Liver transplantation as therapy for hepatocellular carcinoma

Abstract

Liver transplantation can provide curative therapy in selected patients with hepatocellular carcinoma. Well‐established criteria include tumours that are within the Milan criteria and without evidence of vascular or extrahepatic involvement. Modest expansion of the original Milan criteria has been shown to achieve similar recurrence‐free survival rates. Overall, HCC recurrence occurs in about 10%‐15% of LT recipients, most within the first 2 years. Predictors of post‐transplant recurrence include high alpha‐foetoprotein, macrovascular invasion, as well as tumour size and number. Once HCC recurs after transplantation, prognosis is poor, though better if detected early. There is no established role for systemic prophylactic post‐transplant chemotherapy.

Risk Factors for Hepatocellular Carcinoma Recurrence and Survival after Liver Transplantation in Patients with HCV-Related Cirrhosis

“…Still, HCV recurrence was a big concern some years ago, when HCV treatment was hardly performed after LT. Therefore, it is vital to analyze the outcomes according to the main underlying liver diseases, such as HCV in the Western world, where HCC accounts for approximately 30% of liver transplants [ 26 ].…”

“…When LT is proposed for a patient with HCC, one of the main concerns involves the possibility of multicentric recurrence and intrahepatic distant recurrence, which often occur in the first 2 years and are particularly common in HCV-related HCC, contributing to the worse outcomes in this population [ 3 , 26 , 27 ]. Although the need for PRBC transfusion in LT had already been associated with length of hospital stay and acute rejection [ 28 ], a recent study found that patients with HCC had a 5 times higher chance of requiring massive intraoperative transfusion of 10 or more PRBC units than patients without HCC [ 29 ].…”

“…Rates of HCC recurrence after LT usually vary from 5% to 15% [ 13 , 26 , 33 ]. However, those estimates were derived from heterogeneous samples in hospitals where most patients had an early diagnosis and were submitted to LT with small tumors.…”

Hepatocellular carcinoma in patients with non-alcoholic steatohepatitis – epidemiology, risk factors, clinical implications and treatment

“…After transplantation, due to HCC in patients meeting the Milan criteria, cancer recurrences occur in 10% to 15% of cases. After broadening eligibility criteria, in larger lumps, they occur far more often [ 55 , 56 ]. In order to improve the results of liver transplantation, many centres adopted various auxiliary criteria, including α-fetoprotein (AFP) concentration in serum, which turned out to be helpful in determining the risk of recurrence, and therefore in the assessment of prognosis.…”

“…The level of 1000 ng/ml was adopted as the boundary AFP concentration, above which the risk of recurrence is very high. However, some centres indicate the level of 400 ng/ml [ 56 ]. NASH is currently the second indication for liver transplantation in the USA in terms of frequency [ 57 ].…”