Recurrence of hepatocellular carcinoma following liver transplantation

ABSTRACT

Introduction

Hepatocellular carcinoma (HCC) is an increasingly common disease with liver transplant (LT) the best long-term therapy for early stage disease. We will review the data for assessing risk and managing recurrence for patients undergoing LT for HCC.

Areas Covered

In this review, we will provide an overview of methods of patient risk stratification in the post-transplant period, the data around surveillance for HCC recurrence, and the evidence for and against post-LT adjuvant treatment strategies. Finally, we will provide data regarding treatment options for patients with HCC recurrence after LT. Using an extensive search of original papers and society guidelines, this paper provides a comprehensive review of the data for assessing risk and managing recurrence for patients undergoing LT for HCC.

Expert Opinion

The development of multiple post-transplant prognostic scoring systems have allowed for improved assessment of recurrence risk and stratification of patients. However, the ability to translate this information into surveillance and therapeutic strategies that improve patient outcomes still have to be fully demonstrated. Post-LT immunosuppression strategies have been implemented in order to attempt to reduce this risk. Evidence-based strategies for managing recurrent HCC are evolving. We expect that with further understanding of individual patient characteristics will allow for optimal therapeutic selection.

KEYWORDS:

• HCC
• liver transplant
• transplant oncology
• immunosuppression
• RETREAT
• alpha-fetoprotein (AFP)
• immunotherapy
• mammalian target of rapamycin (mTOR)

Article highlights

• HCC prevalence is rising worldwide and it is an increasingly common reason for liver transplant

• Pre- and Post-Transplant scoring systems can help optimize risk stratification and guide follow up after OLT for HCC

• Increased surveillance may improve post-recurrence survival, though optimal surveillance strategies have yet to be proven

• Post-LT immunosuppression strategies to minimize recurrence include reducing CNIs. Whether there is a patient population that gains specific anti-tumor benefit from mTOR inhibitors has yet to be proven definitively.

• Patients with recurrent HCC benefit from treatment with curative intent, ranging from LRT to resection

• Systemic therapies for recurrent HCC include Sorafenib, Regorafenib, and traditional chemotherapy agents such as capecitabine. Immunotherapy has shown promising results but must be used with caution.

Declaration of interests

N Mehta has served on advisory boards for WAKO Diagnostics and has received institutional research funding from Wako Diagnostics, Glycotest, and Target Pharmasolutions. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.