European Society of Organ Transplantation (ESOT) Consensus Report on Downstaging, Bridging and Immunotherapy in Liver Transplantation for Hepatocellular Carcinoma

Abstract

Liver transplantation offers the best chance of cure for most patients with non-metastatic hepatocellular carcinoma (HCC). Although not all patients with HCC are eligible for liver transplantation at diagnosis, some can be downstaged using locoregional treatments such as ablation and transarterial chemoembolization. These aforementioned treatments are being applied as bridging therapies to keep patients within transplant criteria and to avoid them from dropping out of the waiting list while awaiting a liver transplant. Moreover, immunotherapy might have great potential to support downstaging and bridging therapies. To address the contemporary status of downstaging, bridging, and immunotherapy in liver transplantation for HCC, European Society of Organ Transplantation (ESOT) convened a dedicated working group comprised of experts in the treatment of HCC to review literature and to develop guidelines pertaining to this cause that were subsequently discussed and voted during the Transplant Learning Journey (TLJ) 3.0 Consensus Conference that took place in person in Prague. The findings and recommendations of the working group on Downstaging, Bridging and Immunotherapy in Liver Transplantation for Hepatocellular Carcinoma are presented in this article.

Safety, efficacy, and survival of different transarterial chemoembolization techniques in the management of unresectable hepatocellular carcinoma: a comparative single-center analysis

“…TACE has become a cornerstone in the management of HCC (Lucatelli et al 2021 ; Reig et al 2022 ; Claasen et al 2023 ). However, current guidelines do not uniformly recommend which TACE technique is favorable for specific patient and tumor characteristics, leaving the decision of which technique to use to the interventional radiologist on a case-by-case basis (Marrero et al 2018 ; Angeli et al 2018 ; Lucatelli et al 2021 ).…”

“…The indication for TACE typically includes patients with intermediate-stage HCC, as defined by the Barcelona clinic liver cancer (BCLC) staging system, for whom curative options such as surgical resection or local ablation are not an option and systemic therapies are contraindicated or have resulted in tumor progression (Reig et al 2022 ). In addition to its use in the palliative setting for intermediate tumor stages, TACE is used as a bridging treatment to liver transplantation (LT) to control local tumor growth or for down-staging the patient’s tumor burden aiming to reach eligibility for LT (Claasen et al 2023 ).…”

Bridge Therapy before Liver Transplant for Advanced Hepatocellular Carcinoma

“…For patients within the conventional transplant criteria, bridging therapies are used to delay tumor progression and minimize the risk of de-listing [ 14 ]. There are different bridging and downstaging strategies: surgery (liver resection), TACE, TARE, RFA, PEI, PLA, cryoablation, and MWA.…”

Clinical Outcomes After Personalized Dosimetry for90Y Radioembolization of Advanced Hepatocellular Carcinoma: Defining the Role of a Device in a Pharma-Centric Landscape

“…Eleven of 31 (32%) patients in the personalized dosimetry arm were downstaged to resection, resulting in improved survival in this subset. Recent guidelines from the European Society of Organ Transplantation recommend that all HCC patients without extrahepatic disease or macrovascular invasion be considered for downstaging (10). More data are required, but advanced HCC patients with unilobar disease and adequate hepatic reserve should be afforded the opportunity to be downstaged to either resection or transplantation.…”