Liver transplantation in cancer--a review

Whilst liver transplantation is an accepted therapeutic modality for end stage cirrhosis, its application for hepatic malignancy has remained a controversial issue. This is due to the early experience in several centres of tumour recurrence within the first year. More recently, stringent patient selection criteria have been established to decrease the risk of tumour recurrence. Pre-operative assessment including liver biopsy, computerised axial tomography (CT) of both the thorax and abdomen, bone scans and pre-transplant laparotomy are routinely performed to exclude extrahepatic spread. Of the primary tumours, the most common groups are the hepatocellular carcinomas (HCC) and cholangiocarcinomas. A hierarchy of tumours favourable for transplantation exists, with HCC giving the best results, followed by central bile duct carcinoma, cholangiocellular carcinoma (peripheral), and secondaries, in descending order of suitability. With better patient selection based on adequate staging, and the confinement of liver grafting to lymph node negative stages, there has been a marked improvement in survival in otherwise unresectable and mainly untreatable tumours. The improved results support the application of liver grafting for malignancy, and suggest that the often discussed danger of tumour growth enhancement because of immunosuppression may not significantly be present. Despite the risk of tumour recurrence, liver transplantation gives worthwhile survival with the chance of cure for some and in others, considerable palliation with prolonged survival.