Management of hepatocellular carcinoma prior to liver transplantation: latest developments

Hepatocellular carcinoma (HCC) is a highly morbid malignancy that is a leading cause of death in patients with cirrhosis or chronic hepatitis B. Liver transplantation is considered a curative therapy for HCC, with 5-year survival rates exceeding 75%. Current allocation policy in the US restricts transplant to patients with early HCC, and priority for transplant is granted after 6 months on the waitlist, thus patients often require therapies for cancer control while awaiting liver transplantation. The most commonly applied therapies for HCC in patients awaiting liver transplantation are locoregional therapies, including ablative, radiation, and arterial based therapies. Using these therapies patient can be effectively bridged or downstaged to liver transplantation, however there are risks of progressive liver decompensation with locoregional therapies in patients with portal hypertension. There are emerging data for the use of immune checkpoint inhibitor-based immunotherapies in the treatment of HCC. While there has been concern for rejection with the administration of immunotherapy prior to liver transplantation, early data suggest that the risk can be minimized with sufficient washout time prior to liver transplantation. Herein we aim to review management strategies for patients with HCC awaiting liver transplantation.