Role of Neoadjuvant and Adjuvant Treatment in HCC Recurrence After Liver Transplantation

Abstract

Liver transplantation (LT) for hepatocellular carcinoma (HCC) within Milan criteria is a curative approach that is considered standard of care. Liver-directed therapy before LT has been used as a bridging therapy and as a down-staging method for patients with intermediate HCC. Transarterial chemoembolization (TACE) and radiofrequency ablation are effective treatments that can down-stage intermediate staged HCC to fulfill Milan criteria for LT. New modalities such as drug-eluting beads (DEB) TACE, transarterial radioembolization (TARE), and stereotactic radiation therapy (SBRT) have shown similar efficacy in advanced HCC over conventional TACE with better toxicity profiles. Use of multimodality approach, taking advantage of the benefits of different locoregional therapy for HCC have been adopted as down-staging and bridging therapy for LT. HCC recurrence rates after LT for patients within the Milan criteria have been shown to be 8–15 % and higher in those patients beyond the Milan criteria. The value of adjuvant therapy using systemic cytotoxic chemotherapy after LT has been disappointing. Sorafenib has been used for treatment in recurrent HCC after LT, and the data of safety and efficacy profile in post-transplant setting suggest potential role as adjuvant treatment in high-risk patients.