Orthotopic Liver Transplantation: Indications and Contraindications

Abstract

At the beginning of the third millennium, liver transplantation (LT) has turned from dream into a reality. Thomas E. Starzl, who first performed LT in March 1963, and many of his scholars allowed to live one of the most extraordinary adventures of modern medicine. Twenty years later, in 1983, the National Institute of Health Consensus Development Conference concluded that LT was "a promising alternative to current therapy in the management of late phase of several forms of serious liver diseases" and that it had the potential to become a "clinical service" as opposed to an experimental procedure. Half a century later, LT progressed at high speed resulting in a worldwide, curative, treatment of more than 50 different liver as well as liver-based diseases. Today the 250,000 mark has been reached. This chapter gives a detailed overview of all the different aspects of this medical adventure, stressing thereby also the last innovations and forthcoming revolutions to expect.

Liver Transplantation for Hepatocellular Carcinoma. Working Group Report from the ILTS Transplant Oncology Consensus Conference

“…[3][4][5][6][7][8][9][10] Especially in areas with organ shortages, the pendulum has largely swung away from expanded criteria for several reasons. These include an emphasis on performing LT in those HCC patients most likely to derive significant transplant survival benefit, 11 concerns that implementation of expanded tumor criteria could reduce access to LT for patients with better post-LT prognosis, 12,13 and longer wait times leading to increased use of local-regional therapy (LRT) as a bridge to LT. 14 There is also mounting evidence that tumor burden is just one of many factors that predict post-LT outcome. 15,16 In this context, selection criteria have begun to shift to include surrogates of tumor biology (eg, alpha-fetoprotein [AFP]) and response to LRT, with a number of pre-LT selection criteria recently proposed.…”

“…The question of offering LT to resectable, Child's A patients with single small HCC takes on greater importance after Berry and Ioannou 95 found that HCC patients derive a significantly lower survival benefit from LT than non-HCC patients. Further, several studies have shown that HCC patients with favorable tumor (single tumor <3 cm and AFP ≤20 ng/mL) and liver-related characteristics (Child's A cirrhosis and MELD-Na <15) 11,96,97 have reduced urgency for LT. Such patients who subsequently undergo LRT with complete radiographic response have a very low risk of waitlist dropout 11,96,98 and thus exceedingly low LT urgency with decreased LT survival benefit.…”

“…Further, several studies have shown that HCC patients with favorable tumor (single tumor <3 cm and AFP ≤20 ng/mL) and liver-related characteristics (Child's A cirrhosis and MELD-Na <15) 11,96,97 have reduced urgency for LT. Such patients who subsequently undergo LRT with complete radiographic response have a very low risk of waitlist dropout 11,96,98 and thus exceedingly low LT urgency with decreased LT survival benefit. 37 This is especially true for HCC patients unlikely to have liver disease progression (eg, due to effective antiviral treatment or alcohol abstinence) and thus no alternate indication for LT.…”

Liver Transplantation Selection and Allocation Criteria for Hepatocellular Carcinoma: A European Perspective

“…The authors found a MELD >13, AFP < 1,000 ng/mL, and response to downstaging therapies to be highly associated with a benefit gain from transplantation while wait time and age had almost no impact on benefit. 67 Possibly future TBSs can be simplified by only including variables that actually have a major influence on transplant benefit. This is without placing too much weight on variables that may also increase posttransplant recurrence.…”

Transplantation for hepatocellular cancer: pushing to the limits?

“…Lastly, models based on the concept of benefit have been recently created (12)(13)(14)(15). The transplant benefit represents a compromise between utility and priority, trying to define the group of patients better really obtaining a beneficial effect concerning survival after LT (16).…”