Liver Transplantation for HCC: A Review

Abstract

Hepatocellular carcinoma (HCC) often occurs in patients with chronic liver disease or cirrhosis. Liver transplantation for hepatocellular carcinoma has the potential to eliminate both the tumor as well as the underlying cirrhosis and is the ideal treatment for HCC in cirrhotic liver as well as massive HCC in noncirrhotic liver. Limitations in organ availability, necessitate stringent selection of patients who would likely to derive most benefit. Selection criteria have considered tumor size, number, volume as well as biological features. The Milan criteria set the benchmark for tumors that would benefit from liver transplantation but were found to be excessively restrictive. Modest expansion in criteria has also been shown to be associated with equivalent survival. Microvascular invasion is the single most important adverse prognostic factor for survival. Living donor liver transplantation has expanded donor options and has the advantage of lower waiting period and not impacting the non-HCC waiting list. Acceptable outcomes have been obtained with living donor liver transplantation for larger and more numerous tumors in the absence of microvascular invasion. Downstaging of tumors to prevent progression while waiting for an organ or for reduction in size to allow enrolment for transplantation has met with variable success.

Keywords: Alpha-fetoprotein; Chemoembolization; Hepatocellular carcinoma; Liver transplantation; Living donor; Microvascular invasion; Milan criteria; Radiofrequency ablation.

Fig. 1

Worldwide incidence of HCC

Fig. 2

Events in evolution of LT for HCC

Fig. 3

The HCC weather forecast Cartesian plot

Fig. 4

Unresectable HCC: how we do it