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Kornberg et al. Hepatoma Res 2018;4:60 I http://dx.doi.org/10.20517/2394-5079.2018.86 Page 13 of 19

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in a higher number of liver recipients . As suggested in small study samples, this might be a promising IS-
based approach to reduce the oncological risk in LT patients with HCC. However, larger prospective studies
are needed.

CONCLUSION
As pointed out in this review, there are several important non-HCC related factors of prognosis that have
to be considered in LT for HCC. However, comparability of related studies is rather limited by their mostly
retrospective character and the use of different outcome variables [Tables 1-7]. Nevertheless, there is growing
evidence that these non-oncological features trigger a series of unfavorable immunomodulatory processes
related to inflammation and immunosuppression, and thereby promoting the oncological risk following
LT. This may be particularly relevant for patients with advanced HCC stages, who are per se exposed to an
increased risk of HCC recurrence. Therefore, these non-oncological factors should play an important role in
individual decision making. The presented data suggest that adequate patient and graft selection, limitation
of ischemia time, reduction of surgical complications and minimizing post-LT immunosuppressive drug
load may be essential components for preserving immunbalance and, thereby, for improving cancer-specific
survival.

Since all of these features are well-known prognostic factors that are generally affecting outcome of LT patients
even without underlying malignancy, it is a particular challenge to determine the individual transplant benefit
based on both tumor biology data and non-HCC variables. In this context, there is currently no applicable
clinical algorithm which is implementing both aspects for risk assessment. However, what became clear from
our review is that such an approach should include concepts of mitigating hepatic I/R damage not only to
improve early posttransplant patient and graft survival, but to reduce the potency of metastatic tumor cell
implantation and growth. Thus, the HCC patients’ selection criteria might be safely expanded beyond current
macromorphologic tumor burden limits.

DECLARATIONS
Authors’ contributions
Conceived the study, analyzed data and wrote the manuscript: Kornberg A
Analyzed data and revised the manuscript: Schernhammer M

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Both authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2018.