Prophylactic liver transplantation for high-risk recurrent hepatocellular carcinoma

Table 1 Comparison between prophylactic liver transplant and wait-and-see before hepatocellular carcinoma recurrence

The strategy	Prophylactic LT	Wait-and-see
Immunosuppressant exposure	Life-long	Nil
Surgical morbidity and mortality	Present	Nil
Long-term HCC recurrence	Lower[32]	Higher[11]
Survival benefit (5-year survival rate)	84.6%[32]	Around 70%[7-10]
Further management after recurrence	Hepatectomy, RFA, TACE, Sorafenib, Yttrium-90	SLT, repeat hepatectomy, RFA, TACE, Sorafenib, Yttrium-90

LT: Liver transplant; RFA: Radiofrequency ablation; TACE: Transcatheter arterial chemoembolization; HCC: Hepatocellular carcinoma.

Table 2 Prognostic factors of early hepatocellular carcinoma recurrence after liver resection and after liver transplantation

Risk factor of HCC recurrence	After liver resection	After liver transplantation
Serological
AFP	> 400 ng/mL[49]	> 1000 ng/mL[34,35]
Tumor gross
Tumor size	> 3 cm[30] or > 5 cm[37,41,65]	> 6 cm[35]
Tumor number	> 3[65]	≥ 4[35]
Satellite nodules	Yes[30,63,66]	Yes[33]
Tumor microscopic
Tumor differentiation	Intermediate, or poor differentiation, or undifferentiation[30,49,65]	Poor differentiation, or undifferentiation[33]
Microvascular invasion	Yes[30,37,41,49,64-66]	Yes[33,34]
Liver parenchyma
Severity of cirrhosis	Controversial[67-69]	No
Milan criteria	Yes[68] (predict recurrence within/beyond MC)	Yes[3]

HCC: Hepatocellular carcinoma; AFP: Alpha-fetoprotein; MC: Milan criteria.

Table 3 Scoring systems for predicting hepatocellular carcinoma recurrence

Ref.	Basis of scoring system	Prognostic factors	Discriminated scores
Pan et al[76]	Glasgow prognostic score	Preoperative	0, 1, 2
		CRP > 10 mg/L (1 point)
		Albumin < 3.5 g/L (1 point)
Fuks et al[32]	Histological features	Microscopic vascular invasion	< 3 factors
		Presence of satellite nodules	≥ 3 factors
		Tumor size > 3 cm
		Poor differentiated tumor
		Cirrhosis
Roayaie et al[66]	Degree of vascular invasion	Invasion of a vessel with a muscular wall (1 point)	0, 1, 2
		Invasion of a vessel ≥ 1 cm from the tumor capsule (1 point)
Lee et al[68]	Clinical risk score	Initial disease beyond Milan criteria	0, 1, 2, 3
		Microsatellites or multiple tumors
		Lymphovascular invasion (1 point for each factor)

Higher scores indicate higher recurrence rate. CRP: C-reactive protein.