Locoregional Treatments for Bridging and Downstaging HCC to Liver Transplantation

SIMPLE SUMMARY: Liver transplantation is the first-line treatment for patients diagnosed with unresectable early stage hepatocellular carcinoma in the setting of cirrhosis. Patients with tumours beyond this stage may benefit from liver transplantation if their tumours are successfully downstaged. Loco-regional therapies, including ablation, trans-arterial and radiotherapeutical approaches are commonly used to treat patients before transplant, with the aim of reducing the risk of drop off from the waiting list due to tumor progression for patients within transplantation criteria as well as decreasing tumour dimension to meet acceptable criteria. In this review, current evidence on the safety, efficacy and utility of locoregional therapies as neoadjuvant therapies before liver transplantation are summarized. ABSTRACT: Liver transplantation (LT) is the first-line treatment for patients diagnosed with unresectable early-stage hepatocellular carcinoma (HCC) in the setting of cirrhosis. It is well known that HCC patients within the Milan criteria (solitary tumour ≤ 5 cm or ≤3 tumours, each <3 cm) could undergo LT with excellent results. However, there is a growing tendency to enlarge inclusion criteria since the Milan criteria are nowadays considered too restrictive and may exclude patients who would benefit from LT. On the other hand, there is a persistent shortage of donor organs. In this scenario, there is consensus about the role of loco-regional therapy (LRT) during the waiting list to select patients who would benefit more from LT, reducing the risk of drop off from the waiting list as well as decreasing tumour dimension to meet acceptable criteria for LT. In this review, current evidence on the safety, efficacy and utility of LRTs as neoadjuvant therapies before LT are summarized.