2008 Annual Meeting Abstracts

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Introduction: Although liver transplantation (LT) is the treatment of choice for patients (pts) with hepatocellular carcinoma (HCC) and advanced cirrhosis, the management of pts with early HCC within the Milan criteria and well-compensated cirrhosis is controversial. The purpose of the current study was to compare the outcome of pts with early HCC and compensated cirrhosis who were treated with initial resection (RSX) vs LT.
Methods: Between 1985 and 2007, 42 pts underwent hepatic RSX and 61 pts underwent LT for HCC within the Milan criteria. All pts had well-compensated Childs A or B cirrhosis. Data on morbidity, recurrence, and long-term survival were collected. Prognostic factors were evaluated using univariate and multivariate analyses; survival was calculated using the Kaplan-Meier method.
Results: RSX pts were younger than LT pts (mean age: 42 y vs 61 y, respectively; P=0.01) but had the same gender distribution (male: 83% vs 82%, respectively; P=0.54). There was no difference in the incidence of hepatitis (RSX 64% vs LT 82%; P=0.07). The median number of hepatic lesions was 1 (range: 1 to 3) in both treatment groups (P=0.10). However, tumors in the resected group tended to be larger (mean size: RSX 3.2 cm vs LT 2.7 cm; P=0.03). No pt in either group had preoperative evidence of major vascular invasion. For pts who underwent RSX, surgery consisted of wedge resection (n=34, 80%), hemihepatectomy (n=5, 12 %) or extended hepatectomy (n=3, 7%). 6 (14%) pts had a positive margin. Of the LT patients, 5 (8%) underwent living donor LT and 56 (92%) had orthotopic LT. On pathologic analysis, there was no difference in the incidence of microscopic vascular invasion (RSX 26% vs LT 15%; P=0.12) or tumor grade (P=0.08). 30-day operative mortality was similar (RSX 4.7% vs LT, 6.5%; P=0.83). Overall morbidity was also the same (RSX 52% vs LT 67%; P=0.15), with most complications being minor (Clavien grade 1-2) (RSX 31% vs LT 39%; P=0.83). The recurrence rate was 38% following RSX and 20% following LT (P=0.05). Pts who underwent RSX had a similar 5-year survival rate (34%) compared with pts treated with LT (47%) (P=0.19). Survival remained comparable when stratified by pre-MELD vs post-MELD era (both P>0.05). Presence of microscopic vascular invasion predicted worse long-term prognosis (HR=5.35, P=0.005).
Conclusion: In well-compensated pts with early-stage HCC, RSX and LT have comparable morbidity, mortality, and long-term survival. Given current limitations in organ availability, RSX should be considered as initial treatment in select pts with HCC.

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