Hepatocellular carcinoma (HCC) is one of the most lethal cancers worldwide. According to Hong Kong Cancer Registry, liver cancer ranks the fifth in incidence and the third in cancer-related mortality in 2020. Liver transplantation (LT) is the best treatment option as total hepatectomy eliminates detectable and undetectable tumor lesions as well as the cirrhotic liver due to underlying liver disease. But since few liver transplant donors are available, meticulous selection of patients to minimize the recurrence and optimize long-term survival are crucial.
The Milan criteria (single tumor 5cm, or up to three tumors 3cm have been the gold stndard for selecting patients with HCC for LT for over the two decades. Since then, patient’s eligibility for LT continued to evolve; one attractive strategy is the application of locoregional treatment (LRT) to downstage patients whose tumor burden exceeding the established limits to within the Milan Criteria. One of the commonly used criteria is the University of California, San Francisco downstaging (UCSF-DS) criteria. Several large-scale studies showed that patients with successful downstaging after LT had similar outcomes to patients with HCC initially meeting the Milan criteria.
The last 15 years have witnessed a dramatic increase on the number of systemic therapies for the treatment of advanced HCC. Emerging data further showed that combined systemic therapy and LRT is associated with better efficacy than single-modality treatment. The promising response rates, longer time-to-progression, and potential in altering disease trajectory of the modern-era combination modality treatment have rendered it a promising downstaging therapy for LT. Yet, to date, few prospective data available.
In this lecture, I would discuss the latest evidence on systemic therapy and combination therapy in management of patients with HCC and their potential application as down-staging treatment for liver transplantation.
