Surgical treatment of hepatocellular carcinoma in North America: can hepatic resection still be justified?
BACKGROUND
The incidence of hepatocellular cancer (HCC) is increasing dramatically worldwide. Optimal management remains undefined, especially for well-compensated cirrhosis and HCC.


METHODS
This retrospective analysis included 5 US liver cancer centers. Patients with surgically treated HCC between 1990 and 2011 were analyzed; demographics, tumor characteristics, and survival rates were included.


RESULTS
There were 1,765 patients who underwent resection (n = 884, 50.1%) or transplantation (n = 881, 49.9%). Overall, 248 (28.1%) resected patients were transplant eligible (1 tumor <5 cm or 2 to 3 tumors all <3 cm, no major vascular invasion); these were compared with 496 transplant patients, matched based on year of transplantation and tumor status. Overall survivals at 5 and 10 years were significantly improved for transplantation patients (74.3% vs 52.8% and 53.7% vs 21.7% respectively, p < 0.001), with greater differences in disease-free survival (71.8% vs 30.1% at 5 years and 53.4% vs 11.7% at 10 years, p < 0.001). Ninety-seven of the 884 (11%) resected patients were within Milan criteria and had cirrhosis; these were compared with the 496 transplantation patients, with similar results to the overall group. On multivariate analysis, type of surgery was an independent variable affecting all survival outcomes.


CONCLUSIONS
The increasing incidence of HCC stresses limited resources. Although transplantation results in better long-term survival, limited donor availability precludes widespread application. Hepatic resection will likely remain a standard therapy in selected patients with HCC. In this large series, only about 10% of patients with cirrhosis were transplant-eligible based on tumor status. Although liver transplantation results are significantly improved compared with resection, transplantation is available only for a minority of patients with HCC.
Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO. Electronic address: chapmanw@wustl.edu.
William C
WC
Chapman
Department of Surgery, Baylor University, Waco, TX.
Goran
G
Klintmalm
Department of Surgery, University of California San Diego Health System, San Diego, CA.
Alan
A
Hemming
Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO.
Neeta
N
Vachharajani
Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO.
Maria B
MB
Majella Doyle
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
Ron
R
DeMatteo
Department of Surgery, University of Virginia Health System, Charlottesville, VA.
Victor
V
Zaydfudim
Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO.
Haniee
H
Chung
Department of Surgery, Baylor University, Waco, TX.
Keith
K
Cavaness
Department of Surgery, Baylor University, Waco, TX.
Robert
R
Goldstein
Department of Surgery, University of Florida Health, Gainesville, FL.
Ivan
I
Zendajas
Department of Surgery, The Cancer Institute of New Jersey, Rutgets Robert Wood Johnson Medical School, New Brunswick, NJ.
Laleh G
LG
Melstrom
Department of Surgery, Mayo Clinic, Rochester, MN.
David
D
Nagorney
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
William
W
Jarnagin
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000453:epidemiology* / Q000601:surgery*; D002648:Child; D018572:Disease-Free Survival; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008113:Liver Neoplasms / Q000453:epidemiology* / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D009656:North America / Q000453:epidemiology; D018579:Patient Selection; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D055815:Young Adult