Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Nov 8, 2016; 8(31): 1309-1317
Published online Nov 8, 2016. doi: 10.4254/wjh.v8.i31.1309
Prophylactic liver transplantation for high-risk recurrent hepatocellular carcinoma
Po-Chih Yang, Cheng-Maw Ho, Rey-Heng Hu, Ming-Chih Ho, Yao-Ming Wu, Po-Huang Lee
Po-Chih Yang, Department of Surgery, National Taiwan University Hospital Hsinchu Branch, Hsinchu City 300, Taiwan
Cheng-Maw Ho, Rey-Heng Hu, Ming-Chih Ho, Yao-Ming Wu, Po-Huang Lee, Department of Surgery, National Taiwan University Hospital, Taipei 10002, Taiwan
Author contributions: Yang PC performed the majority of the writing, prepared the figures and tables; Ho CM designed the outline and coordinated the writing of the paper; Hu RH and Ho MC performed data accusation and writing; Wu YM provided the input in writing the paper; Lee PH assisted with the design and interpretation of this study.
Conflict-of-interest statement: There is no conflict of interest associated with any of the senior authors or other coauthors who contributed to this manuscript.
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:
Correspondence to: Cheng-Maw Ho, MD, PhD, Clinical Assistant Professor, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan S. Rd., Taipei 10002, Taiwan.
Telephone: +886-2-23123456 Fax: +886-2-23568810
Received: June 27, 2016
Peer-review started: June 27, 2016
First decision: August 18, 2016
Revised: August 24, 2016
Accepted: September 13, 2016
Article in press: September 18, 2016
Published online: November 8, 2016

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death in the world. Radical treatment of HCC in early stages results in a long disease-free period and improved overall survival. The choice of optimal management strategy for HCC mainly depends on the severity of the underlying liver disease. For patients with decompensated liver cirrhosis and HCC within Milan criteria (MC), liver transplant (LT) is the choice of treatment. However, for patients with good residual liver reserve and HCC within MC, selection of other curative treatments such as liver resection (LR) or radiofrequency ablation may be a reasonable alternative. For patients without cirrhosis, LR can result in an overall survival similar to that provided by LT. Therefore, it is an accepted alternative to LT especially in areas with organ shortage. However, the cumulative 5-year recurrence rate of HCC post LR might be as high as 70%. For initial transplant-eligible (within MC) patients with recurrent HCC post LR, salvage liver transplant (SLT) was first proposed in 2000. However, most patients with recurrent HCC considered for SLT are untransplantable cases due to HCC recurrence beyond MC or comorbidity. Thus, the strategy of opting for SLT results in the loss of the opportunity of LT for these patients. Some authors proposed the concept of “de principe liver transplant” (i.e., prophylactic LT before HCC recurrence) to prevent losing the chance of LT for these potential candidates. Factors associated with the failure of SLT will be dissected and discussed in three parts: Patient, tumor, and underlying liver disease. Regarding patient-related factors, the rate of transplantability depends on patient compliance. Patients without regular follow-up tend to develop HCC recurrence beyond MC at the time of tumor detection. Advancing age is another factor related to severe comorbidities when LT is considered for HCC recurrence, and these elderly candidates become ineligible as time goes by. Regarding tumor-related factors, histopathological features of the resected specimen are used mostly for determining the prognosis of early HCC recurrences. Such prognostic factors include the presence of microvascular invasion, poor tumor differentiation, the presence of microsatellites, the presence of multiple tumors, and the presence of the gene-expressing signature associated with aggressive HCC. These prognostic factors might be used as a selection tool for SLT or prophylactic LT, while remaining mindful of the fact that most of them are also prognostic factors for post-transplant HCC recurrence. Regarding underlying liver disease-related factors, progression of chronic viral hepatitis and high viral load may contribute to the development of late (de novo) HCC recurrence as a consequence of sustained inflammatory reaction. However, correlation between the severity of liver fibrosis and tumor recurrence is still controversial. Some prognostic scoring systems that integrate these three factors have been proposed to predict recurrence patterns after LR for HCC. Theoretically, after excluding patients with high risk of post-transplant HCC recurrence, either by observation of a cancer-free period or by measurement of biological factors (such as alpha fetoprotein), prophylactic LT following curative resection of HCC could be considered for selected patients with high risk of recurrence to provide longer survival.

Keywords: Liver transplant, Hepatocellular carcinoma, Salvage, Risk factor, Resection, Microvascular invasion, Recurrence, Prophylactic

Core tip: In this minireview, we discuss about the strategy of prophylactic liver transplant after liver resection for patients with a high risk of recurrence. Prognostic risk factors and scoring systems for recurrence are also analyzed.