Hepatocellular Carcinoma and Liver Transplantation: Changing Patterns and Practices.

OPINION STATEMENT: Benefits of liver transplantation (LT) for patients with hepatocellular carcinoma (HCC) are well established. However, there is debate regarding optimal and equitable selection of patients best served by LT, particularly in the face of limited organ availability. Herein, we discuss topics regarding LT selection criteria for patients with HCC. Recent change in UNOS policy currently mandates a 6-month observation period prior to priority listing and institutes a cap of 34 MELD exception points for patients with HCC. Additionally, two further proposed changes to UNOS policy include (1) requiring locoregional therapy for those with small (2-3 cm) unifocal HCC prior to applying for exception points and (2) allowing downstaging in select patients with UNOS T3 lesions. These policies move beyond simply using tumor burden to using markers of tumor biology for selecting patients who have the lowest risk of post-transplant recurrence and best chance at long-term post-transplant survival. Given increasing time on transplant waiting lists and shortage of donor grafts, LT should be reserved for patients who may achieve significant benefit compared to non-transplant therapies. Potential benefit to HCC patients must be weighed against the harm from delaying or precluding LT for non-HCC patients on the waiting list, particularly in regions with limited donor availability. The relative benefit of LT in patients with small (<3 cm) HCC is likely limited; surgical resection (in absence of portal hypertension) and local ablative therapy (if portal hypertension present) are both efficacious and more cost-effective and should likely be regarded as first line therapies for these patients. Salvage LT can be considered as a rescue option for those with recurrent disease. Downstaging for selected patients with UNOS T3 lesions may identify those with good tumor biology and acceptable post-transplant outcomes; however, current studies have had a wide variation in reported outcomes. While awaiting more data, a standardized downstaging protocol including a priori inclusion criteria and a mandatory waiting time prior to LT to observe tumor biology likely yields the best outcomes.