Resection versus Transplantation
Liver transplantation remains the best theoretical option for HCC because it removes the tumor and underlying diseased liver. Clearly, in patients with advanced liver disease who are not candidates for resection, transplantation represents the only option with a significant chance of cure. Deceased donor organ shortages and poor outcomes in advanced cases, however, have limited transplant applicability to only early-stage disease with < 30% of patients eligible for transplantation at presentation.[18,19] Although transplantation in patients with stage III tumors (outside of Milan criteria) is offered at some institutions either through expanded criteria such as the University of California San Francisco (UCSF) criteria[20,21] or utilizing downstaging strategies,[22,23] these strategies have not been uniformly adopted.
Hepatocellular carcinoma in the absence of chronic liver disease accounts for ~10 to 20% of cases.[24,25] The fibrolamellar variant most commonly occurs in young Caucasian females often with lymph node metastasis and without elevations of alpha-fetoprotein. Patients with fibrolamellar and sporadic HCC commonly present when tumors have grown large and symptomatic. When feasible, resection is the mainstay of therapy and is often well tolerated due to the ability of the healthy remnant liver to regenerate. As expected, 5-year-survival rates for patients without chronic liver disease are as high as 50% despite the often advanced stage at presentation, highlighting the significant role that the presence or absence of underlying liver disease plays in both management and outcome.[16,28]
Every patient with early-stage HCC cannot be offered transplantation; another form of extirpative therapy must be considered for select patients. Liver resection is immediately available, requires no waiting time, allows complete pathologic evaluation of the tumor, and does not, in theory, preclude future transplantation. Clearly, patients without chronic liver disease should undergo resection when technically feasible. Patients with end-stage liver disease, Child-Turcotte-Pugh (CTP) class B and C, should undergo transplantation if available, as should patients with relatively preserved hepatic function, but multifocal disease that is within Milan criteria. The difficulty lies in deciding which patients with chronic liver disease and small (< 5 cm) solitary tumors are best served by resection and which should proceed with transplant evaluation; this is the focus of this article.
Semin Liver Dis. 2013;33(3):282-292. © 2013 Thieme Medical Publishers