Place of liver transplantation in the treatment of hepatocellular carcinoma in the normal liver

Abstract

Hepatocellular carcinoma (HCC) is a relatively common cancer and occurs mainly in patients with liver cirrhosis (85%-95%). A significant number of cases are, however, diagnosed in normal and noncirrhotic/nonfibrotic livers. In contrast to HCC in a cirrhotic liver, noncirrhotic hepatocellular carcinoma (NC-HCC) predominantly occurs in young and healthy female patients in their 30s, and the diagnosis is frequently made at an advanced stage in the absence of a clear etiological factor. [1][2][3] The same holds true for the uncommon fibrolamellar hepatocellular carcinoma (FL-HCC) variant. [1][2][3] Several studies have shown that the 3-year overall survival (OS) rates with different pharmaceutical, radiological, and surgical therapies for HCC (if they are adequately performed) are approximately 60%. 4 After 3 years, the results of these treatments start to diverge substantially with respect to OS and, most importantly, with respect to disease-free survival (DFS). Long-term follow-up (5-10 years) has clearly shown that surgical resection is the only curative treatment for any kind of HCC. [2][3][4][5] With respect to very long-term DFS (>5 years), liver transplantation (LT) offers the best results. 2,4-6 In order to be successful, surgery has to be adapted to the tumor, the underlying condition of the patient, and the patient's liver. Liver resection and LT should have complementary roles rather than competing ones, and they should be associated with each other instead of being opposed. 5 Partial resection for HCC can be considered only for patients with well-compensated cirrhosis or fibrosis or with normal liver tissue. For patients with decompensated liver disease, cirrhosis, or a technically unresectable tumor, LT offers the best chance for a cure. This option indeed addresses the tumor as well as the underlying liver disease.Despite the extensive experience with LT for the treatment of HCC in patients with cirrhosis, the experience with LT for the treatment of NC-HCC is anecdotal and is limited to situations in which resection is not possible.The aims of this study were as follows: (1) to analyze the results from recent series of partial liver resections for NC-HCC, (2) to compare these results with the results of LT for the same condition; and (3) to propose an adaptation of the therapeutic algorithm for NC-HCC on the basis of these analyses.

Liver transplantation for unresectable hepatocellular carcinoma in normal livers

“…The other known risk factors for NC-HCC recurrence after partial liver resection are incomplete tumor resection, multiple tumors, poor tumor differentiation, absence of tumor capsule and perioperative administration of blood transfusion [10,32,35,[37][38][39]. Liver transplantation will be futile in those patients with aggressive tumor biology whereas transplantation may be justified in patients with milder tumor behavior.…”

Hepatocellular Carcinoma in the Absence of Cirrhosis in United States Veterans Is Associated With Nonalcoholic Fatty Liver Disease

“…The majority of published studies on HCC in the absence of cirrhosis included patients undergoing either resection or liver transplantation. 5, 8–10 Furthermore, most studies reported data from tertiary referral centers 11–12 and may not be representative of the actual prevalence and risk factors of HCC in the absence of cirrhosis in the general population. Given that most strategies for preventing HCC, including surveillance and chemoprevention, have targeted individuals with cirrhosis, it is important to obtain a better understanding about the development of HCC in the absence of cirrhosis because of its potential implications on current clinical paradigms.…”

Orthotopic Liver Transplantation: Indications and Contraindications

“…Despite the dogma that partial liver resection is "the" therapeutic gold standard in these patients, 5-year recurrence rates are very high ranging from 40 % to 70 %. LT might therefore be of value both in the treatment of initially non-resectable HCC or in case of recurrence after resection (Lerut et al 2011). The ELTR-ELITA analysis, dealing with 62 patients with initially "non-resectable" NC-HCC, confirmed that excellent 5-year disease-free survival rates of 60 % and 48 % can be obtained after primary and salvage LT for intrahepatic recurrence (Mergental et al 2012).…”