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

Abstract

Objective: To evaluate the survival results and pattern of recurrence after resection of potentially transplantable small hepatocellular carcinomas (HCC) in patients with preserved liver function, with special reference to the implications for a strategy of salvage transplantation.

Summary background data: Primary resection followed by transplantation for recurrence or deterioration of liver function has been recently suggested as a rational strategy for patients with HCC 5 cm or smaller and preserved liver function. However, there are no published data on transplantability after HCC recurrence or long-term deterioration of liver function after resection of small HCC in Child-Pugh class A patients. Such data are critical in determining the feasibility of salvage transplantation.

Methods: From a prospective database of 473 patients with resection of HCC between 1989 and 1999, 135 patients age 65 years or younger had Child-Pugh class A chronic liver disease (chronic hepatitis or cirrhosis) and transplantable small HCC (solitary < or =5 cm or two or three tumors < or = 3 cm). Survival results were analyzed and the pattern of recurrence was examined for eligibility for salvage transplantation based on the same criteria as those of primary transplantation for HCC.

Results: Overall survival rates at 1, 3, 5, and 10 years were 90%, 76%, 70%, and 35%, respectively, and the corresponding disease-free survival rates were 74%, 50%, 36%, and 22%. Cirrhosis and oligonodular tumors were predictive of worse disease-free survival. Patients with concomitant oligonodular tumors and cirrhosis had a 5-year overall survival rate of 48% and a disease-free survival rate of 0%, which were significantly worse compared with other subgroups. At a median follow-up of 48 months, 67 patients had recurrence and 53 (79%) of them were considered eligible for salvage transplantation. Decompensation from Child-Pugh class A to B or C without recurrence occurred in only six patients.

Conclusions: For Child-Pugh class A patients with small HCC, hepatic resection is a reasonable first-line treatment associated with a favorable 5-year overall survival rate. A considerable proportion of patients may survive without recurrence for 5 or even 10 years; among those with recurrence, the majority may be eligible for salvage transplantation. These data suggest that primary resection and salvage transplantation may be a feasible and rational strategy for patients with small HCC and preserved liver function. Primary transplantation may be a preferable option for the subset of patients with oligonodular tumors in cirrhotic liver in view of the poor survival results after resection.

Figure 1. Cumulative overall survival curve of 135 Child-Pugh class A patients after resection of small hepatocellular carcinoma (≤5 cm).

Figure 2. Cumulative disease-free survival curve of 130 Child-Pugh class A patients after resection of small hepatocellular carcinoma (≤5 cm; 5 patients with hospital death were excluded from analysis).

Figure 3. Cumulative disease-free survival curves of patients with chronic hepatitis (n = 43) and those with cirrhosis (n = 87) (P = .022).

Figure 4. Cumulative disease-free survival curves of patients with solitary tumor (n = 110) and those with oligonodular (two or three) tumors (n = 20) (P = .029).

Figure 5. Pattern of recurrence according to the site (intrahepatic or extrahepatic) and number of recurrent tumors. Oligonodular means two or three tumor nodules; multinodular means four or more tumor nodules. IHR, intrahepatic recurrence; EHR, extrahepatic recurrence.