title: Prospective validation of ab initio liver transplantation in hepatocellular carcinoma upon detection of risk factors for recurrence after resection.
abstract: A decade ago we proposed to enlist for transplantation those patients with resected hepatocellular carcinoma in whom pathology registered pejorative histological markers (microvascular invasion and/or satellites; ab initio indication) and not wait for the appearance of recurrence. This study evaluates the outcome of this approach. From 1995 to 2012, 164 patients with hepatocellular carcinoma underwent resection. Eighty-five patients were potential candidates for liver transplantation and were considered for it upon detection of pejorative histological markers. Patients without these markers were followed, and salvage liver transplantation was considered upon development of tumor recurrence/liver function impairment. Thirty-seven patients were at high risk and 48 at low risk of recurrence at pathology. Twenty-three out of 37 high-risk patients recurred during follow-up, but in nine of them the tumor burden extent contraindicated liver transplantation. Seventeen were finally transplanted: 10 of them presented recurrence at imaging/explant. After a median posttransplant follow-up of 50.9 months, hepatocellular carcinoma had recurred in two patients and five patients had died, the 5-year survival being 82.4%. Twenty-six of the 48 low-risk patients developed recurrence, and 11 of them were transplanted. After a median posttransplant follow-up of 59 months, two patients developed recurrence and five died, their 5-year survival being 81.8%.
  
  
  CONCLUSIONS
  Enlistment of patients at high risk of HCC recurrence after resection but before recurrence development seems a valid strategy and is associated with excellent long-term outcome; as early (<6 months) recurrence reflects an aggressive tumor behavior leading to tumor extent exceeding transplant criteria, we propose to wait at least 6 months before enlistment; however, once included on the waiting list, priority strategies should be implemented in order to reach effective transplantation prior to the appearance of recurrence.
authors.affiliation: HepatoBilioPancreatic Surgery and Transplant Unit, Department of Surgery, University of Barcelona, Barcelona, Spain.|Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clinic Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain.
authors.forename: Joana
authors.initials: J
authors.lastname: Ferrer-Fàbrega
authors.affiliation: Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clinic Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain.|Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Forner
authors.affiliation: Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clinic Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Liccioni
authors.affiliation: Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clinic Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain.|Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain.|Department of Pathology, Hospital Clinic Barcelona, University of Barcelona, Barcelona, Spain.
authors.forename: Rosa
authors.initials: R
authors.lastname: Miquel
authors.affiliation: HepatoBilioPancreatic Surgery and Transplant Unit, Department of Surgery, University of Barcelona, Barcelona, Spain.
authors.forename: Víctor
authors.initials: V
authors.lastname: Molina
authors.affiliation: Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain.|Liver Transplantation Unit, Liver Unit, Hospital Clinic Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain.
authors.forename: Miquel
authors.initials: M
authors.lastname: Navasa
authors.affiliation: HepatoBilioPancreatic Surgery and Transplant Unit, Department of Surgery, University of Barcelona, Barcelona, Spain.|Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain.
authors.forename: Constantino
authors.initials: C
authors.lastname: Fondevila
authors.affiliation: HepatoBilioPancreatic Surgery and Transplant Unit, Department of Surgery, University of Barcelona, Barcelona, Spain.|Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain.
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: García-Valdecasas
authors.affiliation: Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clinic Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain.|Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain.
authors.forename: Jordi
authors.initials: J
authors.lastname: Bruix
authors.affiliation: HepatoBilioPancreatic Surgery and Transplant Unit, Department of Surgery, University of Barcelona, Barcelona, Spain.|Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clinic Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain.|Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain.
authors.forename: Josep
authors.initials: J
authors.lastname: Fuster
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000601:surgery*; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control*; D018579:Patient Selection; D011446:Prospective Studies; D012307:Risk Factors; D013030:Spain / Q000453:epidemiology