Salvage liver transplantation or repeat hepatectomy for recurrent hepatocellular carcinoma: An intent‐to‐treat analysis

Abstract

The salvage liver transplantation (LT) strategy was conceived for initially resectable and transplantable hepatocellular carcinoma (HCC) to obviate upfront transplantation, with salvage LT in the case of recurrence. The longterm outcomes of a second resection for recurrent HCC have improved. The aim of this study was to perform an intention-to-treat analysis of overall survival (OS) comparing these 2 strategies for initially resectable and transplantable recurrent HCC. From 1994 to 2011, 391 patients with HCC who underwent salvage LT (n = 77) or a second resection (n = 314) were analyzed. Of 77 patients in the salvage LT group, 21 presented with resectable and transplantable recurrent HCC and 18 underwent transplantation. Of 314 patients in the second resection group, 81 presented with resectable and transplantable recurrent HCC and 81 underwent a second resection. The 5-year intention-to-treat OS rates, calculated from the time of primary hepatectomy, were comparable between the 2 strategies (72% for salvage transplantation versus 77% for second resection; P = 0.57). In patients who completed the salvage LT or second resection procedure, the 5-year OS rates, calculated from the time of the second surgery, were comparable between the 2 strategies (71% versus 71%; P = 0.99). The 5-year disease-free survival (DFS) rates were 72% following transplantation and 18% following the second resection (P < 0.001). Similar results were observed after propensity score matching. In conclusion, although the 5-year OS rates were similar in the salvage LT and second resection groups, the salvage LT strategy still achieves better DFS. Second resection for recurrent HCC might be considered to be the best alternative option to LT in the current organ shortage. Liver Transplantation 23 1553-1563 2017 AASLD.

Does meeting the Milan criteria at the time of recurrence of hepatocellular carcinoma after curative resection have an impact on prognosis?

“…In terms of curative treatment, salvage LT was associated with best survival outcome only in the IN‐rIN group ( P = 0.000) (Fig. ), which was acceptable and comparable to the findings of other studies . However, its impact in the IN‐rOUT and OUT‐rIN groups was not significant because of the small sample size of each treatment group and possible selection bias.…”

“…However, there are no treatment guidelines for recurrence except salvage LT. In previous studies, indications for salvage LT were similar to those for primary LT and were based on the status of recurrent HCC . Referred studies of salvage LT were performed on small cohorts focused on the first recurrence.…”

Recurrence beyond the Milan criteria after curative‐intent resection of hepatocellular carcinoma: A novel tumor‐burden based prediction model

“…Surgeons frequently face the dilemma of waiting for an appropriate donor vs proceeding with a curative-intent upfront resection for transplant-eligible patients. 4,5,24,25 Although transplantation is considered superior to resection for patients with compromised liver function and inadequate future liver remnant, 4 the two treatment when an intention-to-treat analysis is utilized. [25][26][27][28] Indeed, delaying a potentially curative liver resection increases the likelihood of disease progression and, thus, compromises patient outcomes.…”

Recent advances in liver transplantation for cancer: The future of transplant oncology

“…36,37 However, the risk of recurrence after salvage LT may be lower than secondary resection. 38,39 The decision to treat with secondary resection or salvage LT remains controversial and depends on the availability of organs within each jurisdiction.…”