Extrahepatic cancer risk after liver transplantation for hepatocellular carcinoma: incidence, risk and prevention

Abstract

This article synthesises the current evidence on the risk of de novo extrahepatic cancer in people living with a liver transplant after hepatocellular carcinoma, the risk factors for cancer, and the recommended approaches to cancer prevention and surveillance. People living with a transplanted liver have an elevated risk of cancer and cancer death, and the indication for transplantation does not markedly alter the cancer risk. The excess risk of cancer is double that of the age-and sex-matched general population. Virus-related cancers, especially non-Hodgkin lymphoma, Kaposi sarcoma, Merkel cell carcinoma, oral, and anogenital cancers occur at increased risk, as do cancers causally associated with high prior sun exposure, smoking and excessive alcohol consumption, including skin, oesophageal, larynx, lung, kidney, and bladder cancer. The risk of incident breast and prostate cancer is not increased. Cancer-related deaths largely mirror that for cancer incidence, and extend to include the more common malignancies such as breast, colorectal, prostate cancer and non-melanoma skin cancer. As medical immunosuppression is the principal risk factor for cancer, the regimen should be reviewed on a regular basis to achieve immunosuppression minimisation. An individual, risk-based approach to cancer screening according to test characteristics and personal and family cancer history, medical history, lifestyle factors, and life expectancy is recommended. Multicomponent interventions may achieve the best results in supporting the adoption and maintenance of cancer risk-reducing behaviours. Regular, empowering patient counselling and education is a cornerstone for the care of people living with a liver transplant.

Immunotherapy as a Complement to Surgical Management of Hepatocellular Carcinoma

“…Outside of "bridging therapy", immunotherapy has been studied in the post-transplant setting to address malignancies. Transplanted patients are uniquely at increased risk of extrahepatic malignancies, particularly skin malignancies, with incidence rates of 1.3% within the first year of transplantation, and 18.8% within 20 years [94]. Additionally, the rate of recurrent HCC in patients who had undergone LT for this indication was approximately 10-15%, often early after transplantation [90].…”