Liver Transplantation, Liver Resection, and Transarterial Chemoembolization for Hepatocellular Carcinoma in Cirrhosis: Which Is the Best Oncological Approach?

Abstract

The aim of the study was to evaluate our institutional experience with monotherapies for hepatocellular carcinoma (HCC) in the setting of cirrhosis. A retrospective cohort study was carried out at the tertiary care academic referral center and involved 185 consecutive HCC patients with cirrhosis and no previous treatment who underwent resection (n = 61), transarterial chemoembolization (TACE) (n = 64), or liver transplantation (LT) (n = 60). Long-term survival and survival according to the Milan criteria were the main outcomes measured. Median survival after resection, TACE, and LT was 11, 14, and 23 months, respectively. Five-year cumulative survival after resection, TACE, and LT was 23, 10, and 59%, respectively (P = 0.001). Five-year cumulative disease-free survival after resection and LT was 15% and 77%, respectively (P = 0.002). The presence of complications in the resection group (P = 0.004), MELD score (P = 0.0003), and maximum tumor diameter (P = 0.05) in the TACE group, and tumor grade (P = 0.01) and complications (P = 0.004) in the LT group were found to be independent predictors of survival. Five-year survival for patients within the Milan criteria after resection, TACE, and LT was 26, 37, and 66%, respectively. Five-year survival for patients outside the Milan criteria for patients undergoing LT was 53%. The results suggest that LT represents the best oncological treatment option for patients with HCC in the setting of cirrhosis, even for those beyond the Milan criteria. Considering the scarcity of available organs, liver resection remains the best alternative option. TACE remains a potential therapy in patients within the Milan criteria, where it may be more beneficial than resection.

Long-term experience with liver transplantation for hepatocellular carcinoma

“…The overall survival rate for the whole group of 89 patients that underwent LT for HCC in the 12-year period between 1995 and 2007 (including those that expired within 2 months of the liver transplant) was 60% at 5 years and 54% at 10 years, with a tumor recurrence of 11%, results that are comparable to those of other studies reporting 5-year survivals of 59-75% [14,15]. It should be noted that significantly lower recurrence rates have been reported in the description of the Japanese experience with LDLT for HCC, where overall recurrence rates were 13-14% but only 1.4% when the tumors were within the Milan criteria [16,17].…”

Improved Long-Term Survival after Major Resection for Hepatocellular Carcinoma: A Multicenter Analysis Based on a New Definition of Major Hepatectomy

“…In patients with underlying liver disease, outcomes after extended hepatectomy remain superior to outcomes after nonsurgical treatments (e.g., transarterial chemoembolization). 47,48 These findings emphasize the importance of patient selection for surgical therapy. One important tool that may assist in the selection of surgical candidates is the degree of hypertrophy after PVE.…”

Is Hepatectomy for Huge Hepatocellular Carcinoma (≥10cm in Diameter) Safe and Effective? A Single-center Experience

“…Subgroup analysis showed that patients with fibrosis or cirrhosis who underwent extended hepatectomy resulted in poorer short-term and long-term survival than patients without fibrosis or cirrhosis, but major hepatectomy did not associate with outcomes. Patients who had underlying liver disease and received extended hepatectomy remain superior to patients receiving nonsurgical treatments (e.g., transarterial chemoembolization) (Ruzzenente et al, 2009;Sotiropoulos et al, 2009). These findings emphasize the importance of patient selection for liver resection.…”