title: Bridging and downstaging treatments for hepatocellular carcinoma in patients on the waiting list for liver transplantation.
abstract: Several therapeutic procedures have been proposed as bridging treatments for patients with hepatocellular carcinoma (HCC) awaiting liver transplantation (LT). The most used treatments include transarterial chemoembolization and radiofrequency ablation. Surgical resection has also been successfully used as a bridging procedure, and LT should be considered a rescue treatment in patients with previous HCC resection who experience tumor recurrence or post-treatment severe decompensation of liver function. The aims of bridging treatments include decreasing the waiting list dropout rate before transplantation, reducing HCC recurrence after transplantation, and improving post-transplant overall survival. To date, no data from prospective randomized studies are available; however, for HCC patients listed for LT within the Milan criteria, prolonging the waiting time over 6-12 mo is a risk factor for tumor spread. Bridging treatments are useful in containing tumor progression and decreasing dropout. Furthermore, the response to pre-LT treatments may represent a surrogate marker of tumor biological aggressiveness and could therefore be evaluated to prioritize HCC candidates for LT. Lastly, although a definitive conclusion can not be reached, the experiences reported to date suggest a positive impact of these treatments on both tumor recurrence and post-transplant patient survival. Advanced HCC may be downstaged to achieve and maintain the current conventional criteria for inclusion in the waiting list for LT. Recent studies have demonstrated that successfully downstaged patients can achieve a 5-year survival rate comparable to that of patients meeting the conventional criteria without requiring downstaging.
authors.affiliation: Maurizio Pompili, Francesca Romana Ponziani, Department of Internal Medicine, Università Cattolica del Sacro Cuore, 8-00168 Rome, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Pompili
authors.forename: Giampiero
authors.initials: G
authors.lastname: Francica
authors.forename: Francesca Romana
authors.initials: FR
authors.lastname: Ponziani
authors.forename: Roberto
authors.initials: R
authors.lastname: Iezzi
authors.forename: Alfonso Wolfango
authors.initials: AW
authors.lastname: Avolio
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality; D020360:Neoadjuvant Therapy / Q000009:adverse effects / Q000401:mortality; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D010352:Patient Dropouts; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014850:Waiting Lists / Q000401:mortality
keywords: Bridging treatment; Downstaging; Dropout rate; Hepatocellular carcinoma; Liver cirrhosis; Liver resection; Liver transplantation; Waiting list; Waiting time