Harm and Benefits of Primary Liver Resection and Salvage Transplantation for Hepatocellular Carcinoma

Abstract

Primary transplantation offers longer life-expectancy in comparison to hepatic resection (HR) for hepatocellular carcinoma (HCC) followed by salvage transplantation; however, livers not used for primary transplantation can be reallocated to the remaining waiting-list patients, thus, the harm caused to resected patients could be balanced, or outweighed, by the benefit obtained from reallocation of livers originating from HCC patients first being resected. A Markov model was developed to investigate this issue based on literature data or estimated from the United Network for Organ Sharing database. Markov model shows that primary transplantation offers longer life-expectancy in comparison to HR and salvage transplantation if 5-year posttransplant survival remains higher than 60%. The balance between the harm for resected patients and the benefit for the remaining waiting list depends on (a) the proportion of HCC candidates, (b) the percentage shifted to HR and (c) the median expected time-to-transplant. Faced with a low proportion of HCC candidates, the harm caused to resected patients was higher than the benefit that could be obtained for the waiting-list population from re-allocation of extra livers. An increased proportion of HCC candidates and/or an increased median time-to-transplant could lead to a benefit for waiting-list patients that outweighs this harm.

Liver Resection and Transplantation in Hepatocellular Carcinoma

“…The most important result of this intention-totreat study was that approximately half of our patients with HCC recurrence following LR did not undergo transplantation, including one-third because of recurrence beyond the MC. This result is a matter of debate concerning the respective roles of LR and LT in the treatment of HCC [7,73,76]. Analysis of the subgroup of patients who could not undergo transplantation at the time of recurrence showed that three factors were associated with failure.…”

“…Initial LR of HCC as primary therapy in patients who otherwise could have been transplanted offers good quality of life and is less demanding than LT. Patients do not need long-term immunosuppression; in addition, grafts are saved for the community and can be transplanted to other patients with no alternative to LT [7,9,73]. For LR as primary therapy for tumor recurrence or deterioration in liver function, "salvage transplantation" was first proposed by Majno et al [75] This attractive concept seems to be applicable in a significant proportion of patients with long-term survival similar to that of patients who undergo primary LT [9,73,76].…”

Current advances made in the surgical treatment of hepatocellular carcinoma

“…9 Expansion of criteria for LT in HCC patients is still under investigation and discussion. 10,11 The limited availability of donors for LT, has led to considerable interest for expansion of the donor pool and living donor-related transplantation, 12 and combined treatments involving LR and LT. 9,13 This review presents and discusses recent advances in the surgical treatment of HCC. Advances in the assessment of liver function are also described, along with discussion of patient management.…”

Inappropriate inferences from registry data: Pitfalls of inaccurate data handling?

“…Since MELD priority points were awarded by UNOS from 2002 even for lesions ≤2 cm, the SEER data probably included significant numbers of such cases before revision of points by UNOS. Mathematical models have computed that unless there is more than 30% progression related wait list dropout among patients and more than 10% waitlisted patients for LT have HCC as indication, preferential allocation to HCC patients increases wait list mortality among those not having HCC [32].…”