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Page 4 of 17 Calinescu et al. Hepatoma Res 2021;7:59 https://dx.doi.org/10.20517/2394-5079.2021.26

[33]
(2) Large solitary PRETEXT IV tumor, unless downstaged after chemotherapy .

(3) Large central PRETEXT II and III tumors invading bilaterally the confluence at the porta hepatis or all
three hepatic veins [6,34-38] .

[3]
(4) Local (intra-hepatic) recurrence of HBL after liver resection .
(5) Complications of “extreme resections”, i.e., early liver failure (due to small-for-size, ischemic damage, or
other intraoperative complications) or late complications .
[6]

The two last categories are defined as “rescue” or “salvage” transplantation, accounting for 15%-40% of all
[17]
LT performed for HBL in a recent review . In the latter situations, LT is associated with poor outcome
(30% survival with most deaths due to recurrence ), yet LT remains an option in well selected cases [3,38] .
[39]

Contraindications
Persistence of macroscopic metastasis (visible on imaging) after chemotherapy and not amenable to surgical
excision remains the only absolute contraindication for LT . Although there is no consensus, some
[39]
consider that response to chemotherapy is a requisite for transplantation, with progression of disease under
chemotherapy being a contraindication to LT .
[3,8]

In all indications, although the presence of metastases at diagnosis is not a contraindication, the control
under chemotherapy (with disappearance at imaging) of the metastasis is mandatory before LT. In cases
with some residues at the location of previous metastases, the strategy may consist in surgical resection of
these metastases before LT.

The clearance of lung metastasis prior to LT is of utmost importance: a wedge resection is performed the
most often; in the case of more than four nodules in the same lobe, lobectomy might be considered as a
surgical option . Median sternotomy with manual palpation of both lobes might be a valuable option in
[17]
bilateral lung residual metastasis [40-42] . The alternative is sequential surgeries in the case of bilateral
involvement .
[17]

Surgery tips and tricks
In cases with tumors very close to, encircling or infiltrating, the retro hepatic vena cava, en bloc resection of
liver with the vena cava is recommended, with some teams deliberately using this approach for all cases.
Venous reconstruction is performed by using donor iliac vein allograft in the case of LT with deceased
[39]
donation . As the latter reconstruction is challenging in the context of living donor LT (lack of donor vein
[43]
allograft), this situation (that was once considered a contraindication for LT from living related donors ) is
nowadays managed by using the jugular vein of the recipient or from the same donor [3,44,45] . Other options of
using vessels from the same living donor have been proposed (recanalized umbilical vein, external jugular
vein, or superficial femoral venous graft) and others have proposed cryopreserved vessels from unrelated
donors [45,46] . Of note, in the case of large tumors compressing the inferior vena cava with pre-LT sufficient
venous return via collaterals to the azygous system, caval vein reconstruction has not been systematically
needed .
[47]
The impact of an early inflow (arterial and portal) exclusion with temporary portocaval shunt was studied
for the effect on recurrence: firstly, early inflow interruption might prevent tumor dissemination through
the hepatic veins because of surgical manipulations as well as diminish blood losses minimizing the