Hepatocellular Carcinoma

Resection versus Transplantation

Truman M. Earl; William C. Chapman

Disclosures

Semin Liver Dis. 2013;33(3):282-292. 

In This Article

Abstract and Introduction

Abstract

Hepatic resection and transplantation remain the standard curative therapies for hepatocellular carcinoma. These treatments are limited to either patients with early-stage tumors in the case of transplantation or patients with preserved liver function in the case of resection. Currently, patients with early-stage tumors and advanced liver disease are best served by transplant evaluation; however, the best treatment strategy for patients with well-preserved liver function, absence of portal hypertension, and early-stage HCC is debated. Numerous retrospective studies have documented better disease-free survival with transplantation, although the benefit on overall survival is less clear. This effect is likely due to the availability of effective liver-directed therapies for recurrence postresection and the effect of immunosuppression on tumor progression following posttransplant recurrence. Survival studies based on intention-to-treat principle incorporating patients listed for transplantation, but did not undergo the procedure due to waitlist dropoff have also suggested that overall survival rates may not be different despite high recurrence rates following resection. Transplantation has been shown to offer a survival advantage beyond 5-years; however, improvements in adjuvant therapies may narrow this gap. Determining optimal therapy for an individual patient requires consideration of numerous factors including tumor stage, severity of liver disease, and comorbidities as well as geographic and logistical factors that may affect transplant availability.

Introduction

Hepatic transplantation and resection remain the cornerstone surgical therapies for hepatocellular carcinoma (HCC) and the therapeutic options with the greatest likelihood of cure. Relatively few patients, however, are candidates for transplantation due to advanced stage, and advanced chronic liver disease commonly limits suitability for resection.[1] In the Barcelona Clinic Liver Cancer (BCLC) treatment algorithm, which best incorporates tumor, liver, and patient characteristics, these potentially curative therapies are limited to patients with early stage (A) disease with palliative therapy for patients with intermediate (B) and advanced (C) stages disease.[2] Liver transplantation offers excellent outcomes with 5-year disease-free survival rates of ~70% as it eliminates the tumor and associated diseased liver.[3,4,5] Transplantation, however, is restricted to those with relatively small, early-stage lesions, and donor organ availability further limits its broader applicability. Although improvements in HCC screening among cirrhotics and utilization of Model of Endstage Liver Disease (MELD) exemptions has improved transplantation rates and survival among patients with HCC, the majority of patients continue to present outside of the Milan criteria.[1,6,7,8,9,10,11,12] Due to limitations in donor organ availability and very high costs as well as improvements in patient selection, operative and anesthetic techniques, and postoperative care, there has been renewed interested in resection for HCC.[13,14,15,16,17] The results of liver resection for HCC depend in large part on the functional capacity of the remnant liver, comorbid illness of the patient, tumor size/stage, and intraoperative factors such as blood loss. Transplantation and resection are often compared; however, significant differences in baseline characteristics of patients undergoing these procedures make interpretation of outcome data problematic.

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