Liver transplantation for hepatic and biliary malignancy

The treatment of liver cancer by transplantation has evolved into a process of selecting early stage tumors that have a high likelihood of cure. Carefully selected cirrhotic patients with early hepatocellular cancer (< or = 5 cm. diameter and single; < or = 3 cm. diameter if multiple and 3 or fewer lesions; no vascular invasion) have 5-year actuarial survival rates of approximately 75% after transplantation. Preoperative imaging should be as extensive as necessary to accurately define the characteristics of tumor size, location, and number and exclude signs of extrahepatic involvement. Adjuvant and neoadjuvant chemotherapy became part of treatment protocols in many centers at the same time that more stringent criteria for transplant candidacy were applied to patients with cancer, making it difficult to attribute improved results to the chemotherapy. Nevertheless, neoadjuvant chemoembolization for hepatocellular cancer is logical for patients who may wait long periods before receiving transplants. The fibrolamellar variant of hepatoma is a less aggressive tumor and patients can do well after transplantation, but late recurrences are common. Hepatoblastoma in children can respond very favorably to chemotherapy combined with transplantation. Cholangiocarcinoma remains a dreadful malignancy. The rare cases of insitu cholangiocarcioma in patients who receive transplants for sclerosing cholangitis can be cured, but known cholangiocarcinoma has an exceedingly high rate of recurrence after transplantation alone. Recent work combining chemotherapy and radiation with transplantation has not had dramatic success at improving cure rates. Patients with metastatic neuroendocrine tumors of the liver can receive good palliation by transplantation, but the majority of patients eventually develop recurrent cancer.