Liver Transplantation for Hepatocellular Carcinoma in Cirrhosis

Abstract

H epatocellular carcinoma (HCC), when left untreated, has an extremely poor prognosis with only 1 to 6 months’ survival from the time of diagnosis’; for this reason, many surgeons were initially enthusiastic for liver transplantation in the treatment of HCC in cirrhosis. However, since 1985, it has become apparent that the results of transplantation for hepatobiliary malignancy with cirrhosis have been less than ideal.2 Although liver transplantation for this primary hepatobiliary malignancy has traditionally been associated with decreased operative mortality,3 it actually has adversely affected short-term survival in cirrhosis”7 and, more distressing, at 5 years has the lowest long-term survival after transplantation compared with benign indications for liver transplantation. 2+‘* Further confusion arises from survival analysis, which includes noncirrhotic patients, fibrolamellar HCC, and unknown lesions,5,6,‘z~‘3 all elements associated with different outcomes and a major consideration in the ambiguity related to the exact role of transplantation for HCC in cirrhosis.t5 Presently, most institutions, with some variation, practice a restrictive transplantation policy’” for any type of primary hepatobiliary malignancys because of the dismal results. Conversely, the excellent potential for cure in patients with unknown HCC found on the hepatectomy specimen after transplantation”; the good results for small, less numerous lesionst7; and the poor long-term results after liver resection for HCC in cirrhosis have maintained support for persisting with liver transplantation. Some offer an approach with more advancedstage disease,4-6 whereas others have been conservative by only carefully selecting patients with a chance for cure.” Present multimodality therapy, primarily without transplantation, in the East’* and adjuvant and neoadjuvant protocols, with transplantation, in the West’g*20 emphasizes this complex