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Hepatocellular carcinoma—resection or transplant?

Nature Reviews Gastroenterology & Hepatology volume 9, pages 732–737 (2012)Cite this article

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Abstract

Resection and liver transplantation are considered effective treatments for early-stage hepatocellular carcinoma (HCC). As data from randomized trials are lacking, the choice of technique is controversial. Retrospective analyses suggest that for patients with suboptimal liver function, transplantation is the preferred treatment. For patients with preserved liver function and HCC within the Milan criteria, the overall survival rate is similar for both techniques; therefore resection is the preferred treatment. For tumours beyond the Milan criteria but within acceptable expanded criteria, transplantation has a more favourable outcome than resection. As liver grafts are in short supply, resection followed by transplantation once intrahepatic recurrence is detected would spare patients with favourable or very aggressive tumours from transplantation and enable patients with moderately aggressive tumours to undergo timely transplantation. Currently, resection and transplantation are considered complementary in the management of HCC. Expanding the transplantation and resection criteria of HCC needs to be investigated.

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Figure 1: Salvage transplantation.

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References

  1. International Agency for Research on Cancer. Liver cancer incidence, mortality and prevalence worldwide in 2008 [online], (2012).

  2. Roskams, T. & Kojiro, M. Pathology of early hepatocellular carcinoma: conventional and molecular diagnosis. Semin. Liver Dis. 30, 17–25 (2010).

    Article  Google Scholar 

  3. Torimura, T. et al. Mechanism of fibrous capsule formation surrounding hepatocellular carcinoma. Immunohistochemical study. Arch. Pathol. Lab. Med. 115, 365–371 (1991).

    CAS  PubMed  Google Scholar 

  4. Kojiro, M. in Pathology of Hepatocellular Carcinoma 31–49 (Blackwell Publishing, Malden, 2006).

    Book  Google Scholar 

  5. Zhu, L. X., Wang, G. S. & Fan, S. T. Spontaneous rupture of hepatocellular carcinoma. Br. J. Surg. 83, 602–607 (1996).

    Article  CAS  Google Scholar 

  6. O'Malley, M. E., Takayama, Y. & Sherman, M. Outcome of small (10–20 mm) arterial phase-enhancing nodules seen on triphasic liver CT in patients with cirrhosis or chronic liver disease. Am. J. Gastroenterol. 100, 1523–1528 (2005).

    Article  Google Scholar 

  7. Yang, Z. F., Poon, R. T., To, J., Ho, D. W. & Fan, S. T. The potential role of hypoxia inducible factor 1α in tumor progression after hypoxia and chemotherapy in hepatocellular carcinoma. Cancer Res. 64, 5496–5503 (2004).

    Article  CAS  Google Scholar 

  8. Man, K. et al. Molecular signature linked to acute phase injury and tumor invasiveness in small-for-size liver grafts. Ann. Surg. 251, 1154–1161 (2010).

    Article  Google Scholar 

  9. Penn, I. The effect of immunosuppression on pre-existing cancers. Transplantation 55, 742–747 (1993).

    Article  CAS  Google Scholar 

  10. Fan, S. T. et al. Continuous improvement of survival outcomes of resection of hepatocellular carcinoma: a 20-year experience. Ann. Surg. 253, 745–758 (2011).

    Article  Google Scholar 

  11. Kubota, K. et al. Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors. Hepatology 26, 1176–1181 (1997).

    CAS  PubMed  Google Scholar 

  12. Takayama, T. & Makuuchi, M. Preoperative portal vein embolization: is it useful? J. Hepatobiliary Pancreat. Surg. 11, 17–20 (2004).

    Article  Google Scholar 

  13. Gaba, R. C. et al. Radiation lobectomy: preliminary findings of hepatic volumetric response to lobar yttrium-90 radioembolization. Ann. Surg. Oncol. 16, 1587–1596 (2009).

    Article  Google Scholar 

  14. Ishizawa, T. et al. Neither multiple tumors nor portal hypertension are surgical contraindications for hepatocellular carcinoma. Gastroenterology 134, 1908–1916 (2008).

    Article  Google Scholar 

  15. Finkelstein, S. D. et al. Microdissection-based allelotyping discriminates de novo tumor from intrahepatic spread in hepatocellular carcinoma. Hepatology 37, 871–879 (2003).

    Article  CAS  Google Scholar 

  16. Sherman, M. Recurrence of hepatocellular carcinoma. N. Engl. J. Med. 359, 2045–2047 (2008).

    Article  CAS  Google Scholar 

  17. Fan, S. T. et al. Prediction of posthepatectomy recurrence of hepatocellular carcinoma by circulating cancer stem cells: a prospective study. Ann. Surg. 254, 569–576 (2011).

    Article  Google Scholar 

  18. Okamura, Y. et al. Prognostic significance of postoperative complications after hepatectomy for hepatocellular carcinoma. J. Surg. Oncol. 104, 814–821 (2011).

    Article  Google Scholar 

  19. Hoshida, Y. et al. Gene expression in fixed tissues and outcome in hepatocellular carcinoma. N. Engl. J. Med. 359, 1995–2004 (2008).

    Article  CAS  Google Scholar 

  20. Huang, J. et al. A randomized trial comparing radiofrequency ablation and surgical resection for HCC conforming to the Milan criteria. Ann. Surg. 252, 903–912 (2010).

    Article  Google Scholar 

  21. Mazzaferro, V. et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N. Engl. J. Med. 334, 693–699 (1996).

    Article  CAS  Google Scholar 

  22. Yao, F. Y. Liver transplantation for hepatocellular carcinoma: beyond the Milan criteria. Am. J. Transplant. 8, 1982–1989 (2008).

    Article  CAS  Google Scholar 

  23. Zheng, S. S. et al. Liver transplantation for hepatocellular carcinoma: Hangzhou experiences. Transplantation 85, 1726–1732 (2008).

    Article  CAS  Google Scholar 

  24. DuBay, D. et al. Liver transplantation for advanced hepatocellular carcinoma using poor tumor differentiation on biopsy as an exclusion criterion. Ann. Surg. 253, 166–172 (2011).

    Article  Google Scholar 

  25. Lee, S. G. et al. Expanded indication criteria of living donor liver transplantation for hepatocellular carcinoma at one large-volume center. Liver Transpl. 14, 935–945 (2008).

    Article  Google Scholar 

  26. Chan, S. C., Fan, S. T., Lo, C. M., Liu, C. L. & Wong, J. Toward current standards of donor right hepatectomy for adult-to-adult live donor liver transplantation through the experience of 200 cases. Ann. Surg. 254, 110–117 (2007).

    Article  Google Scholar 

  27. Bhangui, P. et al. Intention-to-treat analysis of liver transplantation for hepatocellular carcinoma: living versus deceased donor transplantation. Hepatology 53, 1570–1579 (2011).

    Article  Google Scholar 

  28. Fan, S. T. et al. Outcome after partial hepatectomy for hepatocellular cancer within the Milan criteria. Br. J. Surg. 98, 1292–1300 (2011).

    Article  CAS  Google Scholar 

  29. Lo, C. M. et al. Living donor versus deceased donor liver transplantation for early irresectable hepatocellular carcinoma. Br. J. Surg. 94, 78–86 (2007).

    Article  CAS  Google Scholar 

  30. Fan, S. T. in Living Donor Liver Transplantation, 2nd edn 322 (World Scientific, Singapore, 2011).

    Book  Google Scholar 

  31. Chan, S. C. et al. Survival advantage of primary liver transplantation for hepatocellular carcinoma within the up-to-7 criteria with microvascular invasion. Hepatol. Int. http://dx.doi.org/10.1007/s12072-011-9318-3.

  32. Klintmalm, G. B. Liver transplantation for hepatocellular carcinoma: a registry report of the impact of tumor characteristics on outcome. Ann. Surg. 228, 479–490 (1998).

    Article  CAS  Google Scholar 

  33. Fung, J. et al. Entecavir monotherapy is effective in suppressing hepatitis B virus after liver transplantation. Gastroenterology 141, 1212–1219 (2011).

    Article  CAS  Google Scholar 

  34. Doyle, M. B. et al. Liver transplantation for hepatocellular carcinoma: long-term results suggest excellent outcomes. J. Am. Coll. Surg. 215, 19–28 (2012).

    Article  Google Scholar 

  35. Portolani, N. et al. Limited liver resection: a good indication for the treatment of hepatocellular carcinoma in elderly patients. Jpn J. Clin. Oncol. 41, 1358–1365 (2011).

    Article  Google Scholar 

  36. Koniaris, L. G. et al. Is surgical resection superior to transplantation in the treatment of hepatocellular carcinoma? Ann. Surg. 254, 527–538 (2011).

    Article  Google Scholar 

  37. Mazzaferro, V. et al. Predicting survival after liver transplantation in patients with hepatocellular carcinoma beyond the Milan criteria: a retrospective, exploratory analysis. Lancet Oncol. 10, 35–43 (2009).

    Article  Google Scholar 

  38. Ng, K. K. et al. Survival analysis of patients with transplantable recurrent hepatocellular carcinoma. Arch. Surg. 143, 68–74 (2008).

    Article  Google Scholar 

  39. Majno, P. E., Sarasin, F. P., Mentha, G. & Hadengue, A. Primary liver resection and salvage transplantation or primary liver transplantation in patients with single, small hepatocellular carcinoma and preserved liver function: an outcome-oriented decision analysis. Hepatology 31, 899–906 (2000).

    Article  CAS  Google Scholar 

  40. Fuks, D. et al. Benefit of initial resection of hepatocellular carcinoma followed by transplantation in case of recurrence: an intention-to-treat analysis. Hepatology 55, 132–140 (2012).

    Article  Google Scholar 

  41. Poon, R. T., Fan, S. T., Lo, C. M., Liu, C. L. & 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. 235, 373–382 (2002).

    Article  Google Scholar 

  42. Sala, M. et al. High pathological risk of recurrence after surgical resection for hepatocellular carcinoma: an indication for salvage liver transplantation. Liver Transpl. 10, 1294–1300 (2004).

    Article  Google Scholar 

  43. Scatton, O. et al. Hepatocellular carcinoma developed on compensated cirrhosis: resection as a selection tool for liver transplantation. Liver Transpl. 14, 779–788 (2008).

    Article  Google Scholar 

  44. Landman, M. P., Feurer, I. D., Pinson, C. W. & Moore, D. E. Which is more cost-effective under the MELD system: primary liver transplantation, or salvage transplantation after hepatic resection or after loco-regional therapy for hepatocellular carcinoma within Milan criteria? HPB (Oxford) 13, 783–791 (2011).

    Article  Google Scholar 

  45. Ito, T. et al. Expansion of selection criteria for patients with hepatocellular carcinoma in living donor liver transplantation. Liver Transpl. 13, 1637–1644 (2007).

    Article  Google Scholar 

  46. Sugawara, Y., Tamura, S. & Makuuchi, M. Living donor liver transplantation for hepatocellular carcinoma: Tokyo University series. Dig. Dis. 25, 310–312 (2007).

    Article  Google Scholar 

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  1. Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pok Fu Lam Road, Hong Kong

    Sheung Tat Fan

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Fan, S. Hepatocellular carcinoma—resection or transplant?. Nat Rev Gastroenterol Hepatol 9, 732–737 (2012). https://doi.org/10.1038/nrgastro.2012.158

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