Liver transplantation for hepatocellular carcinoma: current topics in France

Excellent survival obtained with liver transplantation (LT) for limited hepatocellular carcinoma (HCC) in patients with chronic liver disease is still challenged by the increasing discrepancy between candidates and grafts available. We review the current strategy of LT for HCC in our country highlighting the tendency: (1) to expand recipient selection beyond the Milan criteria, (2) to use systematic pre-LT treatments with a greater number of resections and (3) new rules for graft attribution.

Although the vast majority of cirrhotic patients with HCC are transplanted within the Milan criteria; the number of candidates is continually rising, while the number of grafts available is stable with a disappearance of adult LDLTs. Moreover, the new rules for organ allocations, mainly based on the MELD score, minimize the accessibility to liver grafts for patients with HCC and compensated liver disease. For these reasons, in France we have observed an increase in waiting time for HCC patients, leading to the extensive use of pre-LT treatments in order to limit the list dropouts. Many studies have been performed on transarterial chemo-embolization (TACE) and supraselective TACE. Moreover, the use of liver resection (LR) as a bridge therapy, showing that initial resection does not impair short- and long-term survival, led French surgeons to develop the concept of LR as a way to select patients who might benefit from LT and to use it, in selected cases, as a primary therapy, considering LT as salvage treatment in case of recurrence.

The number of HCC candidates who cannot benefit from a LT is increasing worldwide. The French answer to this situation involves pre-LT treatments, particularly partial LR, based mainly on the excellent Japanese results in this field. Moreover, the country of égalité is actually modifying the rules of graft attribution in order to reduce the inequality between the HCC patients with poor and good liver function.