Liver Transplantation for Hepatocellular Carcinoma

Management After the Transplant

Elizabeth C. Verna; Yuval A. Patel; Avin Aggarwal; Archita P. Desai; Catherine Frenette; Anjana A. Pillai; Reena Salgia; Anil Seetharam; Pratima Sharma; Courtney Sherman; Georgios Tsoulfas; Francis Y. Yao


American Journal of Transplantation. 2020;20(2):333-347. 

In This Article

Abstract and Introduction


Hepatocellular carcinoma (HCC) is an increasingly common indication for liver transplantation (LT) in the United States and in many parts of the world. In the last decade, significant work has been done to better understand how to risk stratify LT candidates for recurrence of HCC following transplant using a combination of biomarker and imaging findings. However, despite the high frequency of HCC in the LT population, guidance regarding posttransplant management is lacking. In particular, there is no current evidence to support specific post-LT surveillance strategies, leading to significant heterogeneity in practices. In addition, there are no current recommendations regarding recurrence prevention, including immunosuppression regimen or secondary prevention with adjuvant chemotherapy. Finally, guidance on treatment of disease recurrence is also lacking and there is significant controversy about the use of immunotherapy in transplant recipients due to the risk of rejection. Thus, outcomes for patients with recurrence are poor. This paper therefore provides a comprehensive review of the current literature on post-LT management of patients with HCC and identifies gaps in our current knowledge that are in urgent need of further investigation.


In this era of rising hepatocellular carcinoma (HCC) incidence, HCC is an increasingly common indication for liver transplantation (LT). In 2015, HCC was the indication for 24% of liver transplant registrants and 27% of liver transplants, rendering it the most common reason for LT and waitlist additions, regardless of underlying etiology.[1]

LT began to evolve as a therapy for HCC when the incidental finding of small HCC in explanted livers was not found to alter outcomes as compared to explants without HCC.[2] The landmark study by Mazzaferro in 1996 then established LT as an effective treatment for early HCC defined by the Milan Criteria (one lesion ≤5 cm or 3 lesions all ≤3 cm without evidence of vascular invasion or extrahepatic spread).[3] Survival following LT for HCC has improved over time with advances in care and is similar to that of nonmalignant indications.[4–8]

Though LT for HCC is a highly effective cure for early stage disease, guidance regarding tailored posttransplant management of this unique population to optimize outcomes is lacking. Given the heterogeneity of HCC burden and tumor biology seen in patients that present for transplantation, it is essential for transplant providers to consider the unique features of a given patient's HCC when devising their posttransplant management plan. This paper aims to comprehensively review the current literature on posttransplant management of patients with HCC, as well as identify gaps in our current knowledge that are in urgent need of further investigation.