What Should Be the Rules for Downstaging for Hepatocellular Carcinoma?
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REVIEW ARTICLE
What Should Be the Rules for Downstaging for Hepatocellular Carcinoma? Abuzer Dirican 1 & Serdar Karakas 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Introduction Liver transplantation remains the main curative treatment method for hepatocellular carcinoma. There are several criteria for hepatocellular carcinoma to be eligible for liver transplantation, and it depends on main transplantation centers worldwide. Locoregional treatments and downstaging protocols are used for either to achieve these criteria or to prevent drop outs on the transplant waiting lists. But who can benefit from these bridging therapies effectively for the main purpose of curative treatment? Main contraindications are known for locoregional treatments like cirrhosis or low hepatic function, total main portal vein occlusion, and extrahepatic metastasis. HCCs, which are confined to liver but have high tumor burden, remains the main controversial issue. Aim On this aspect, we reviewed the literature for downstaging protocols for hepatocellular carcinoma with their effect on survival and recurrence rates after liver transplantation. Conclusion Although candidates for downstaging is still controversial, with the absence of main contraindications, LRT can be applied to selected HCCs, which have a certain degree of tumor burden. Keywords Liver transplantation . Downstaging protocol . Locoregional treatment . Hepatocellular carcinoma
Abbreviations LT Liver transplantation HCC Hepatocellular carcinoma AFP Alpha fetoprotein DCP Des-gamma-carboxy prothrombin LRT Locoregional treatment BCLC Barcelona Clinic Liver Cancer AJCC American Joint Committee on Cancer UNOS United Network for Organ Sharing TACE Transarterial chemoembolization TARE Transarterial radioembolization RFA Radiofrequency ablation
Introduction Hepatocellular carcinoma (HCC) is an aggressive tumor. It is the second most common cause of cancer death worldwide [1]. * Serdar Karakas [email protected] 1
Faculty of Medicine, Department of Surgery, Institute of Liver Transplantation, Inonu University, 44280 Malatya, Turkey
It often occurs in the setting of chronic liver disease and cirrhosis. Curative treatment options of HCC are resection and liver transplantation (LT). Patients who cannot be treated with liver resection can be the candidates for potentially curative LT. Unfortunately, the majority of patients are not eligible for either resection or transplantation because of high tumor stage, underlying liver dysfunction due to cirrhosis, and shortage of donor organs. As a result of this, many other treatments for HCC have been developed, including locoregional therapy (LRT). Most common staging systems for HCC include the Barcelona Clinic Liver Cancer (BCLC) [2] and the American Joint Committee on Cancer (AJCC) tumor/node/ metastasis (TNM) classification. The United Network for Organ Sharing (UNOS) has incorporated the Milan criteria into T1 and T2 in a modified staging system for HCC. There are more than one criteria for trans
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