Liver Transplantation for Solitary Hepatocellular Carcinoma Less than 3 cm in Diameter in Child A Cirrhosis

Abstract

Liver transplantation for hepatocellular carcinoma (HCC) is the treatment of choice for patients with unresectable tumors within the Milan criteria associated with Child B or C cirrhosis. Liver transplantation provides the best cure for both the HCC and the underlying cirrhosis. In recent years, some authors have advocated liver transplantation even for resectable early HCC associated with Child A cirrhosis, leading to a controversy of whether resection or transplantation should be the first-line therapy for patients with small HCC in Child A cirrhosis. Recent studies comparing liver resection and transplantation for early HCC demonstrated similar long-term survival of 60–70%, but liver transplantation is associated with a lower tumor recurrence rate. However, the current shortage of deceased donor liver grafts limits the applicability of liver transplantation for HCC. The use of live donor liver transplantation for patients with a small solitary HCC in Child A cirrhosis that is resectable may not be justified ethically because of the potential risk to the donors. Patients put on a transplantation waiting list run a significant risk of tumor progression and dropout, while liver resection is immediately applicable to all. Advocating primary liver transplantation for patients with early HCC associated with compensated cirrhosis will increase the waiting time for transplantation and further increases the chance of dropout. Resection first and salvage transplantation for recurrent tumors or liver failure is an alternative strategy that may reduce the use of liver grafts. However, the long-term survival result of such a strategy compared with primary liver transplantation remains unclear.

Survival advantage of primary liver transplantation for hepatocellular carcinoma within the up-to-7 criteria with microvascular invasion

“…Justification of LDLT is therefore poor [32]. In a study from Asan Medical Center [33], LR and LT did not cause any difference in survival for patients with Child–Pugh A cirrhosis and a single HCC smaller than 3 cm.…”

“…The high drop-out rate during waiting time, according to an intention-to-treat analysis, often compromises the survival of patients having this treatment modality [40]. Current mathematical models [41] and treatment policies [32] are based on the fact that there is a shortage of liver grafts for LT. Thus, primary LR and salvage LT are advocated.…”

Multidisciplinary Management of Hepatocellular Carcinoma

“…11 Fifty percent to 75% of cirrhotic patients with a single lesion and no portal hypertension, but less than 55% in those with portal hypertension or multiple or large lesions, survive for 5 years. 15,16,34,35 HCC recurs within 5 years in up to 80% of patients treated by resection. 15,36 Factors that increase the risk of recurrence include larger size and number of HCC lesions, higher histologic tumor grade, higher levels of ␣-fetoprotein, and macrovascular and microvascular invasion.…”

Liver transplantation for advanced hepatocellular carcinoma in patients with Child-Pugh A and B

“…LDLT for HCC has achieved favorable survival rates, especially with the advent of recent operative techniques and perioperative management [17][18][19]. In Western transplant centers, LT is the treatment of choice for HCC meeting the Milan criteria in cases of CP class B or A cirrhosis [20]. In contrast, in Japan today, LT is considered only for such patients after uncontrollable recurrence occurs following repeated curative non-transplant treatment, such as TACE, percutaneous ablation therapy, combined TACE and ablation therapy or hepatic resection [2].…”

“…Moreover, it is arguable whether subjecting a live donor to the small but definite risk of mortality from live donor hepatectomy is ethically acceptable when the patient has the treatment option of resection, even though left lobe graft LDLT can significantly reduce the burden on the donor [20,21]. Therefore, to reduce the use of scarce liver grafts, hepatic resection as the initial treatment and transplantation as a salvage treatment in cases of tumor recurrence or liver failure may be the optimal treatment strategy for patients with early HCC and CP A cirrhosis.…”