Hepatocellular carcinoma and liver transplantation

Hepatocelluar carcinoma (HCC) continues to grow in scope and magnitude as a clinical entity. Liver transplantation has been shown to be a potentially curative treatment for a select group of patients with HCC. The role of liver transplantation as part of the multidisciplinary treatment of HCC continues to evolve.

The use of liver transplantation as treatment for HCC continues to grow as selection criteria are refined to optimize outcomes. The Milan criteria (T2) are considered the standard selection criteria but have been challenged in recent years as being too limiting. Treatment for HCC patients awaiting liver transplantation includes a number of ablative techniques that may arrest tumor growth. Similar treatments may potentially downsize large (>T2) HCC so that they fall into the exception criteria for liver transplantation (downstaging), which is an area of ongoing study. Prioritizing HCC patients on the liver transplantation waiting list remains a difficult balance with non-HCC patients. After several downward adjustments of priority for HCC patients, the current system of awarding set, defined priority scores with time-dependent increases for HCC patients who remain within Milan criteria (compared to a continuous priority scale for non-HCC patients), continues to give HCC patients excess priority in access to liver transplantation. Despite this, outcomes for HCC patients remain inferior to non-HCC patients after liver transplantation.

Liver transplantation remains an acceptable treatment for select HCC patients. Optimizing patient selection and pretransplant treatment, and refining prioritization in relation to non-HCC patients for these scarce resource cadaveric livers continues to challenge the transplant community.