Transplantation versus liver resection in patients with hepatocellular carcinoma

Abstract

Hepatocellular carcinoma (HCC) is one of the most common solid cancers in the world. Its treatment strategies have evolved significantly over the past few decades but the best treatment outcomes remain in the surgical arena. Especially for early HCCs, the options are abundant. However, surgical resection and liver transplantation provide the best long-term survival. In addition, there are evidence the ablative therapy such as radiofrequency ablation, could provide equivalent outcome as compared to resection. However, HCC is a unique malignancy as the majority of patients develop this cancer in the background of cirrhotic livers. As such, the treatment consideration should not only look at the oncological perspective but also the functional status of the liver parenchyma, i.e., the state of cirrhosis and presence of portal hypertension. Even with the most widely adopted staging systems for HCC such as the Barcelona Clinic Liver Cancer (BCLC) staging system and many other staging systems, none of them are ideal in including the various considerations for patients with HCCs. In this article, the key issues between choosing surgical resection and liver transplantation are discussed. A comprehensive review of the current surgical options are outlined in order to explore the pros and cons of each option.

Keywords: Hepatocellular carcinoma (HCC); liver; resection; transplantation.

Figure 1

Key considerations in deciding between liver resection or liver transplantation in patients with HCC. HCC, hepatocellular carcinoma.

Figure 2

Computer tomography (CT) scan of hepatocellular carcinoma in multiple phases (triphasic CT scan). (A) Arterial enhancing lesion on arterial phase in segment IVb of the liver (arrow); (B) washout of the enhancing lesion in segment IVb of the liver during portovenous phase (arrow); (C) the contrast washout continues into the delayed phase in a multiphasic liver scan (arrow).

Figure 3

Three major areas for consideration in liver resection for HCC. HCC, hepatocellular carcinoma.

Figure 4

Large HCC such as this was often deemed unsuitable for liver resection previously. HCC, hepatocellular carcinoma.

Figure 5

Considering technical resectability of HCC in patients with cirrhosis. HCC, hepatocellular carcinoma.

Figure 6

Key steps in ALPPS surgery and progression before and after first and second stage operations. (A) A chronic hepatitis B carrier who was diagnosed with 3 lesions in the right lobe of the liver involving segment IVA. A right trisectionectomy was required to achieve R0 resection but the FLR on the left lateral section was too small to allow safe liver resection. The initial FLR was measured to be only 19%; (B) an ALPPS procedure was performed, with ligation of the right portal vein and isolation of the right hepatic artery and right hepatic duct and complete liver parenchymal transection during the first stage of ALPPS; (C) the intended FLR grew to 38% when CT volumetry was repeated on POD 10; (D) second stage of ALPPS where the FLR had grown to 38% and healthy looking; (E) repeat CT scan was performed for patients 3 months after surgery as part of routine post-surgery surveillance showing a large and healthy FLR. This patient remains well without recurrence 5 years after the ALPPS procedure.