Hepatocellular Carcinoma & Liver Transplantation
Hepatocellular carcinoma (HCC) is the most common primary liver cancer and a leading indication for liver transplantation in patients with cirrhosis. This page covers diagnosis, Milan/UCSF criteria, exception points, bridging/downstaging therapies, and post-transplant outcomes.
What Is Hepatocellular Carcinoma?
Hepatocellular carcinoma arises from hepatocytes in the setting of chronic liver disease and cirrhosis. Major risk factors: hepatitis B, hepatitis C, alcohol, NAFLD/NASH, and aflatoxin. Globally, HCC is the 4th leading cause of cancer death. In cirrhosis, annual incidence is 2–5%; surveillance with ultrasound ± AFP every 6 months is mandatory.[1]
Diagnosis & LI-RADS
Non-invasive diagnosis via contrast-enhanced CT/MRI showing arterial hyperenhancement + washout/capsule (LI-RADS 5 = definitive HCC). Biopsy reserved for atypical lesions. AFP >200 ng/mL supports diagnosis. LI-RADS standardizes reporting, improving reproducibility and transplant allocation accuracy across centers.[1]
Staging & Prognosis
BCLC staging guides therapy: very early/early (0/A) → curative options including transplant; intermediate (B) → locoregional; advanced (C/D) → systemic/palliative. Key prognostic factors: tumor size/number, vascular invasion, extrahepatic spread, performance status, and liver function (Child-Pugh/MELD).[1]
Transplant Eligibility
Liver transplantation offers the only chance of cure in cirrhosis + HCC. Standard criteria: Milan (1 tumor ≤5 cm OR ≤3 tumors ≤3 cm, no macrovascular invasion/extrahepatic spread) → 5-yr survival 70–80%. UCSF and Up-to-7 expand eligibility with comparable outcomes. UNOS grants MELD exception points (initial 22–28, increasing every 3 months).[2]
Bridging & Downstaging Therapies
While waiting, locoregional therapy prevents progression: TACE, Y-90 radioembolization, ablation (RFA/MWA). Downstaging protocols treat beyond-Milan tumors to within criteria — 50–70% success rate, with post-LT survival matching Milan if downstaged successfully.[3]
Post-Transplant Care & Recurrence
5-year recurrence-free survival 70–85% within Milan. Risk factors: high AFP, poor differentiation, microvascular invasion. Surveillance: CT/MRI + AFP every 6–12 months first 3 years. mTOR inhibitors (sirolimus/everolimus) may reduce recurrence risk. Recurrence treatment: surgery, ablation, or systemic therapy (atezolizumab-bevacizumab).[4]
References
- Marrero JA, et al. AASLD Practice Guidance on Prevention, Diagnosis, and Treatment of Hepatocellular Carcinoma. Hepatology 2023;78(6):1922-1965.
- OPTN Policy 9.5.I: Requirements for Hepatocellular Carcinoma (HCC) MELD or PELD Score Exceptions. Updated 2024.
- Tabrizian P, et al. Ten-Year Outcomes of Liver Transplant and Downstaging for Hepatocellular Carcinoma. JAMA Surg 2022;157(9):779-788.
- Sapisochin G, et al. Recurrence of Hepatocellular Carcinoma After Liver Transplantation. Transplantation 2023;107(1):50-61.