Management of Hepatocellular Carcinoma Recurrence after Liver Transplantation

Abstract

Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT), occurring in 10–15% of cases, is a major concern. A lot of work has been done in order to refine the selection of LT candidates with HCC and to improve the outcome of patients with recurrence. Despite this, the prognosis of these patients remains poor, partly due to the several areas of uncertainty in their management. Even if surveillance for HCC recurrence is crucial for early detection, there is currently no evidence to support a specific and cost-effective post-LT surveillance strategy. Concerning preventive measures, consensus on the best immunosuppressive drugs has not been reached and not enough data to support adjuvant therapy are present. Several therapeutic approaches (surgical, locoregional and systemic treatments) are available in case of recurrence, but there are still few data in the post-LT setting. Moreover, the use of immune checkpoint inhibitors is controversial in transplant recipients considered the risk of rejection. In this paper, the available evidence on the management of HCC recurrence after LT is comprehensively reviewed, considering pre- and post-transplant risk stratification, post-transplant surveillance, preventive strategies and treatment options.

Hepatocellular Carcinoma Recurrence and Mortality Rate Post Liver Transplantation: Meta-Analysis and Systematic Review of Real-World Evidence

“…AFP levels play a significant role in pre- and post-transplant outcomes. The current guidelines and recommendations indicate that pre-LT AFP levels provide a prognosis value for post-transplant outcomes, although a fixed threshold has not been established thus far given the broad discrepancies in the published literature to date [ 25 ]. Upon stratifying the analysis by mean AFP levels prior to the transplant, we identified a recurrence to be higher in those studies with a mean AFP of 50 ng/m.…”

Liver-Directed Treatment Options Following Liver Tumor Recurrence: A Review of the Literature

“…Repeat hepatectomy for recurrent HCC is safe with comparable complication rates to initial hepatectomy and is often the curative-intent treatment of choice (66). While patients who develop recurrent HCC following liver transplantation have a worse prognosis versus patients who undergo partial hepatectomy with a median overall survival after recurrence of 10-13 months versus 24 months, hepatectomy is also the treatment of choice in post-transplant patients (67). As most patients with HCC have underlying liver disease, assessment of preoperative liver function, identification of portal hypertension, and determination of an adequate functional liver remnant are key in appropriate patient selection to limit the risk of postoperative morbidity.…”

Therapeutic strategies for post-transplant recurrence of hepatocellular carcinoma

“…Studies evaluating the outcome of patients with post-LT HCC recurrence mostly consist of small and heterogeneous series burdened by significant biases in terms of transplant criteria, availability of different treatments and patients’ selection to curative and palliative options[ 86 ]. Survival of post-LT HCC recurrence is dismal and significantly worse than relapse after resection (median OS around 12 mo vs nearly 2 years in transplanted and resected patients, respectively), and immunosuppression is a potential driver of such a difference[ 87 , 88 ]. A number of factors have an impact on survival, and there is a small subset of patients with more favorable prognosis in whom curative treatments may be undertaken.…”