title: Surgical treatment of hepatocellular carcinoma beyond Milan criteria. Results of liver resection, salvage transplantation, and primary liver transplantation.
abstract: BACKGROUND
  There is no clear consensus regarding the best treatment strategy for patients with advanced hepatocellular carcinoma (HCC).
  
  
  METHODS
  Patients with cirrhosis and HCC beyond Milan who had undergone liver resection (LR) or primary orthotopic liver transplantation (OLT) between November 1995 and December 2005 were included in this study. Pathological tumor staging was based on the American Liver Tumor Study Group modified Tumor-Node-Metastasis classification.
  
  
  RESULTS
  A total of 23 HCC patients were primarily treated by means of LR, 5 of whom eventually underwent salvage OLT. An additional 32 patients underwent primary OLT. The overall actuarial survival rates at 3 and 5 years were 35% after LR, and 69% and 60%, respectively, after primary OLT. Recurrence-free survival at 5 years was significantly higher after OLT (65%) than after LR (26%). Of the patients who underwent LR, 11 (48%) experienced HCC recurrence only in the liver; 6 of these 11 presented with advanced HCC recurrence, poor medical status, or short disease-free intervals and were not considered for transplantation. Salvage OLT was performed in 5 patients with early stage recurrence (45% of patients with hepatic recurrence after LR and 22% of all patients who underwent LR). At a median of 18 months after salvage OLT, all 5 patients are alive, 4 are free of disease, and 1 developed HCC recurrence 16 months after salvage OLT.
  
  
  CONCLUSIONS
  For patients with HCC beyond Milan criteria, multimodality treatment-including LR, salvage OLT, and primary OLT-results in long-term survival in half of the patients. When indicated, LR can optimize the use of scarce donor organs by leaving OLT as a reserve option for early stage HCC recurrence.
authors.affiliation: Liver Transplant & Hepatobiliary Service, Westchester Medical Center, New York Medical College, 95 Grasslands Road, Valhalla, New York 10595, USA. facciutom@wcmc.com
authors.forename: Marcelo E
authors.initials: ME
authors.lastname: Facciuto
authors.forename: Baburao
authors.initials: B
authors.lastname: Koneru
authors.forename: Juan P
authors.initials: JP
authors.lastname: Rocca
authors.forename: David C
authors.initials: DC
authors.lastname: Wolf
authors.forename: Leona
authors.initials: L
authors.lastname: Kim-Schluger
authors.forename: Paul
authors.initials: P
authors.lastname: Visintainer
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Klein
authors.forename: Hoo
authors.initials: H
authors.lastname: Chun
authors.forename: Michael
authors.initials: M
authors.lastname: Marvin
authors.forename: Grigory
authors.initials: G
authors.lastname: Rozenblit
authors.forename: Manuel
authors.initials: M
authors.lastname: Rodriguez-Davalos
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Sheiner
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000556:secondary / Q000601:surgery*; D015331:Cohort Studies; D018572:Disease-Free Survival; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008103:Liver Cirrhosis / Q000473:pathology / Q000601:surgery*; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery*; D016031:Liver Transplantation; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery*; D009367:Neoplasm Staging; D011379:Prognosis; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods*; D015996:Survival Rate; D016896:Treatment Outcome