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World J Gastroenterol. Dec 7, 2018; 24(45): 5081-5094
Published online Dec 7, 2018. doi: 10.3748/wjg.v24.i45.5081
Multidisciplinary approach for post-liver transplant recurrence of hepatocellular carcinoma: A proposed management algorithm
Kin Pan Au, Kenneth Siu Ho Chok
Kin Pan Au, Department of Surgery, Queen Mary Hospital, Hong Kong, China
Kenneth Siu Ho Chok, Department of Surgery and State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
Author contributions: Chok KSH proposed the study; Au KP and Chok KSH conducted the literature review and wrote up the manuscript.
Correspondence author to: Kenneth Siu Ho Chok, FRCS (Ed), Associate Professor, Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China. chok6275@hku.hk
Telephone: +86-852-22553025 Fax: +86-852-28165284
Received: September 1, 2018
Peer-review started: September 1, 2018
First decision: October 14, 2018
Revised: October 21, 2018
Accepted: November 7, 2018
Article in press: November 7, 2018
Published online: December 7, 2018
Processing time: 97 Days and 13.6 Hours
Abstract

A large number of liver transplants have been performed for hepatocellular carcinoma (HCC), and recurrence is increasingly encountered. The recurrence of HCC after liver transplantation is notoriously difficult to manage. We hereby propose multi-disciplinary management with a systematic approach. The patient is jointly managed by the transplant surgeon, physician, oncologist and radiologist. Immunosuppressants should be tapered to the lowest effective dose to protect against rejection. The combination of a mammalian target of rapamycin inhibitor with a reduced calcineurin inhibitor could be considered with close monitoring of graft function and toxicity. Comprehensive staging can be performed by dual-tracer positron emission tomography-computed tomography or the combination of contrast computed tomography and a bone scan. In patients with disseminated recurrence, sorafenib confers survival benefits but is associated with significant drug toxicity. Oligo-recurrence encompasses recurrent disease that is limited in number and location so that loco-regional treatments convey disease control and survival benefits. Intra-hepatic recurrence can be managed with graft resection, but significant operative morbidity is expected. Radiofrequency ablation and stereotactic body radiation therapy (SBRT) are effective alternative strategies. In patients with more advanced hepatic disease, regional treatment with trans-arterial chemoembolization or intra-arterial Yttrium-90 can be considered. For patients with extra-hepatic oligo-recurrence, loco-regional treatment can be considered if practical. Patients with more than one site of recurrence are not always contraindicated for curative treatments. Surgical resection is effective for patients with pulmonary oligo-recurrence, but adequate lung function is a pre-requisite. SBRT is a non-invasive and effective modality that conveys local control to pulmonary and skeletal oligo-recurrences.

Keywords: Hepatocellular carcinoma; Recurrence; Liver transplantation

Core tip: We propose a multi-disciplinary management algorithm for recurrent hepatocellular carcinoma after liver transplantation. The combination of a mammalian target of rapamycin inhibitor with a reduced calcineurin inhibitor can be considered. Staging is performed to differentiate between disseminated recurrence and oligo-recurrence. In patients with disseminated recurrence, sorafenib may confer survival benefits but is associated with significant toxicity. Oligo-recurrence encompasses recurrent disease that is limited in number and location so that loco-regional treatments convey disease control and survival benefits. Intra-hepatic and extra-hepatic oligo-recurrences can be managed with surgical resection, ablative therapy or regional treatments depending on the disease status.