What about patients with liver cancer?

Liver cancer is a feared complication of cirrhosis. For patients with cirrhosis on the waiting list, the risk of developing liver cancer can range from 1% to 10%. Transplant physicians periodically test the liver for the development of liver cancer by performing an alpha-fetoprotein (AFP) blood test and conducting an ultrasound, CT (computed tomography), or MRI (magnetic resonance imaging) of the liver.

Some, but not all, patients with liver cancer may be candidates for liver transplantation. To be a viable candidate, the patient must fit into the Milan Criteria (developed in Milan, Italy). The Milan Criteria state that the patient with liver cancer has a low risk of recurrence after transplantation if

1. There is a single tumor measuring less than or equal to 5 centimeters in diameter, or

2. There are two or three tumors, each measuring less than 3 centimeters in diameter (Figure 6).

In each case there must be no evidence that the tumor has spread outside the liver or into blood vessels. A CT or MRI of the abdomen and chest and other tests as needed can rule out spread of the tumor. If there are

four tumors in the liver, regardless of their size, the patient is characterized as “outside Milan Criteria.”

In the past, before the Milan Criteria were established and applied, liver transplantation was attempted for a variety of tumor sizes and numbers. When transplantation occurred “outside Milan Criteria,” the likelihood of a tumor recurring in the newly transplanted liver was nearly 80% within 1 year and nearly 100% within 3 years. The reason the tumor is thought to recur in the transplanted liver is related to immunosuppression. The intact immune system has the ability to identify and eradicate any stray tumor cells that may have escaped the liver. Once the liver transplant is performed and the patient begins to take immunosuppressive drugs, however, the immune system may lose its ability to recognize and kill these cells. The tumor cells may then return to the new liver or settle in other sites, such as the lungs or bones.

Unfortunately, chemotherapy either before or after transplantation has been largely ineffective in changing the tumor recurrence rates.

Some patients with liver cancer may be candidates for surgical resection of the tumor while awaiting liver transplantation. This procedure may be an option only for patients who have good liver function, minimal ascites, and a tumor located in the left lobe or lower periphery of the right lobe. Other candidates may be treated with radiofrequency ablation (RFA), transarterial chemoembolization (TACE), or with transarterial radioactive beads in an effort to control the growth of the tumor to remain within the Milan Criteria while awaiting transplantation.