Surgical management of hepatocellular carcinoma: Is the jury still out?

Introduction: Hepatocellular carcinoma (HCC) is currently the fifth most common neoplasm worldwide. The only therapies which are capable of providing cure are hepatic resection and liver transplantation. Results from either resection or transplantation show 5-year survival rates of up to 70% in selected patients. Patient assessment is key to selecting candidates for surgery be it resection or transplantation. Methods: A search was performed of the English Medline database for the period 1997-2006 using the MeSH headings: hepatocellular carcinoma, liver resection, and liver transplantation, with the main analysis concentrated on survival data for all patients undergoing resection or transplantation. Results: There is a large variation in the mortality and recurrence rate following resection /transplantation due to differences in definition in different series. The median perioperative (30 day/in-hospitai) mortality rate following resection was a median of 4.7%. The median 1, 3 and 5 year overall survival rates were 80.1%, 55% and 37.1%, respectively. The disease-free survivals at identical time intervals were 64%, 38% and 27%. The median 30 day mortality following liver transplant was 4.7% and the median 3-month mortality was 13.3%. The median overall 1, 3, and 5-year survival rates were 80.9%, 70.2% and 62%, respectively, whilst the disease-free survivals at identical time intervals were 79%, 62.5% and 54.5%. Several risk factors for overall and/or disease-free survival following resection and transplantation were found in those papers where a multivariate analysis was included. Discussion: A possible algorithm would be to perform resection for patients with preserved liver function and offer transplantation to those of Child-Pugh status B or C who fit within Milan criteria. If recurrence occurred after resection or underlying liver disease progresses, salvage transplants may be performed. Conclusion: The current evidence base for resection and transplantation in the treatment of HCC is inadequate to provide a definite answer as to which is optimal therapy and a randomised controlled trial to compare the outcomes of resection and transplantation is now required. (C) 2008 Elsevier Ltd. All rights reserved.