{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T06:15:34Z","timestamp":1788156934196,"version":"build-2803163510"},"reference-count":43,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,8,30]],"date-time":"2026-08-30T00:00:00Z","timestamp":1788048000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,8,30]],"date-time":"2026-08-30T00:00:00Z","timestamp":1788048000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Surgical Oncology"],"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:p>Liver transplantation (LT) is the definitive treatment for early hepatocellular carcinoma (HCC), based on established criteria. Pre\u2010transplant imaging occasionally underestimates the tumor burden or biological aggressiveness, leading to explant pathology that exceeds the projection criteria, such as Milan. This paper aims to review the incidence, prognostic implications, post\u2010transplant management, and outcomes of explant pathology in patients with HCC beyond Milan. We conducted a narrative review of the literature focusing on imaging\u2013pathology discrepancies, recurrence risk stratification, immunosuppression strategies, surveillance, and adjuvant therapeutic considerations. A significant proportion of LT recipients had explant findings that exceeded the predicted criteria. These patients are at higher risk of recurrence, particularly those with microvascular invasion and poor differentiation. Currently, no standard adjuvant therapy exists; however, individualized surveillance and immunosuppression optimization, including sirolimus\u2010based regimens, are reasonable strategies. Prospective studies are needed to define the optimal post\u2010transplant pathways. Explant\u2010beyond\u2010criteria HCC represents a distinct high\u2010risk population that requires individualized post\u2010transplant management. While no validated adjuvant therapy exists, risk stratification using tools such as the RETREAT score, immunosuppression optimization with mammalian target of rapamycin (mTOR) inhibitors, and intensified surveillance may improve outcomes. Prospective studies are needed to define the optimal management strategies for this challenging population.<\/jats:p>","DOI":"10.1002\/jso.70380","type":"journal-article","created":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T05:39:25Z","timestamp":1788154765000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["When Explant Surprises: Management and Outcomes of Hepatocellular Carcinoma Beyond Milan Criteria Discovered Post\u2010Transplant\u2010 A Narrative Review of Literature"],"prefix":"10.1002","author":[{"given":"Serkan","family":"Sucu","sequence":"first","affiliation":[{"name":"Department of Surgery University of Cincinnati Cincinnati Ohio USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian","family":"Longbottom","sequence":"additional","affiliation":[{"name":"Department of Surgical Oncology, MD Anderson Houston Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0406-1946","authenticated-orcid":false,"given":"Hassan","family":"Aziz","sequence":"additional","affiliation":[{"name":"Department of Surgery University of Iowa Health Care Iowa City Iowa USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,8,30]]},"reference":[{"key":"e_1_2_8_2_1","doi-asserted-by":"publisher","DOI":"10.3322\/caac.21834"},{"key":"e_1_2_8_3_1","doi-asserted-by":"publisher","DOI":"10.1097\/HEP.0000000000000466"},{"key":"e_1_2_8_4_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199603143341104"},{"key":"e_1_2_8_5_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1477-2574.2009.00022.x"},{"key":"e_1_2_8_6_1","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(11)70175-9"},{"key":"e_1_2_8_7_1","doi-asserted-by":"publisher","DOI":"10.1002\/cam4.6161"},{"key":"e_1_2_8_8_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000002056"},{"key":"e_1_2_8_9_1","doi-asserted-by":"publisher","DOI":"10.1155\/2019\/8747438"},{"key":"e_1_2_8_10_1","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1148\/radiol.2017170376","article-title":"Interreader Reliability of LI\u2010RADS Version 2014 Algorithm and Imaging Features for Diagnosis of Hepatocellular Carcinoma: A Large International Multireader Study","volume":"286","author":"Fowler K. J.","year":"2018","journal-title":"Radiology"},{"key":"e_1_2_8_11_1","doi-asserted-by":"crossref","first-page":"977","DOI":"10.1002\/lt.25787","article-title":"Risk Factors and Center\u2010Level Variation in Hepatocellular Carcinoma Under\u2010Staging for Liver Transplantation","volume":"26","author":"Mahmud N.","year":"2020","journal-title":"Liver Transplantation"},{"key":"e_1_2_8_12_1","doi-asserted-by":"publisher","DOI":"10.3390\/cancers16051043"},{"key":"e_1_2_8_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejphar.2013.11.032"},{"key":"e_1_2_8_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.transproceed.2018.02.145"},{"key":"e_1_2_8_15_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00330-019-06424-0"},{"key":"e_1_2_8_16_1","doi-asserted-by":"crossref","first-page":"720","DOI":"10.1007\/s00259-017-3880-4","article-title":"Preoperative Prediction of Microvascular Invasion of Hepatocellular Carcinoma Using 18F\u2010FDG PET\/CT: A Multicenter Retrospective Cohort Study","volume":"45","author":"Hyun S. H.","year":"2018","journal-title":"European Journal of Nuclear Medicine and Molecular Imaging"},{"key":"e_1_2_8_17_1","doi-asserted-by":"crossref","first-page":"1146","DOI":"10.1007\/s12149-025-02075-y","article-title":"Diagnostic Performance of FDG PETt\/CT Radiomics in Predicting Microvascular Invasion in Hepatocellular Carcinoma Compared to Conventional Metabolic Parameters: A Systematic Review and Meta\u2010Analysis","volume":"39","author":"Lee S. W.","year":"2025","journal-title":"Annals of Nuclear Medicine"},{"key":"e_1_2_8_18_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2024.06.018"},{"key":"e_1_2_8_19_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.hpb.2018.03.002"},{"key":"e_1_2_8_20_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1477-2574.2011.00342.x"},{"key":"e_1_2_8_21_1","doi-asserted-by":"publisher","DOI":"10.1002\/lt.20039"},{"key":"e_1_2_8_22_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41416-019-0513-7"},{"key":"e_1_2_8_23_1","doi-asserted-by":"publisher","DOI":"10.3748\/wjg.v19.i11.1811"},{"key":"e_1_2_8_24_1","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1007\/s12072-023-10594-x","article-title":"Serial Circulating Tumor DNA Profiling Predicts Tumor Recurrence After Liver Transplantation for Liver Cancer","volume":"18","author":"Huang A.","year":"2024","journal-title":"Hepatology International"},{"key":"e_1_2_8_25_1","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0b013e3181896278"},{"key":"e_1_2_8_26_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2013.07.012"},{"key":"e_1_2_8_27_1","doi-asserted-by":"publisher","DOI":"10.1111\/tri.12372"},{"key":"e_1_2_8_28_1","doi-asserted-by":"publisher","DOI":"10.1111\/ctr.14823"},{"key":"e_1_2_8_29_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000000965"},{"key":"e_1_2_8_30_1","doi-asserted-by":"publisher","DOI":"10.3390\/jcm9103264"},{"key":"e_1_2_8_31_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000003394"},{"key":"e_1_2_8_32_1","doi-asserted-by":"publisher","DOI":"10.3390\/cancers16071243"},{"key":"e_1_2_8_33_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamaoncol.2016.5116"},{"key":"e_1_2_8_34_1","doi-asserted-by":"publisher","DOI":"10.3390\/jcm10173932"},{"key":"e_1_2_8_35_1","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(15)00198-9"},{"key":"e_1_2_8_36_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2021.12.276"},{"issue":"4","key":"e_1_2_8_37_1","first-page":"307","article-title":"Sorafenib as Adjuvant Therapy for High\u2010Risk Hepatocellular Carcinoma in Liver Transplant Recipients: Feasibility and Efficacy","volume":"8","author":"Saab S.","year":"2010","journal-title":"Experimental and Clinical Transplantation: Official Journal of The Middle East Society for Organ Transplantation"},{"key":"e_1_2_8_38_1","doi-asserted-by":"publisher","DOI":"10.1155\/2014\/913634"},{"key":"e_1_2_8_39_1","doi-asserted-by":"publisher","DOI":"10.1186\/1477-7819-10-41"},{"key":"e_1_2_8_40_1","doi-asserted-by":"crossref","unstructured":"A.Yopp M.Kudo M.Chen et al. Updated Efficacy and Safety Data From IMbrave050: Phase 3 Study of Adjuvant Atezolizumab + Bevacizumab vs Active Surveillance in Patients with Resected or Ablated High\u2010Risk Hepatocellular Carcinoma.2024.","DOI":"10.1016\/j.annonc.2024.08.2279"},{"key":"e_1_2_8_41_1","doi-asserted-by":"publisher","DOI":"10.3390\/cancers15184574"},{"key":"e_1_2_8_42_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000005240"},{"key":"e_1_2_8_43_1","volume-title":"Pretransplant Immunotherapy in Hepatocellular Carcinoma: A Systematic Review","author":"Kim H.","year":"2022"},{"key":"e_1_2_8_44_1","doi-asserted-by":"crossref","DOI":"10.3390\/ijms252111676","article-title":"Immune Checkpoint Inhibition in the Pre\u2010Liver Transplant Setting for Hepatocellular Carcinoma","volume":"25","author":"Zhao Y.","year":"2024","journal-title":"International Journal of Molecular Sciences"}],"container-title":["Journal of Surgical Oncology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/jso.70380","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/jso.70380","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/jso.70380","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T05:39:27Z","timestamp":1788154767000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/jso.70380"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,30]]},"references-count":43,"alternative-id":["10.1002\/jso.70380"],"URL":"https:\/\/doi.org\/10.1002\/jso.70380","archive":["Portico"],"relation":{},"ISSN":["0022-4790","1096-9098"],"issn-type":[{"value":"0022-4790","type":"print"},{"value":"1096-9098","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,30]]},"assertion":[{"value":"2026-05-25","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-12","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-30","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"jso.70380"}}