Primary resection, followed by transplantation for recurrence or deterioration of liver function, has recently been suggested as a rational strategy for patients with preserved liver function and hepatocellular carcinomas (HCC) 5 cm or smaller.
However, there are no published data on transplantability after HCC recurrence, or on 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.
Writing in the March issue of the journal, scientists from the Center for the Study of Liver Disease and Department of Surgery at the University of Hong Kong Medical Center, Hong Kong, China, describe the efforts they took to try and rectify this lack of data.
The research group evaluated the survival results and pattern of recurrence after resection of potentially transplantable small HCC in patients with preserved liver function, with special reference to the implications for a strategy of salvage transplantation.
Using a prospective database, the team examined information on a total of 473 patients who had undergone resection of HCC between 1989 and 1999.
Within the study group, 135 patients aged 65 years or younger, had Child-Pugh class A chronic liver disease (chronic hepatitis or cirrhosis) and transplantable small HCC (solitary 5 cm or two or three tumors 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.
Overall survival rates at 1, 3, 5, and 10 years were 90%, 76%, 70%, and 35%, respectively.
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.
|Strategy for small HCC with good liver function: resection and later salvage transplantation
|Annals of Surgery|
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 6 patients.
Dr Ronnie Tung-Ping Poon, speaking on behalf of the research group commented "For Child-Pugh class A patients with small HCC, hepatic resection is a reasonable first-line treatment, and is associated with a favorable 5-year overall survival rate."
He continued, "A considerable proportion of patients may survive without recurrence for 5 or even 10 years, and 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."
"However, 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", he concluded.