Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 21, 2018; 24(31): 3469-3471
Published online Aug 21, 2018. doi: 10.3748/wjg.v24.i31.3469
Locoregional therapy response in patients with hepatocellular cancer waiting for liver transplantation: Only selection or biological effect?
Quirino Lai, Michele Di Martino, Pierleone Lucatelli, Gianluca Mennini
Quirino Lai, Gianluca Mennini, Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Rome 00161, Italy
Michele Di Martino, Pierleone Lucatelli, Department of Radiology, Sapienza University of Rome, Rome 00161, Italy
Author contributions: Lai Q, Di Martino M, Lucatelli P and Mennini G conceived the study and drafted the manuscript; both authors approved the final version of the article.
Conflict-of-interest statement: The authors have no conflict of interest to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Quirino Lai, MD, PhD, Academic Fellow, Academic Research, Doctor, Senior Lecturer, Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy. lai.quirino@libero.it
Telephone: +39-34-93020126 Fax: +39-6-499701
Received: May 18, 2018
Peer-review started: May 19, 2018
First decision: May 29, 2018
Revised: June 29, 2018
Accepted: July 16, 2018
Article in press: July 16, 2018
Published online: August 21, 2018

Locoregional treatments (LRT) represent a broad strategy used for reducing the risk of drop-off and contextually improving the survivals in patients with hepatocellular cancer receiving a liver transplantation (LT). However, it is not sufficiently clear if LRT are only a surrogate of tumor aggressiveness or if they consent a real benefit in terms of tumor stabilization. A recent study by Pommergaard et al reported the results from the European Liver Transplant Registry. Patients receiving LRT before LT had better 5-year survival rates respect to no-LRT cases (69.7% vs 65.8%; P < 0.001). When the number of LRT was tested, one-to-two treatments were connected with improved survivals respect to no treatment [hazard ratio (HR) = 0.85 and 0.71, respectively]. The efficacy of LRT was also reported in the presence of larger tumors (HR = 0.78) and micro-macrovascular invasion (HR = 0.71). The results observed in the present study are partially in discordance with other analyses showing a detrimental effect of LRT. The main problem in the interpretation of these results is connected with the possible initial selection biases present in the studies. The most recent guidelines suggest to perform LRT before the transplant, but the level of evidence is typically low due to the absence of prospectively designed studies.

Keywords: Allocation, Recurrence, Trans-arterial chemo-embolization, Radiofrequency ablation, Model for end-stage liver disease

Core tip: The role of locoregional treatments in the setting of hepatocellular cancer and liver transplantation is controversial. On one side, neoadjuvant approaches should consent a selection of tumor aggressiveness. On the other side, a real survival improvement thanks to the tumor ablation should be achieved. Recent evidences report an effective beneficial role of locoregional strategies in terms of survival and recurrence. However, several biases must be taken into account in these studies, due to the heterogeneous characteristics of treated vs untreated subjects. Further studies are need with the intent to clarify this important topic.