Liver transplantation for hepatocellular carcinoma: current topics in France

Abstract

Background Excellent survival obtained with liver transplantation (LT) for limited hepatocellular carcinoma (HCC) in patients with chronic liver disease is still challenged by the increasing discrepancy between candidates and grafts available. We review the current strategy of LT for HCC in our country highlighting the tendency: (1) to expand recipient selection beyond the Milan criteria, (2) to use systematic pre-LT treatments with a greater number of resections and (3) new rules for graft attribution. Results Although the vast majority of cirrhotic patients with HCC are transplanted within the Milan criteria; the number of candidates is continually rising, while the number of grafts available is stable with a disappearance of adult LDLTs. Moreover, the new rules for organ allocations, mainly based on the MELD score, minimize the accessibility to liver grafts for patients with HCC and compensated liver disease. For these reasons, in France we have observed an increase in waiting time for HCC patients, leading to the extensive use of pre-LT treatments in order to limit the list dropouts. Many studies have been performed on transarterial chemo-embolization (TACE) and supraselective TACE. Moreover, the use of liver resection (LR) as a bridge therapy, showing that initial resection does not impair short-and long-term survival, led French surgeons to develop the concept of LR as a way to select patients who might benefit from LT and to use it, in selected cases, as a primary therapy, considering LT as salvage treatment in case of recurrence. Conclusions The number of HCC candidates who cannot benefit from a LT is increasing worldwide. The French answer to this situation involves pre-LT treatments, particularly partial LR, based mainly on the excellent Japanese results in this field. Moreover, the country of « égalité » is actually modifying the rules of graft attribution in order to reduce the inequality between the HCC patients with poor and good liver function.

Benefit of initial resection of hepatocellular carcinoma followed by transplantation in case of recurrence: An intention-to-treat analysis

“…Patients with HCC are given a score (extra points) corresponding to their risk of wait list mortality or dropout. Although we observed a higher rate of LT for HCC during the second period,21 the mean waiting time for patients with HCC was similar before and after MELD was adopted (5.8 ± 8 versus 7.1 ± 5 months, respectively). For all patients, collection of data ended in December 2010.…”

Early and resectable HCC: Definition and validation of a subgroup of patients who could avoid liver transplantation

“…The median donor age was 51.5 years . The median cold ischemia time was 9 hr . The postoperative mortality rate after liver transplantation was 13.9%.…”

Hepatocellular carcinoma and liver transplantation

“…Ugyanakkor egyre nyomasztóbb a HCC miatt transzplantációra várók egyre jelentősebb tömege. Franciaországban például e betegek már a várólistán lévők 22%-át jelentik [9]! A cadaverdonációk és az ebből elérhető beültethető májak száma mindenütt a világon jelentős probléma.…”