Multiple Choice and Discussion Questions

Bridging therapies commonly used to treat HCC while awaiting transplant include chemoembolization (transcatheter arterial chemoembolization (TACE) and hepatic arterial therapy (HAT)), alcohol ablation, and radiofrequency ablation. Combination bridging therapies have also been utilized.

Adjuvant treatment with TACE, percutaneous ethanol injection, and/or radiofrequency ablation (RFA) in T1- and T2-staged HCC resulted in tumor-free survival after transplantation of 95.2% after 4 years and ITT survival of 94%, 85%, and 79% at 1, 2, and 3 years, respectively. Percutaneous therapies carry risks of tumoral seeding between 0.1% and 0.6%. There use is somewhat controversial, however. To date, there is no high-level evidence that waiting-list HCC treatment with these modalities is effective in (i) achieving improvement of post–liver transplant survival, (ii) achieving downstaging of advanced HCC to within Milan criteria, and (iii) preventing waiting list dropout.

Often, combinations of these therapies are utilized to achieve high rates of tumor necrosis, which has been shown to improve recurrence-free survival in posttransplant patients. None of the macromorphological HCC features, but only the absence of increased (18)F-fluoro-deoxy-glucose (FDG) uptake on pretransplant positron emission tomography (PET), was identified as an independent predictor of postinterventional tumor response (P < 0.001). Hence, pretransplant PET assessment may identify those patients with advanced HCC who will benefit from post-interventional bridging therapy (IBT) tumor response and may, thereby, achieve excellent posttransplant outcome.