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. 2009 Aug;11(5):398-404.
doi: 10.1111/j.1477-2574.2009.00073.x.

Surgical dilemma: liver resection or liver transplantation for hepatocellular carcinoma and cirrhosis. Intention-to-treat analysis in patients within and outwith Milan criteria

Marcelo E Facciuto  1 , Caroline Rochon, Mahima Pandey, Manuel Rodriguez-Davalos, Susana Samaniego, David C Wolf, Leona Kim-Schluger, Grigory Rozenblit, Patricia A Sheiner
Affiliations

Surgical dilemma: liver resection or liver transplantation for hepatocellular carcinoma and cirrhosis. Intention-to-treat analysis in patients within and outwith Milan criteria

Marcelo E Facciuto et al. HPB (Oxford). 2009 Aug.

Abstract

Background: The optimal role of surgery in the management of hepatocellular carcinoma (HCC) is in continuous evolution.

Objective: The objective of this study was to analyse survival rates after liver resection (LR) and orthotopic liver transplantation (OLT) for HCC within and outwith Milan criteria in an intention-to-treat analysis.

Methods: During 1997-2007, 179 patients with cirrhosis and HCC either underwent LR (n= 60) or were listed for OLT (n= 119). Patients with incidental HCC after OLT, preoperative macrovascular invasion before LR, non-cirrhosis and Child-Pugh class C cirrhosis prior to OLT were eliminated, leaving 51 patients primarily treated with LR and 106 patients listed for primary OLT (84 of whom were transplanted) to be included in this analysis. A total of 66 patients fell outwith Milan criteria (26 LR, 40 OLT) and 91 continued to meet Milan criteria (25 LR, 66 OLT).

Results: The median length of follow-up was 26 months. The mean waiting time for OLT was 7 months. During that time, 21 patients were removed from the waiting list as a result of tumour progression. Probabilities of dropout were 2% and 13% at 6 and 12 months, respectively, for patients within Milan criteria, and 34% and 57% at 6 and 12 months, respectively, for patients outwith Milan criteria (P < 0.01). Tumour size >3 cm was found to be the independent factor associated with dropout (hazard ratio [HR] 6.0). Postoperative survival was slightly higher after OLT, but this was not statistically significant (64% for OLT vs. 57% for LR). Overall survival from time of listing for OLT or LR did not differ between the two groups (P= 0.9); for patients within Milan criteria, 1- and 4-year survival rates after LR were 88% and 61%, respectively, compared with 92% and 62%, respectively, after OLT (P= 0.54). For patients outwith Milan criteria, 1- and 4-year survival rates after LR were 69% and 54%, respectively, compared with 65% and 40%, respectively, after OLT (P= 0.42). Tumour size >3 cm was again found to be an independent factor for poor outcome (HR 2.4) in the intention-to-treat analysis.

Conclusions: Survival rates for patients with HCC are similar in LR and OLT. Liver resection can potentially decrease the dropout rate and serve as a bridge for future salvage LT, particularly in patients with tumours >3 cm.

Keywords: Milan criteria; hepatocellular carcinoma; resection; transplantation.

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Figures

Figure 1
Figure 1
(A) Kaplan–Meier estimates for dropout probability by Milan criteria. Blue line = patients within the Milan criteria; red line = patients outwith the Milan criteria. (B) Kaplan–Meier estimates for dropout probability by size of lesions. Blue line = lesions ≤3 cm; red line = lesions >3 cm
Figure 2
Figure 2
Kaplan–Meier estimates for survival of patients with recurrent hepatocellular carcinoma (HCC) after liver resection by type of recurrence. Blue line = salvage orthotopic liver transplantation; red line = HCC recurrence; green line = no recurrence
Figure 3
Figure 3
Kaplan–Meier estimates for survival after liver resection or when listed for orthotopic liver transplantation (OLT) in (A) patients within the Milan criteria and (B) patients outwith the Milan criteria. Blue line = liver resection; red line = OLT
See this image and copyright information in PMC

References

    1. 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. - PubMed
    1. Cha CH, Ruo L, Fong Y, Jarnagin WR, Shia J, Blumgart LH, et al. Resection of hepatocellular carcinoma in patients otherwise eligible for transplantation. Ann Surg. 2003;238:315–321. discussion 321–323. - PMC - PubMed
    1. Margarit C, Escartin A, Castells L, Vargas V, Allende E, Bilbao I. Resection for hepatocellular carcinoma is a good option in Child–Turcotte–Pugh class A patients with cirrhosis who are eligible for liver transplantation. Liver Transpl. 2005;11:1242–1251. - PubMed
    1. 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 liver transplantation. Liver Transpl. 2004;10:1294–1300. - PubMed
    1. Roayaie S, Frischer JS, Emre SH, Fishbein TM, Sheiner PA, Sung M, et al. Longterm results with multimodal adjuvant therapy and liver transplantation for the treatment of hepatocellular carcinomas larger than 5 centimetres. Ann Surg. 2002;235:533–539. - PMC - PubMed

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