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World J Transplant. Jun 24, 2016; 6(2): 306-313
Published online Jun 24, 2016. doi: 10.5500/wjt.v6.i2.306
Loco-regional therapies for patients with hepatocellular carcinoma awaiting liver transplantation: Selecting an optimal therapy
Thomas J Byrne, Jorge Rakela
Thomas J Byrne, Jorge Rakela, Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Phoenix, AZ 85054, United States
Author contributions: Byrne TJ and Rakela J contributed equally to the work; Byrne TJ and Rakela J conceptualized the review; Byrne TJ drafted the original manuscript; both authors reviewed and approved the final manuscript as submitted.
Conflict-of-interest statement: The authors declare no conflicts of interest regarding 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: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Thomas J Byrne, MD, Consultant, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, United States. byrne.thomas1@mayo.edu
Telephone: +1-480-3420238 Fax: +1-480-3242324
Received: October 19, 2015
Peer-review started: October 21, 2015
First decision: December 28, 2015
Revised: February 2, 2016
Accepted: March 22, 2016
Article in press: March 23, 2016
Published online: June 24, 2016
Abstract

Hepatocellular carcinoma (HCC) is a common, increasingly prevalent malignancy. For all but the smallest lesions, surgical removal of cancer via resection or liver transplantation (LT) is considered the most feasible pathway to cure. Resection - even with favorable survival - is associated with a fairly high rate of recurrence, perhaps since most HCCs occur in the setting of cirrhosis. LT offers the advantage of removing not only the cancer but the diseased liver from which the cancer has arisen, and LT outperforms resection for survival with selected patients. Since time waiting for LT is time during which HCC can progress, loco-regional therapy (LRT) is widely employed by transplant centers. The purpose of LRT is either to bridge patients to LT by preventing progression and waitlist dropout, or to downstage patients who slightly exceed standard eligibility criteria initially but can fall within it after treatment. Transarterial chemoembolization and radiofrequency ablation have been the most widely utilized LRTs to date, with favorable efficacy and safety as a bridge to LT (and for the former, as a downstaging modality). The list of potentially effective LRTs has expanded in recent years, and includes transarterial chemoembolization with drug-eluting beads, radioembolization and novel forms of extracorporal therapy. Herein we appraise the various LRT modalities for HCC, and their potential roles in specific clinical scenarios in patients awaiting LT.

Keywords: Liver transplantation, Loco-regional therapy, Transarterial chemoembolization, Radioembolization, Hepatocellular carcinoma

Core tip: Hepatocellular carcinoma has increased in incidence in recent decades. Liver transplantation is an excellent therapy for carefully selected patients. Due to the risk of tumor progression while awaiting liver transplantation, loco-regional therapy is frequently used in this setting. An expanding array of treatment options exist and are herein characterized, including descriptions of which modality may be ideal in various settings.