Patients with cirrhosis are at an increased risk of developing hepatocellular carcinoma, also known as hepatoma.  These are primary liver cancers involving the liver.  They need to be differentiated from metastatic liver cancer, which indicates the cancer is first located in a distant site outside of the liver.  Common cancers that metastasize to the liver include breast, colon, and lung.  These specific cancers are not considered for liver transplant. 

Because the risk of developing liver cancer significantly increased in patients with cirrhosis, especially those with chronic hepatitis B, chronic hepatitis C, alcohol-related cirrhosis, fatty liver disease with cirrhosis, and hereditary hemochromatosis, patients with cirrhosis need to undergo surveillance screening for liver cancer at least every six months with an ultrasound of the liver and a blood test called alpha-fetoprotein.  Alpha-fetoprotein (AFP) is a tumor marked, which is elevated in most cases of hepatocellular carcinoma. While alpha-fetoprotein is elevated slightly in many forms of chronic liver disease, was more important is to see arise and alpha-fetoprotein values compared to prior values. So it is not the absolute alpha-fetoprotein level, but rather the change that is seen in, and the rate at which a changes.

Should a tumor be suspected based on an imaging study (ultrasound, MRI, or CT scan) or the alpha-fetoprotein is elevated, based on the size and location, liver transplantation should be considered 

In most patients with cirrhosis, the identified liver cancer cannot be surgically resected.  This would typically cause serious, potentially life-threatening complications, including hepatic failure and death.  Instead, patients are evaluated for liver transplantation, as well as evaluated for some form of local therapy for the tumor.  This may include trans-arterial chemoembolization (TACE) or radiofrequency ablation (RFA) of the tumor.  For larger tumors, Y-90 radiation therapy may be considered. Medical therapy with Sorafenib, a medication taken orally, may also be considered as part of a comprehensive treatment plan. All of her patients with hepatocellular carcinoma will be managed by a multidisciplinary team, including your primary hepatologist, liver transplant surgeon, and oncologist.

In patients that present with hepatocellular carcinoma where the size is between 2 and 5 cm, with no evidence of any spread outside the liver, or without any invasion into any of the blood vessels in the liver, liver transplantation would be considered.  Patients with hepatocellular carcinoma being evaluated for liver transplant are given additional MELD exception points, affording them a theoretically shorter time on the liver transplant waiting list.

While the patients are on the liver transplant waiting list, they will continue to undergo vigorous surveillance for any change in status of the tumor, or looking for any evidence of spread.  Unfortunately, there are cases where the tumor enlarges beyond an acceptable size and they would have to be removed from liver transplant consideration.

Survival for patients with hepatocellular carcinoma that are transplanted has excellent one, three, and five-year survival compared to those without liver cancer.