Published online Sep 14, 2022. doi: 10.3748/wjg.v28.i34.4929
Peer-review started: January 27, 2022
First decision: February 24, 2022
Revised: March 5, 2022
Accepted: July 26, 2022
Article in press: July 26, 2022
Published online: September 14, 2022
Despite stringent selection criteria, hepatocellular carcinoma recurrence after liver transplantation (LT) still occurs in up to 20% of cases, mostly within the first 2–3 years. No adjuvant treatments to prevent such an occurrence have been developed so far. However, a balanced use of immunosuppression with minimal dose of calcineurin inhibitors and possible addition of mammalian target of rapamycin inhibitors is strongly advisable. Moreover, several pre- and post-transplant predictors of recurrence have been identified and may help determine the frequency and duration of post-transplant follow-up. When recurrence occurs, the outcomes are poor with a median survival of 12 mo according to most retrospective studies. The factor that most impacts survival after recurrence is timing (within 1–2 years from LT according to different authors). Several therapeutic options may be chosen in case of recurrence, according to timing and disease presentation. Surgical treatment seems to provide a survival benefit, especially in case of late recurrence, while the benefit of locoregional treatments has been suggested only in small retrospective studies. When systemic treatment is indicated, sorafenib has been proved safe and effective, while only few data are available for lenvatinib and regorafenib in second line. The use of immune checkpoint inhibitors is controversial in this setting, given the safety warnings for the risk of acute rejection.
Core tip: Hepatocellular carcinoma (HCC) is becoming the most common indication for liver transplantation (LT). The problem of tumor recurrence after LT, that occurs in up to 20% of cases, is becoming of increasing interest. We reviewed of the available literature on HCC recurrence after LT. The best preventive measures still rely on pretransplant selection criteria, since no dedicated follow-up guidelines exist and no post-LT adjuvant treatments are available. When recurrence occurs, the prognosis is poor. However, aggressive surgical treatment, particularly in the case of late recurrence, may provide a significant survival benefit.