Abstract
About 10 years ago, several studies made it clear that liver transplantation (LT) for patients with chronic liver disease and limited hepatocellular carcinoma (HCC) without vascular invasion offers better long-term survival than resection alone. However, during the past 10 years, the persistent imbalance between the increasing numbers of candidates for LT and a limited organ supply has made it necessary to temper the enthusiasm for LT. Organ shortage necessarily results in prolonged waiting time. In turn, prolonged waiting time results in tumor growth with an increasing risk of vascular invasion, a source of post-LT recurrence. In parallel, advances in liver surgery have significantly improved the safety of resection. It has been shown that, in contrast to what could be expected, prior resection neither increases operative morbidity nor impairs survival following deceased donor transplantation. Resection can be used as a treatment for HCC before LT in three different settings. First, resection can be used as a primary therapy, with LT reserved as a “salvage” therapy for patients who develop recurrence or liver failure. Second, resection can be used as an initial therapy to select patients who might obtain benefit from LT according to detailed pathological examination of the tumor and the surrounding liver parenchyma. Third, resection can be used as a “bridge” therapy for patients who have been already enlisted for LT. Resection and transplantation should be associated rather than opposed. The use of different strategies depends not only on the availability of graft and waiting time in different centers, but also the expertise of individual centers. This strategy opens a completely new field of investigation with multiple indications of resection in patients eligible for LT.
Similar content being viewed by others
References
Mazzaferro V, Regalia E, Doci R, Andreola S, Pulvirenti A, Bozzetti F, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996;334:693–699.
Mazzaferro V, Battiston C, Perrone S, Pulvirenti A, Regalia E, Romito R, et al. Radiofrequency ablation of small hepatocellular carcinoma in cirrhotic patients awaiting liver transplantation: a prospective study. Ann Surg 2004;240:900–909.
Yao FY, Ferrell L, Bass NM, Watson JJ, Bacchetti P, Venook A, et al. Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival. Hepatology 2001;33:1394–1403.
Margarit C, Escartin A, Castells L, Vargas V, Allende, Bilbao I. Resection for HCC is a good option in Child-Turcotte-Pugh class A patients with cirrhosis who are eligible for liver transplantation. Liver Transplant 2005;11:1242–1251.
Poon RT, Fan ST, Lo CM, Liu CL, Wong J. Long-term survival and pattern of recurrence after resection of small hepatocellular carcinoma in patients with preserved liver function: implications for a strategy of salvage transplantation. Ann Surg 2002;235:373–382.
Cha CH, Ruo L, Fong Y, Jarnagin WR, Shia J, Blumgart LH, DeMatteo RP. Resection of hepatocellular carcinoma in patients otherwise eligible for transplantation. Ann Surg 2003;238:315–321.
Sarasin FP, Giostra E, Mentha G, Hadengue A. Partial hepatectomy or orthotopic liver transplantation for the treatment of respectable hepatocellular carcinoma? A cost-effective analysis. Hepatology 1998;28:436–442.
Poon RT, Fan ST. Resection prior to liver transplantation for hepatocellular carcinoma: a strategy of optimizing the role of resection and transplantation in cirrhotic patients with preserved liver function. Liver Transplant 2004;10:813–815.
Hasegawa K, Kokudo N, Imamura H, Matsuyama Y, Aoki T, Minagawa M, et al. Prognostic impact of anatomic resection for hepatocellular carcinoma. Ann Surg 2005;242:252–259.
Belghiti J, Cortes A, Abdalla EK, Regimbeau J, Prakash K, Durand F, et al. Resection prior to liver transplantation for heaptocellular carcinoma. Ann Surg 2003;238:885–893.
Chirica M, Durand F, Sommacale D, Dondero F, Francoz C, Paradis V, et al. Long-term outcome after resection for small HCC in patients with hepatitis C virus infection: arguments for a strategy of resection as a bridge to transplantation rather than salvage transplantation. Hepatology 2004;40(suppl 1):A162.
Otsuka Y, Duffy JP, Saab S, Farmer DG, Ghobrial RM, Hiatt JR, Busuttil RW. Post-resection hepatic failure: successful treatment with liver transplantation. Liver Transplant 2007;13:672–679.
Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, et al. The “50-50 Criteria” on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg 2005;242:824–829.
Sala M, Fuster J, Llovet JM, Navasa M, Sole M, Varela M, et al. High pathological risk of recurrence after surgical resection for hepatocellular carcinoma. An indication for salvage transplantation. Liver Transplant 2004;10:1294–1300.
Ravaioli M, Grazi GL, Ercolani G, Fiorentino M, Cescon M, Golfieri R, et al. Partial necrosis on hepatocellular carcinoma nodules facilitates tumor recurrence after liver transplantation. Transplantation 2004;78:1780–1786.
Wong LL, Tanaka K, Lau L, Komura S. Pre-transplant treatment of hepatocellular carcinoma: assessment of tumor necrosis in explanted livers. Clin Transplant 2004;18:227–234.
Cherqui D, Laurent A, Tayar C, et al. Laparoscopic liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: midterm results and perspectives. Ann Surg 2006;243:499–506.
Pocard M, Sauvanet A, Regimbeau JM, Duwat O, Farges O, Belghiti J. Limits and benefits of exclusive transthoracic hepatectomy approach for patients with hepatocellular carcinoma. Hepatogastroenterology 2002;49:32–35.
Yao FY, Bass NM, Nikolai B, Davern TJ, Kerlan R, Wu V, et al. Liver transplantation for hepatocellular carcinoma: analysis of survival according to the intention-to-treat principle and dropout from the waiting list. Liver Transplant 2002;8:873–883.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Belghiti, J. Resection and liver transplantation for HCC. J Gastroenterol 44 (Suppl 19), 132–135 (2009). https://doi.org/10.1007/s00535-008-2250-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00535-008-2250-1