Abstract

BACKGROUND: Liver resection (LR) for HCC as the first-line treatment in transplantable patients followed by "salvage transplantation" (ST) in case of recurrence is an attractive concept. The aim was to identify patients who get benefit from this approach in an intention-to-treat study.

METHODS: From 1998 to 2008, among 329 potential candidates for liver transplantation (LT) with HCC within the Milan criteria (MC), 138 with good liver function were resected (LR group) in the perspective of ST in case of recurrence while 191 were listed for LT first (LT group). The 2 groups were compared in intention to treat basis with special reference to management of recurrences and transplantability after LR. Uni and multivariate analysis were performed to identify resected patients who develop recurrence beyond MC.

RESULTS: In intention to treat, 5-year overall and disease-free survival was similar in both groups (LTvs.LR group) (60vs.77% and 56vs.40%, respectively). Among the 138 of LR group, 20 underwent LT before recurrence, 39 (28%) had ST but 51 (37%) with recurrence were not transplanted including 21 within MC excluded for advanced age, acquired co-morbidities or refusal and 30 (22%) with recurrence beyond MC. Predictive factors of non transplantabliity due to recurrence beyond MC included microscopic vascular invasion (HR2.83(1.10-7.29)), satellite nodules (HR2.46(1.01-6.68)), tumor size>3cm (HR1.34(1.03-3.12)), poorly differentiated tumor (HR 3.18(1.31-7.70)) and liver cirrhosis (HR1.90(1.04-3.12)).

CONCLUSION: The high risk of failure of ST after initial LR for HCC within MC advocates the use of tissue analysis as selection criteria. The Salvage LT strategy should be restricted to patients with favorable oncological factors. (HEPATOLOGY 2011.).

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