Arndt Vogel, MD: Patients with HCC should be evaluated for liver transplantation. At the moment, we clearly have criteria that defines who could receive a liver transplantation. These are the Milan criteria, which say that patients should not have more 3 tumor nodules, which should be smaller than 3 cm, or they can have 1 tumor module that needs to be smaller than 5 cm. All patients who are within the Milan criteria are potentially candidates for liver transplantation. So, when we have an early diagnosis of HCC, patients should be referred to a transplantation center and should be evaluated on whether they are candidates for liver transplantation.

In some countries, patients who have larger tumors and are downstaged to a tumor size within the Milan criteria are also candidates for liver transplantation. In Germany, it’s not allowed, so once you are out of the Milan criteria, you are out of the Milan criteria forever. And even if you have a downstaging, you are not allowed to receive liver transplantation. But this is different in other countries. Downstaging has been shown in several retrospective studies, and can be a very effective means to really identify patients who have a good benefit from liver transplantation. So, every patient who has a tumor within the Milan criteria either at first diagnosis or during follow-up treatment should be referred to a transplantation center and should be evaluated for liver transplantation.

Oliver Waidmann, MD: Liver transplantation is a really, really good option for patients with cirrhosis, and, of course, a patient with cirrhosis and HCC. But we have a really, really big problem. There’s the shortness of grafts for the patients, especially here in Europe and in the western world. In some countries, the rates of donors are even decreasing, so we don’t have many organs for these patients. So, I don’t think liver transplantation will be the best option for the patients in the future because we will have increasing rates of HCCs, and we don’t have that many grafts. I think only patients with really advanced cirrhosis who cannot get other treatments should get liver transplantation. If you just do it concerning the transplantation, we can consider if you use so-called marginal organs, which are organs of low quality for patients who are in better shape but have HCC—therefore, patients with so-called end-stage liver disease. Because in these patients, we cannot use marginal organs.

I think every center that is doing liver transplantation is doing some kind of bridging to transplant, maybe options like local ablation, radiofrequency ablation, microwave ablation, but also TACE if you have more nodules to treat. So, I think this is more or less standard, and it’s a bit dependent on the local specialties. And I think also you should discuss such treatments with the surgeon who is doing the transplant because if you do TACE, you can do injuries to the arteries and so on. You should discuss it with your surgeon—what kind of local ablation or local treatment you do and bridging to transplant.

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