Fifth Forum on Liver Transplantation
Article Outline
Cancer after Liver Transplantation. The other side of the coin ?
Liver transplantion (LT) patients present most known risk factors associated with the development of cancer, and the combination of several of them may put them at high risk for de novo or recurrent malignancies. As data on long term follow-up in LT patients is still scarce, we may largely underestimate the actual risk of cancer development. Several studies have convincingly shown that cancer is indeed a serious threat to this population, requiring particular vigilance including preventive strategies, early diagnosis and proper therapy. The degree of immunosuppression clearly correlates with the risk of cancer, and many LT candidates are exposed to potent carcinogenic toxins including alcohol, tobacco and viruses such as HBV, HCV, Epstein barr, herpes virus-6 and human papilloma viruses. The single most important factor might be the aging of the candidates for LT; for example according to the European liver transplantation (ELTR) registry [www.ELTR.org] only 8% of LT patients were older than 60
yr of age in the early 90th, while currently this figure exceeds 20%. Issues related to cancer following LT have already been well covered in the previous forum [2], [3], [4], [5], [6], [7]. For example, the last forum on LT focussed on HCC, including topics such as how to treat patients with recurrent HCC after LT [1].
In the 5th forum William Sanchez, Jayant Talwalkar and Greg Gores address the provocative question about whether all LT patients may eventually die from cancer. In a very well balanced review they estimate the long term risk of cancer in this population, and discuss each risk factor for the de novo or recurrent malignancies. Frederico Aucejo, George Rofaiel and Charles Miller provide an excellent update on post-transplantation lymphoproliferative disorders (PTLD), including definition, pathogenesis and incidence with a particular focus on the responsible immunosuppressive agents and viruses (EBV, CMV and Hepatitis C). Building on this, Jean-François Dufour and Martin Fey reviewed the current therapy of PTLD highlighting the challenge of reducing immunosuppression, and the combination of conventional chemotherapy with Rituximab (antiCD 20 antibodies targeting B cells). Skin cancer is the most frequent malignancy after LT, a complication which is often poorly recognized by transplant physicians. Sylvie Euvrard and Jean Kanitakis propose a state of the art update on this topic, where age again appears to be the most significant associated risk factor. This review may be helpful for clinicians dealing with the increasing population of LT patients to apply effective prophylactic measures and better identify and treat the various manifestations of skin cancer including Kaposi's sarcoma. Finally, it remains unclear whether LT patients are at significant increased risk for common cancer such as colorectal cancer. As there is still controversies about how to screen the normal population, Fabiola Delcò and Beat Mullhaupt attempt to propose tailored recommendations about screening for colorectal cancer in LT patients.
Clearly, the long term risk of cancer is the other side of the coin of the otherwise highly successful field of LT. We hope that this 5th forum will provide a stimulating discussion about how to prevent, diagnose and treat the various types of cancer after LT.
References
- . Hepatocellular carcinoma: where are the controversies? Editorial. Fourth forum on liver transplantation.. J Hepatol. 2005;43:556–557
- . Should we biopsy each liver mass suspicious for hepatocellular carcinoma before liver transplantation?—Yes. Fourth forum on liver transplantation.. J Hepatol. 2005;43:558–562
- . Should we biopsy each liver mass suspicious for hepatocellular carcinoma before liver transplantation?—No, please don't. Fourth forum on liver transplantation.. J Hepatol. 2005;43:563–568
- . Should we expand the criteria for liver transplantation for hepatocellular carcinoma—Yes, of course! Fourth forum on liver transplantation. J Hepatol. 2005;43:569–573
- . Should we expand the criteria for hepatocellular carcinoma with living-donor liver transplantation?—No, never. Fourth forum on liver transplantation.. J Hepatol. 2005;43:573–577
- . Is there a customised immunosuppressive regimen for patients transplanted with hepatocellular carcinoma? Fourth forum on liver transplantation.. J Hepatol. 2005;43:577–584
- . How should patients with hepatocellular carcinoma recurrence after liver transplantation be treated? Fourth forum on liver transplantation.. J Hepatol. 2005;43:584–589
PII: S0168-8278(05)00672-0
doi:10.1016/j.jhep.2005.10.006
© 2005 European Association for the Study of the Liver. Published by Elsevier Inc. All rights reserved.
