Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Mar 27, 2019; 11(3): 261-272
Published online Mar 27, 2019. doi: 10.4254/wjh.v11.i3.261
Hepatocellular carcinoma recurrence after liver transplantation: Risk factors, screening and clinical presentation
Norma Arteiro Filgueira
Norma Arteiro Filgueira, Department of Internal Medicine, Universidade Federal de Pernambuco, Recife, Pernambuco 50670-901, Brazil
Author contributions: Filgueira NA contribuate to conception and design, literature review and writing of article.
Conflict-of-interest statement: No potential conflicts of interest, no financial support
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Norma A Filgueira, MD, PhD, Professor, Department of Internal Medicine, Universidade Federal de Pernambuco, Av. Prof. Moraes Rego, 1235, Cidade Universitária, Recife, Pernambuco 50670-901, Brazil.
Telephone: +55-81-9991416308
Received: February 6, 2019
Peer-review started: February 6, 2019
First decision: March 5, 2019
Revised: March 6, 2019
Accepted: March 16, 2019
Article in press: March 16, 2019
Published online: March 27, 2019

Liver transplantation is the best treatment option for cirrhotic patients with early-stage hepatocellular carcinoma, but it faces the problem of scarcity of donors and the risk of tumor recurrence, which affects between 15% and 20% of the cases, despite the use of restrictive criteria. The risk of recurrence depends on a number of factors, related to the tumor, the patient, and the treatment, which are discussed in this review. Some of these factors are already well established, such as the histopathological characteristics of the tumor, Alpha-fetoprotein (AFP) levels, and waiting time. Other factors related to the biological behavior of the tumor and treatment should be recognized because they can be used in the refinement of the selection criteria of transplant candidates and in an attempt to reduce recurrence. This review also discusses the clinical presentation of recurrence and its prognosis, contributing to the identification of a subgroup of patients who may have better survival, if they are timely identified and treated. Development of recurrence after the first year, with AFP levels ≤ 100 ng/mL, and single site capable of locoregional therapy are associated with better survival after recurrence.

Keywords: Hepatocellular carcinoma, Liver transplantation, Recurrence, Risk factors, Alpha-fetoprotein, Survival, Prognosis

Core tip: Recurrence of hepatocellular carcinoma (HCC) after liver transplantation usually portends a poor prognosis with short survival. Besides well recognized risk factors for post-transplant HCC recurrence, as tumor staging and vascular invasion, this review discusses other factors strongly associated with the recurrence risk, such as alpha-fetoprotein levels, tumor uptake of FDG in Pet scan, response to locoregional therapy and post-transplant immunosuppression. We present proposals of a screening protocol for tumor recurrence after transplantation and of criteria to identify patients with good prognosis after recurrence, who might benefit from aggressive antitumor therapy.