title: Resection or transplantation for early hepatocellular carcinoma in a cirrhotic liver: does size define the best oncological strategy?
abstract: BACKGROUND
  Resection and liver transplantation (LT) are the only curative options for hepatocellular carcinoma in cirrhotic patients (HCC-cirr).
  
  
  OBJECTIVE
  We tried to define the best primary intention-to-treat strategy in patients undergoing either resection or LT for early single HCC-cirr (≤5 cm).
  
  
  METHODS
  From 1990 to 2010, 198 patients with early HCC-cirr underwent either resection (group R, n = 97) or LT (group T, n = 101) as the primary procedure. Our policy was to prioritize Childs A patients with peripheral lesions for resection rather than LT. Patient and tumor characteristics, and outcomes (recurrence-free survival [RFS] and overall survival [OS]), were studied.
  
  
  RESULTS
  A longer diagnosis-to-surgery interval, more Child Pugh B/C patients, and more tumor nodules (on histopathological examination) were found in group T patients. The postoperative mortality (4.1% vs 3.0%, P = 0.72) and rate of major complications (19.1% vs 24.7%, P = 0.35) were similar in groups R and T, respectively, whereas tumor recurrence was higher in group R (62% vs 10% in group T, P < 0.0001). The 5-year OS (75% vs 52%, P = 0.0008) and RFS (72% vs 20%, P < 0.0001) were better in group T; similarly, more patients were disease free at last follow-up (27% vs 62%, P < 0.0001). Resection as the surgical procedure, tumor diameter 3 cm or more on histology, and microvascular tumor invasion were poor prognostic factors for OS and RFS. Including dropout patients from LT list in the analysis, the outcomes in group T were still better (70% and 61% vs 51% and 36% at 5 and 10 years, P = 0.01).
  
  
  CONCLUSIONS
  On an intention-to-treat basis, LT is associated with the best survival outcomes in patients with early HCC-cirr. Resection may achieve comparable OS in patients with single HCC-cirr of size smaller than 3 cm; however, the RFS still remains lower than that in patients of group T. This study could serve as a guide for HCC-cirr patients who are candidates for either resection or LT.
authors.affiliation: AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France. rene.adam@pbr.aphp.fr
authors.forename: Rene
authors.initials: R
authors.lastname: Adam
authors.forename: Prashant
authors.initials: P
authors.lastname: Bhangui
authors.forename: Eric
authors.initials: E
authors.lastname: Vibert
authors.forename: Daniel
authors.initials: D
authors.lastname: Azoulay
authors.forename: Gilles
authors.initials: G
authors.lastname: Pelletier
authors.forename: Jean-Charles
authors.initials: JC
authors.lastname: Duclos-Vallée
authors.forename: Didier
authors.initials: D
authors.lastname: Samuel
authors.forename: Catherine
authors.initials: C
authors.lastname: Guettier
authors.forename: Denis
authors.initials: D
authors.lastname: Castaing
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000150:complications / Q000473:pathology* / Q000601:surgery*; D061345:Early Medical Intervention; D005260:Female; D006498:Hepatectomy; D006801:Humans; D057194:Intention to Treat Analysis; D008103:Liver Cirrhosis / Q000150:complications; D008113:Liver Neoplasms / Q000150:complications / Q000473:pathology* / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011379:Prognosis