Resection prior to liver transplantation for hepatocellular carcinoma

Abstract

Objective: To evaluate the feasibility and postoperative course of liver transplantation (LT) in cirrhotic patients who underwent liver resection prior to LT for HCC.

Summary background data: Although LT provides longer survival than liver resection for treatment of small HCCs, donor shortage and long LT wait time may argue against LT. The feasibility and survival following LT after hepatic resection have not been previously examined.

Methods: Between 1991 and 2001, among 107 patients who underwent LT for HCC, 88 met Mazzafero's criteria upon pathologic analysis of the explant. Of these, 70 underwent primary liver transplantation (PLT) and 18 liver resection prior to secondary liver transplantation (SLT) for recurrence (n = 11), deterioration of liver function (n = 4), or high risk for recurrence (n = 3). Perioperative and postoperative factors and long-term survival were compared.

Results: Comparison of PLT and SLT groups at the time of LT revealed similar median age (53 vs. 55 years), sex, and etiology of liver disease (alcohol/viral B/C/other). In the SLT group, the mean time between liver resection and listing for LT was 20 months (range 1-84 months). Overall time on LT waiting list of the two groups was similar (3 vs. 5 months). Pathologic analysis after LT revealed similar tumor size (2.2 vs. 2.3 cm) and number (1.6 vs. 1.7). Perioperative and postoperative courses were not different in terms of operative time (551 vs. 530 minutes), blood loss (1191 vs. 1282 mL), transfusion (3 vs. 2 units), ICU (9 vs. 10 days) or hospital stay (32 vs. 31 days), morbidity (51% vs. 56%) or 30-day mortality (5.7% vs. 5.6%). During a median follow-up of 32 months (3 to 158 months), 3 patients recurred after PLT and one after SLT. After transplantation, 3- and 5-year overall survivals were not different between groups (82 vs. 82% and 59 vs. 61%).

Conclusions: In selected patients, liver resection prior to transplantation does not increase the morbidity or impair long-term survival following LT. Therefore, liver resection prior to transplantation can be integrated in the treatment strategy for HCC.

FIGURE 1. Analysis of perioperative and postoperative factors in secondary liver transplantation group (n = 18) based on surgical approach to resection prior to liver transplantation. A trend toward greater operative difficult and longer hospital course emerged in patients who underwent major (n = 5) as opposed to minor resection (n = 13) prior to SLT. Conversely, those who underwent prior transthoracic tumor resection had the lowest perioperative and postoperative morbidity measured by need for blood transfusion, duration of operation, and length of hospital stay.

FIGURE 2. Kaplan-Meier survival plots for PLT versus SLT groups. The survival rates measured from the time of liver transplantation in the group of patients who underwent primary (—) versus secondary (—) liver transplantation for HCC. There was a single death (5.6%) in the first 30 days postoperatively in the SLT group and 4 postoperative deaths (5.7%) in the PLT group. Patients who died in the postoperative period were excluded.