Page 77 - Read Online

Page 12 of 17 Calinescu et al. Hepatoma Res 2021;7:59 https://dx.doi.org/10.20517/2394-5079.2021.26

The use of sorafenib has shown better survival rates in the adult population, demonstrating an
[95]
improvement in median overall survival (10.7 months vs. 7.9 months) ; in children, few data have been
[15]
published in this respect .
Overall survival was not different in subgroups according to 5 cm cut off, vascular invasion, and the Milan
criteria . No differences in survival have been found when comparing living donors to deceased donors .
[96]
[89]
When studying treatment choice, a 21-patient series comparing outcomes for resection and chemotherapy
vs. LT in pediatric HCC reveals a superior survival (72% vs. 40%) in the LT subgroup, pointing out the need
for the early evaluation of transplantability of pediatric HCC patients in the treatment course .
[88]
Recurrences after liver transplantation for hepatocellular carcinoma
During surgery for HCC, operative manipulation, increased intraoperative blood loss, and blood
transfusions are thought to be potential mechanisms for tumor recurrence [97,98] .

The risk factors identified for recurrence of HCC are as follows: tumor stage, vascular invasion, and lymph
node involvement. In the long term, older age and metastatic disease were additionally identified [1,4,90] .

Few series describe the outcome of HCC patients with macrovascular invasion undergoing LT; a 5-year
[99]
recurrence free survival of 89% is reported in a 10-patient series .
Unlike adults, the risk for recurrence is not higher if patients do not meet the Milan criteria . Given higher
[8]
recurrence rates of HCC after surgical resection than after LT, it is hypothesized that LT should be
liberalized even for resectable tumors .
[8]

Of note, no recurrence was identified in the patients for whom HCC was incidentally discovered in the liver
explant .
[1]
The recurrences and impact on survival of deceased versus living LT has been studied in the adult literature
[100]
but very few data are available within the pediatric literature .
Whether corticosteroids and calcineurin inhibitors increase the likelihood of tumor recurrence after LT for
HCC is not clear yet; it is the reason for some centers to privilege the use of sirolimus, as it has been shown
to inhibit the growth of a wide variety of tumors . An adult study did not show an improved long-term
[3]
recurrence free survival beyond five years, but it increased the overall survival and the recurrence-free
survival in the first three to five years after LT .
[101]

ONGOING AREAS OF RESEARCH
Pediatric LT has a growing place in the management of unresectable HBL and HCC. There are still
unanswered questions concerning the role of post-LT chemotherapy for HBL, immunosuppression
modulation, and the correlation of the AFP levels after LT with survival. Besides an obvious need for
validated LT criteria for pediatric HCC patients, the impact of chemotherapy and waiting time for LT are
still to be studied.