title: Salvage Versus Primary Liver Transplantation for Early Hepatocellular Carcinoma: Do Both Strategies Yield Similar Outcomes?
abstract: In compensated cirrhotics with early hepatocellular carcinoma (HCC-cirr), upfront liver resection (LR) and salvage liver transplantation (SLT) in case of recurrence may have outcomes comparable to primary LT (PLT).
  
  
  
  An intention-to-treat (ITT) analysis comparing PLT and SLT strategies.
  
  
  
  Of 130 HCC-cirr patients who underwent upfront LR (group LR), 90 (69%) recurred, 31 could undergo SLT (group SLT). During the same period, 366 patients were listed for LT (group LLT); 26 dropped-out (7.1%), 340 finally underwent PLT (group PLT). We compared survival between groups LR and LLT, LR and PLT, and PLT and SLT.
  
  
  
  Feasibility of SLT strategy was 34% (31/90). In an ITT analysis, group LLT had better 5-yr/10-yr overall survival (OS) compared with group LR (68%/58% vs. 58%/35%; P = 0.008). Similarly, 5-yr/10-yr OS and disease-free survival (DFS) were better in group PLT versus group LR (OS 73%/63% vs. 58%/35%, P = 0.0007; DFS 69%/61% vs. 27%/21%, P < 0.0001). Upfront resection and microvascular tumor invasion were poor prognostic factors for both OS and DFS, presence of satellite tumor nodules additionally predicted worse DFS. Group SLT had similar postoperative and long-term outcomes compared with group PLT (starting from time of LT) (OS 54%/54% vs. 73%/63%, P = 0.35; DFS 48%/48% vs. 69%/61%, P = 0.18, respectively).
  
  
  
  In initially transplantable HCC-cirr patients, ITT survival was better in group PLT compared with group LR. SLT was feasible in only a third of patients who recurred after LR. Post SLT, short and long-term outcomes were comparable with PLT. Better patient selection for the "resection first" approach and early detection of recurrence may improve outcomes of the SLT strategy.
authors.affiliation: *AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Univ Paris-Sud, Villejuif, France†Univ Paris-Sud, Villejuif, France‡Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India§Inserm, Unité 935, Villejuif, France¶Inserm, Unité 785, Villejuif, France.
authors.forename: Prashant
authors.initials: P
authors.lastname: Bhangui
authors.forename: Marc Antoine
authors.initials: MA
authors.lastname: Allard
authors.forename: Eric
authors.initials: E
authors.lastname: Vibert
authors.forename: Daniel
authors.initials: D
authors.lastname: Cherqui
authors.forename: Gilles
authors.initials: G
authors.lastname: Pelletier
authors.forename: Antonio Sa
authors.initials: AS
authors.lastname: Cunha
authors.forename: Catherine
authors.initials: C
authors.lastname: Guettier
authors.forename: Jean-Charles Duclos
authors.initials: JC
authors.lastname: Vallee
authors.forename: Faouzi
authors.initials: F
authors.lastname: Saliba
authors.forename: Henri
authors.initials: H
authors.lastname: Bismuth
authors.forename: Didier
authors.initials: D
authors.lastname: Samuel
authors.forename: Denis
authors.initials: D
authors.lastname: Castaing
authors.forename: René
authors.initials: R
authors.lastname: Adam
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000209:etiology / Q000401:mortality / Q000601:surgery* / Q000628:therapy; D005240:Feasibility Studies; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications; D008113:Liver Neoplasms / Q000209:etiology / Q000401:mortality / Q000601:surgery* / Q000628:therapy; D016031:Liver Transplantation / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000601:surgery* / Q000628:therapy; D011379:Prognosis; D012086:Reoperation; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods; D016019:Survival Analysis; D016896:Treatment Outcome