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the results are biased towards the multimodality treatment group. We recommend surgical resection of
isolated metastasis (either in extra hepatic or intrahepatic location) in carefully selected patients with
good functional status. If resection is not possible, ablative therapy and SBRT should be used especially in
liver, lung or bone metastases. Systemic therapy with Kinase inhibitors (mainly sorafenib) is advisable in
all patients. Furthermore, combination therapy with mTOR inhibitors (sirolimus, everolimus) in order to
reduce CNI doses, may have some benefit over kinase inhibitors alone, as seen in our study.

In conclusion, multimodality treatment for post LT HCC recurrence has shown to further improve survival
rates, which calls for an aggressive approach while formulating a treatment regime for these patients.

DECLARATIONS
Acknowledgments
We would like to acknowledge the core members of our multidisciplinary team in the Institute including
Amit Rastogi, Thiagarajan S, Rohan Chaudhary, Kamal Yadav, Ankur Gupta (all from Department of
Surgery), Sanjiv Saigal, Neeraj Saraf, Narendra Choudhary (all from Department of Hepatology), S S Baijal
(Department of Interventional Radiology), Tejinder Kataria (Department of Radiation Oncology), Dheeraj
Gautam (Department of Pathology) who were actively involved in the management of all these patients
during and post liver transplantation, and after recurrence.

Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Bhangui P, Yadav S
Drafted the manuscript and substantively revised it: Bhangui P, Yadav S, Soin AS

Availability of data and materials
The authors can provide data if required, this data however is a part of the entire HCC database of the
Institute based on which a manuscript is currently undergoing review in another Journal.

Financial support and sponsorship
None.

Conflicts of interest
All 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) 2020.

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