Liver resection or liver transplantation for solitary hepatitis C virus associated hepatocellular carcinoma?

This is my february highlight from the journal HPB

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In the September issue of HPB we published a meta-analysis which showed that outcomes for patients with HCC from all causes were better after liver transplantation than after liver resection but that this benefit disappeared when an intention to treat analysis was performed (Dhir et al., HPB 2012; 14 (9), 635–645).

In the current issue of HPB, Sogawa and colleagues from the Mount Sinai Medical Center present evidence based on patients with hepatitis C virus associated solitary HCC. This group has been the most contentious regarding whether it is better to undertake resection or to transplant the liver. Their study shows that a third of patients with HCV-associated solitary HCC who were listed for transplant died or progressed outside of transplant criteria while waiting for liver transplantation. The intention to treat analysis showed a superior survival of 62 months versus 31 months for patients who underwent liver resection compared with those that underwent liver transplantation; this difference did not achieve statistical significance presumably because the numbers of patients were relatively small.

Recurrence rates for HCC were significantly higher in resected than transplanted patients but almost all recurrences were intrahepatic and a third underwent salvage transplantation and 40% underwent either repeat resection or ablation.

The decision about how best to manage HCC ultimately depends on the availability of livers for transplantation, the status of the patients’ liver function and the outcomes of the individual centre. However, this study clearly shows that, based on intention to treat analyses, resection of solitary HCC on a background of hepatitis C virus is a reasonable strategy to adopt in a landscape with limited organ availability for transplantation.

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2 Responses to Liver resection or liver transplantation for solitary hepatitis C virus associated hepatocellular carcinoma?

  1. Mathew says:

    I have only just graduated from medical school and since i am a foreign grad, i am doing my course work to finish the licensing exams. So please do not think my question is stupid, i am only curious and enquiring professor. When i was a medical student the attending surgeon asked me what are the two criteria for actually performing surgery. As the naive student i said i did not know, and he proceeded to tell me “Surgery is only performed for either a.) quantity of life or b.) quality of life.”
    So in reguards to that, based on the infomation i have read, would not the choice then be to have these patients placed on the transplant list as well as have the liver resection done in the mean time to prolong life and to improve the quality and chances? If a liver just so happens to become available, then also you could do the transplantation is it not? However yes i know, every person is an individual and therefore lots of things may vary, but as doctors and surgeons should we not try to do everything we can for them?
    Sincerely, Mathew

    • That is actually a very sensible question. You are correct that in an ideal world people would have access to liver resection while waiting for a transplant. The registration system used to allow that in the UK but now if a patient had a resection they would no longer have a tumor and therefore no longer be eligible for transplant. Combine that with the evidence that based on intention to treat analysis there does not appear to be an advantage for one or other treatment for small resectable tumors ( in individuals with reasonably well preserved liver function) and you begin to see the complexity of the question. The rules regarding HCC and transplant vary around the world but the resource limitation on access to liver transplantation is pretty much universal. This is one of the major drivers for resection and in a world with unlimited resource for transplant the balance of the argument would likely be very different. Thanks for your interest and good question.

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