Surgical resection versus transplantation for early hepatocellular carcinoma: clues for the best strategy

Abstract

The incidence of hepatocellular carcinoma (HCC) caused by hepatitis C infection is clearly increasing. Although current screening modalities identify about one third of the tumors at a potentially curable stage, 1 the best treatment strategy for early HCC still is far from being established. Current evidence suggests that surgical resection is suitable for only a small subgroup of cirrhotic patients with HCC. European and Japanese centers using highly restrictive selection criteria have reported 5-year survival rates of 60% to 70%. [2][3][4][5] Optimal candidates for resection include Child-Pugh class A cirrhotic patients with normal serum total bilirubin values, absence of clinically relevant portal hypertension, and small asymptomatic tumors. 3,4 Resection should be avoided in the remaining patients since it may reduce their outcome to figures even below the natural history of the disease. 6 In Western countries, where liver cancer typically develops in the setting of well-established cirrhosis, fewer than 5% of HCC patients meet these stringent criteria and are candidates for resection with acceptable risk. 4 In Eastern countries, the applicability of resection could be higher, perhaps reflecting a less advanced liver disease related to chronic hepatitis B virus infection or a higher recognition of hepatitis C virus-positive individuals with silent cirrhosis among the community. 2,5,7 It should be noted also that even in carefully selected patients, the rate of tumor recurrence is 50% after 3 years. 4,7 Regeneration after resection may elicit metachronous tumors; this is a theoretical concern deserving of further attention. Efforts to prevent tumor recurrence have involved administration of retinoids and intra-arterial I 131 labeled lipiodol, 8,9 but the reported benefit of these treatments requires confirmation.Most hepatologists now favor orthotopic liver transplantation (OLT) as the preferred option for early HCC. [10][11][12][13][14] If tumors with a low probability of metastasis are selected and extrahepatic tumor is excluded, OLT removes the entire process and, moreover, can be applied to patients with end-stage liver disease. The first series of OLT reported disappointing results in terms of survival and tumor recurrence because the selection criteria were inappropriate. 10,11 However, more recent data have shown that the restriction of OLT to patients with single tumors less than 5 cm or with three nodules, each less than 3 cm, will result in 5-year survival rates of around 70%. 14-17 Although widely accepted, the data carry certain caveats. Importantly, most of the studies were conducted when program waiting times were relatively short (Ͻ6 months). The average waiting times in 1997 for OLT were 240 and 477 days in Spain and the United States, respectively. 18,19 In view of a 1-year probability of tumor progression of 70%, vascular invasion of 21%, and extrahepatic spread of untreated tumors of 9%, 9 many untreated patients will become ineligible for OLT. At the Liver Unit in Barcelona, the probabilit...

Percutaneous radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation†

“…The vast majority of patients, however, are unsuitable candidates for resection because of tumor location or severity of liver disease, and even those who qualify may later become unsalvageable. 33,34 For these reasons, significant attention has been devoted to minimally invasive therapies that can provide an effective bridge to transplantation over a prolonged waiting period. Of these, TACE has been investigated most widely, though with varying results.…”

Genotyping of hepatocellular carcinoma in liver transplant recipients adds predictive power for determining recurrence-free survival

“…11 Although the facts just stated are generally agreed on, what is not agreed on are the selection criteria that could simultaneously maximize the number of viable candidates for transplantation and reject the smallest number of those who could have benefited. [12][13][14][15][16][17][18] This issue has particular relevance at the present time as the transplant community grapples with how such patients should fit into the newly developed and implemented model for end-stage liver disease (MELD) scoring system, which allows special consideration for patients with HCC.…”

Liver organ allocation for hepatocellular carcinoma: Are we sure?

“…11 Whereas the previous statements meet with general agreement among transplant surgeons, what does not are the selection criteria that should be used to determine which patients with HCC should receive a donor liver, a resource in scarce supply. Theoretically, this ideal allocation system simultaneously would determine the greatest number of suitable candidates for transplantation while rejecting the smallest number of those who could have benefited from LT. [12][13][14][15][16][17][18] Three recent changes in the field of LT have made the resolution of this issue more urgent than ever: Many transplant programs throughout the world as well as UNOS have adopted the criteria for LT in patients with HCC first suggested by Bismuth et al 18 and then modified and further popularized by the transplant program in Milan, Italy. 19 The reported recurrence-free survival rates for patients undergoing transplantation according to these criteria have been superb, but to date no one has examined the fate of those patients excluded from transplantation by these criteria.…”