung Neoplasms / Q000000981:diagnostic imaging / Q000401:mortality / Q000556:secondary*; D008297:Male; D008875:Middle Aged; D055613:Multiple Pulmonary Nodules / Q000000981:diagnostic imaging / Q000401:mortality / Q000556:secondary*; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D003074:Solitary Pulmonary Nodule / Q000000981:diagnostic imaging / Q000401:mortality / Q000556:secondary*; D013030:Spain / Q000453:epidemiology; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014850:Waiting Lists