The best treatment option for patients with single, early hepatocellular carcinoma (HCC) and cirrhosis, good liver function, and absence of portal hypertension remains to be established. The aim of this work was to compare the outcome of liver resection (LR) with that of liver transplantation (LT) for single, early HCC in Child-TurcottePugh class A patients with cirrhosis younger than 70 years of age. Thirty-seven of 134 patients who underwent LR and 36 of 125 who underwent LT for HCC in our unit fulfilled the inclusion criteria. No differences were observed in mean tumor size (3 cm); HCV cirrhosis predominated in the LT group and older age in the LR group. Postoperative mortality was higher and hospital stay longer in the LT group. Patient survival was similar in both groups. Tumor recurrence was higher in the LR group (59% vs. 11%), extrahepatic recurrences predominated after LT and hepatic recurrences after LR. Diseasefree survival was significantly better after LT. Eighteen patients presented hepatic recurrence after LR: 5 advanced and 13 early. Seventeen patients-13 with early HCC recurrence and 4 with liver failure-were potential candidates for salvage LT. However, 10 of 17 patients were older than 70 years at this time. Salvage LT could only be performed in 6 patients: 5 for HCC recurrence and 1 for liver failure. Results of salvage LT were similar to those of primary LT. In conclusion, only 27.6% of resected patients were eligible for LT. LR is a good option since it offers similar survival to LT. Salvage liver transplantation was performed in 16.2% of resected patients, with older age being the main contraindication. Outcome L iver transplantation (LT) is the treatment of choice for early HCC in Child-Turcotte-Pugh class B or C cirrhosis or Child-Turcotte-Pugh class A patients with portal hypertension. 1-3 However, the optimum treatment strategy for patients with early, single HCC and cirrhosis, good liver function, and absence of portal hypertension is far from being established. Liver resection (LR) in these cases is a very safe procedure that can be performed without delay. 4 HCC recurrence will be the rule after a long period of follow-up; when it occurs, salvage LT can be offered if recurrence is diagnosed early. The question then arises as to whether LR is a good option "per se" in those patients eligible for transplantation or whether it is just a bridge to LT, which would be the best primary treatment if sufficient livers were available. No prospective, randomized studies have been reported comparing LR and salvage LT with primary LT for early HCC in cirrhotic patients who could be eligible for both treatments. The principal aim of our study was to compare the results of LR in this group of cirrhotic patients with HCC who would have been eligible for primary transplantation with a group of patients who underwent LT for known HCC with similar tumor stage at diagnosis and preserved liver function (Child-Turcotte-Pugh class A cirrhosis). The assumption was that results of primary transplantation in...

Summary The aim of this prospective randomized trial was to study the efficacy and safety of tacrolimus monotherapy (TACRO) and compare it with our standard treatment of tacrolimus plus steroids (TACRO + ST) after liver transplant (LT). Furthermore, the impact of steroid‐free immunosuppression on outcome of hepatitis C virus (HCV) was analysed. Between 1998 and 2000, 60 patients (mean age: 57 years) were included in the study and randomized to receive TACRO (n = 28) or TACRO + ST (n = 32). Indication for LT was postnecrotic cirrhosis in all cases (58.3% were HCV‐positive). Mean follow‐up was 44 months. Survival, incidence of rejection, infection and side‐effects were compared between the two groups. In patients with HCV infection, incidence and severity of acute hepatitis C, long‐term outcome of recurrent hepatitis C and survival were studied in an intention‐to‐treat analysis or in the real group analysis (real‐TACRO versus real‐TACRO + ST). Patient survival at 1, 3 and 5 years, tacrolimus pharmacokinetics, incidence of rejection infections and side‐effects were similar. In patients with HCV, the incidence and severity of graft hepatitis C tended to be lower in TACRO (47%) compared with TACRO + ST (67%) (P = NS), and also in real‐TACRO (42%) compared with real‐TACRO + ST (61%) (P = NS). A poor outcome considered as evolution to cirrhosis at 3 years was observed in one (9%) living patient in real‐TACRO and nine (45%) in real‐TACRO + ST (P = 0.04). Patient survival at 1, 3 and 5 years was 92%, 92% and 73% for real‐TACRO and 78%, 61% and 51% for real TACRO + ST (P = 0.07). Steroid‐free immunosuppression appears to be safe and efficacious. The main advantage of this regimen could be in HCV patients, as recurrence of hepatitis in the graft was less severe in the group of patients in whom steroids could be avoided completely.

Between 1987 and 1993, 53 hepatic resections for hepatocellular carcinoma (HCC) were performed in 51 patients with cirrhosis. Limited hepatic resection was performed in 66 per cent of patients. The postoperative mortality rate was 13 per cent. The tumours recurred in 27 patients (53 per cent), and the cumulative recurrence rate at 1 and 4 years was 41 and 89 per cent, respectively. Mean time to recurrence was 11.7 months and the most frequent site was the liver (21 patients). The only significant risk factor for recurrence was symptomatic tumours. The recurrence rate of HCC in patients with cirrhosis with surgical resection alone is high and actuarial survival at 4 years is very low. Other approaches to the treatment of HCC in patients with cirrhosis require consideration.

One hundred twenty-eight records of patients with multiple myeloma were reviewed to assess the incidence and manifestations of liver involvement. Histologic study of the liver was available in 21 patients. Diffuse infiltration of the liver by plasma cells was observed in 10 patients, myeloid metaplasia in four, amyloidosis in two, toxic hepatitis in two, and extrahepatic cholestasis secondary to infiltration of the peripancreatic tissue by plasma cells in one. The clinical signs of plasma cell infiltration of the liver consisted of hepatomegaly in seven patients, mild elevation of liver enzymes in five, and portal hypertension in two. Jaundice was only observed in patients with hepatitis or extrahepatic cholestasis. Liver infiltration by plasma cells did not appear to have a major prognostic significance.

Auxiliary liver transplantation for patients with fulminant hepatic failure supports the patient's failing liver for a period of time until the native liver (NL) has recovered and immunosuppression can be withdrawn. Auxiliary heterotopic liver transplantation (AHLT) with portal vein arterialization (PVA) has several advantages over auxiliary orthotopic liver transplantation: NL resection is not required, and the hepatic hilum is left untouched; thus, the chances of liver regeneration are optimal. The successful application of emergency AHLT with PVA in a young patient who developed toxic fulminant hepatic failure caused by tuberculostatic drugs is described. Two and one-half months after the procedure, the NL had completely regenerated; the graft was removed, and immunosuppression was suspended. (Liver Transpl 2000;6: 805-809.)A uxiliary liver transplantation (ALT) for patients with fulminant hepatic failure supports the patient's failing liver for a period of time until the native liver (NL) has recovered. 1 A multicenter European study showed that in two thirds of the patients, liver regeneration occurred and immunosuppression could be withdrawn. 2 Auxiliary partial orthotopic liver transplantation (APOLT) has been the more commonly used technique. [3][4][5][6][7] However, this procedure is technically more difficult than orthotopic liver transplantation (OLT) because recipient hemihepatectomy is required for implantation of the partial liver graft. Auxiliary heterotopic liver transplantation (AHLT) with portal vein arterialization (PVA) has several advantages over APOLT: NL resection is not required, and the hepatic hilum is left untouched; therefore, the chances of liver regeneration are optimal. 8,9 We describe the successful application of emergency AHLT with PVA in a young patient who developed toxic fulminant hepatic failure caused by tuberculostatic drugs. Case ReportA 25-year-old black man, an illegal immigrant from an African country, was admitted to our unit with acute liver failure from toxic hepatitis. The patient had been diagnosed with tuberculous pleural effusion and treated with rifampin, 600 mg/d; isoniazid, 250 mg/d; and pyrazinamide, 1,500 mg/d. Twenty days later, he presented with a high fever, headache, vomiting, arthromyalgia, and confusion. Laboratory blood tests showed the following values: aspartate aminotransferase (AST), 11,505 U/L; amylase, 493 U/L; lipase, 3.451 U/L; creatine kinase, 1,286 U/L; international normalized ratio, 2.32; blood urea nitrogen (BUN), 46 mg/dL; and creatinine, 1.6 mg/dL. Cerebrospinal fluid and cranial computed tomography results were normal. A diagnosis of fulminant hepatic failure caused by hepatotoxic antituberculous medications was made, and the patient was referred to our unit.On admission, the patient presented with grade I encephalopathy. Blood analyses showed the following values: bilirubin, 1.6 mg/dL; AST, 7,570 U/L; prothrombin time, 30%; creatinine, 1.6 mg/dL; and negative serologic test results for viral hepatitis A, B, and C. Over the following ...