Hepatocellular Carcinoma On Cirrhosis: Liver Resection, Liver Transplantation Or Both Surgical Treatments?

Introduction: To establish if liver resection (LR) first and liver transplantation (LT) as salvage therapy after LR should be the best surgical strategy for hepatocellular carcinoma (HCC) on cirrhosis in patients with MELD < 11. Methods: Between January 1996 and July 2011 1153 HCC patients were referred to University of Bologna: 590 were listed for LT, 331 was treated by primary LT (PLT) and 37 by salvage LT (SLT). The remaining 563 were submitted to LR and 200 (35%) of these were transplantable at the time of LR. Considering PLT vs SLT patients, no differences resulted in terms of gender, age, MELD score and ethiology of cirrhosis. Preoperative TACE was performed in 44.8% vs 40.9%, RFA in 12.7% vs 36.4% and combined TACE/RFA in 8.2% vs 18.2% (p=0.003) in PLT and SLT group, respectively. HCC G3 was present in 57.3% vs 50% and G4 in 2.8% vs 10.2% in PLT vs SLT group, respectively (p=0.007). Results: Post-operative mortality was 0% vs 3.3% in SLT vs PLT group (p=NS). No differences were observed in terms of median time on waiting list (202 days vs 304 days), intraoperative red blood cells infusion (1850 vs 1500 cc), HCC recurrence (10% vs 13.5%) in PLT vs SLT group, respectively (p=NS). Five-year intention to treat survival of HCC listed patients vs LR transplantable patients was 60% vs 70.9% (p=NS). Overall survival at 1-, 3- and 5-years was 87.3%, 78% and 71.7% vs 85.9%, 78.5%, 78.5% for PLT vs SLT group, respectively (p=NS). Disease-free survival at 1-, 3-, and 5-years was 85.5%, 75.4% and 70.8% vs 77%, 73.8%, 73.8% for PLT vs SLT group, respectively (p=NS). Conclusion: LR should be the first-line treatment in patients with small HCC and compensated cirrhosis, with salvage LT offered at the time of HCC recurrence or liver decompensation as a safe and effective approach.