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Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Apr 8, 2015; 7(4): 649-661
Published online Apr 8, 2015. doi: 10.4254/wjh.v7.i4.649
Strategies to improve outcome of patients with hepatocellular carcinoma receiving a liver transplantation
Marta Guerrero-Misas, Manuel Rodríguez-Perálvarez, Manuel De la Mata
Marta Guerrero-Misas, Manuel Rodríguez-Perálvarez, Manuel De la Mata, Department of Hepatology and Liver Transplantation, Reina Sofía University Hospital, Maimónides Institute of Biomedical Research of Córdoba, CIBERehd, 14004 Córdoba, Spain
Author contributions: All authors contributed equally to the manuscript; Guerrero-Misas M and Rodríguez-Perálvarez M performed research and wrote the paper; De la Mata M designed research and contributed new reagents.
Conflict-of-interest: The authors of the present manuscript do not have any conflict of interest to disclose.
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: Manuel De la Mata, MD, PhD, Head, Department of Hepatology and Liver Transplantation, Reina Sofía University Hospital, Maimónides Institute of Biomedical Research of Córdoba, CIBERehd, Avda/ Menéndez Pidal s/n, 14004 Córdoba, Spain. mdelamatagarcia@gmail.com
Telephone: +34-957-010450 Fax: +34-957-736014
Received: August 25, 2014
Peer-review started: August 25, 2014
First decision: November 27, 2014
Revised: December 15, 2014
Accepted: January 15, 2015
Article in press: January 19, 2015
Published online: April 8, 2015
Processing time: 232 Days and 17.8 Hours
Abstract

Liver transplantation is the only therapeutic option which allows to treat both, the hepatocellular carcinoma and the underlying liver disease. Indeed, liver transplantation is considered the standard of care for a subset of patients with cirrhosis and hepatocellular carcinoma. However, tumour recurrence rates are as high as 20%, and once the recurrence is established the therapeutic options are scarce and with little impact on prognosis. Strategies to minimize tumour recurrence and thus to improve outcome may be classified into 3 groups: (1) An adequate selection of candidates for liver transplantation by using the Milan criteria; (2) An optimized management within waiting list including prioritization of patients at high risk of tumour progression, and the implementation of bridging therapies, particularly when the expected length within the waiting list is longer than 6 mo; and (3) Tailored immunosuppression comprising reduced exposure to calcineurin inhibitors, particularly early after liver transplantation, and the addition of mammalian target of rapamycin inhibitors. In the present manuscript the available scientific evidence supporting these strategies is comprehensively reviewed, and future directions are provided for novel research approaches, which may contribute to the final target: to cure more patients with hepatocellular carcinoma and with an improved long term outcome.

Keywords: Hepatocellular carcinoma; Recurrence; Bridging therapy; Milan criteria; Immunosuppression; Liver transplantation

Core tip: Liver transplantation is the only therapeutic option which allows to treat both, the hepatocellular carcinoma and the underlying liver disease. However, tumour recurrence rates are 15%-20% with a very poor prognosis. Strategies to minimize tumour recurrence and thus to improve outcome are focused in a careful selection of candidates for liver transplantation, an optimized management within waiting list and a tailored immunosuppression. The available scientific evidence supporting these strategies is reviewed, and future directions are provided for novel research approaches, which may contribute to the final target: to cure more patients with hepatocellular carcinoma with an improved long term outcome.