Liver transplantation for the treatment of moderately or well-differentiated hepatocellular carcinoma

Abstract

Objective: To determine the long-term results of liver transplantation for well- or moderately differentiated hepatocellular carcinoma (HCC).

Summary background data: HCC patient selection for liver transplantation remains controversial, and deciding exclusively on the strength of criteria such as number and size of nodules appears prognostically inaccurate.

Methods: Since 1991, preoperative tumor grading has been used at our center to establish whether a patient with HCC is fit for transplantation. Poorly differentiated HCC cases were excluded, while size and number of nodules were not considered as absolute selection criteria. Thirty-three patients with moderately or well-differentiated HCC were prospectively studied after liver transplantation. A group of 15 patients with incidental HCC transplanted during the same period were also evaluated and compared with the 33 patients with preoperatively diagnosed HCC.

Results: On histologic examination, 38% of the entire group of 48 patients did not meet the "Milan criteria" and 42% were pTNM stages III and IV. The median follow-up was 44 months. The 5-year actuarial survival rate was 75% and recurrence-free survival was 92%. HCC recurred in only 3 patients (6%). The only histomorphologic variable differing significantly between incidental and nonincidental HCC was nodule size. The timing of diagnosis (incidental vs. nonincidental HCC), the Milan criteria, and the TNM stage revealed no statistically significant impact on overall and recurrence-free survival rates.

Conclusions: The routine pre-orthotopic liver transplantation tumor grading may represent a valid tool in the selection of unresectable HCC patients for transplantation.

FIGURE 1. Overall (A) and recurrence-free (B) survival curves after OLT in the 48 patients enrolled in the study. Standard errors at 3 years are 7% and 4.6%, respectively; 95% confidence intervals are represented by dashed lines.

FIGURE 2. Comparison between overall survival curves of HCC-related OLT (iHCC and pkHCC) versus OLT for nonmalignant disease. The log-rank test found no statistically significant differences.

FIGURE 3. A: Comparison between recurrence-free survival curves for iHCC versus pkHCC cases. The log-rank test found no statistically significant differences. B: Comparisons between recurrence-free survival curves for HCC that did versus did not meet the Milan criteria after histologic assessment. The log-rank test found no statistically significant differences.