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• W2068355080 abstract "Liver resection (LR) for patients with small hepatocellular carcinoma (HCC) with preserved liver function, employing liver transplantation (LT) as a salvage procedure (SLT) in the event of HCC recurrence, is a debated strategy.From 1996 to 2005, we treated 227 cirrhotic patients with HCC transplantable: 80 LRs and 147 LTs of 293 listed for transplantation. Among 80 patients eligible for transplantation who underwent LR, 39 (49%) developed HCC recurrence and 12/39 (31%) of these patients presented HCC recurrence outside Milan criteria. Only 10 of the 39 patients underwent LT, a transplantation rate of 26% of patients with HCC recurrence.According to intention-to-treat analysis of transplantable HCC patients who underwent LR (n = 80), compared to all those listed for transplantation (n = 293), 5-year overall survival was 66% in the LR group versus 58% in patients listed for LT, respectively (p = NS); 5-year disease-free survival was 41% in the LR group versus 54% in patients listed for LT (p = NS).Comparable 5-year overall (62% vs. 73%, p = NS) and disease-free (48% vs. 71%, p = NS) survival rates were obtained for SLT and primary LT for HCC, respectively.LR is a valid treatment for small HCC and in the event of recurrence, SLT is a safe and effective procedure. Liver resection (LR) for patients with small hepatocellular carcinoma (HCC) with preserved liver function, employing liver transplantation (LT) as a salvage procedure (SLT) in the event of HCC recurrence, is a debated strategy. From 1996 to 2005, we treated 227 cirrhotic patients with HCC transplantable: 80 LRs and 147 LTs of 293 listed for transplantation. Among 80 patients eligible for transplantation who underwent LR, 39 (49%) developed HCC recurrence and 12/39 (31%) of these patients presented HCC recurrence outside Milan criteria. Only 10 of the 39 patients underwent LT, a transplantation rate of 26% of patients with HCC recurrence. According to intention-to-treat analysis of transplantable HCC patients who underwent LR (n = 80), compared to all those listed for transplantation (n = 293), 5-year overall survival was 66% in the LR group versus 58% in patients listed for LT, respectively (p = NS); 5-year disease-free survival was 41% in the LR group versus 54% in patients listed for LT (p = NS). Comparable 5-year overall (62% vs. 73%, p = NS) and disease-free (48% vs. 71%, p = NS) survival rates were obtained for SLT and primary LT for HCC, respectively. LR is a valid treatment for small HCC and in the event of recurrence, SLT is a safe and effective procedure. Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and its incidence will increase in the next two decades both in Europe and the United States (1El Serag HB Mason AC Rising incidence of hepatocellular carcinoma in the United States.N Engl J Med. 1999; 340: 745-750Crossref PubMed Scopus (2721) Google Scholar,2Bosch FX Ribes J Diaz M Cleries R Primary liver cancer: Worldwide incidence and trends.Gastroenterology. 2004; 127: S5-S16Abstract Full Text Full Text PDF PubMed Scopus (2179) Google Scholar). HCC now constitutes the most frequent cause of death in cirrhotic patients (3Sangiovanni A Del Ninno E Fasani P et al.Increased survival of cirrhotic patients with hepatocellular carcinoma detected during surveillance.Gastroenterology. 2004; 126: 1005-1014Abstract Full Text Full Text PDF PubMed Scopus (516) Google Scholar). Strict follow-up programs in cirrhotic patients allow identification of HCC at an early stage when curative nontransplant treatments are possible (4Llovet JM Burroughs A Bruix J Hepatocellular carcinoma.Lancet. 2003; 362: 1907-1917Abstract Full Text Full Text PDF PubMed Scopus (3812) Google Scholar). Liver resection (LR) is the first-line treatment in patients with HCC and preserved liver function (Child class A) (5Pugh RN Murray-Lyon IM Dawson JL Pietroni MC Williams R Transection of the oesophagus for bleeding oesophageal varices.Br J Surg. 1973; 60: 646-649Crossref PubMed Scopus (6863) Google Scholar) with acceptable results in terms of perioperative risk (6Fan ST Lo CM Liu CL Lam CM Yuen WK Wang J Hepatectomy for hepatocellular carcinoma: Toward zero hospital deaths.Ann Surg. 1999; 229: 322-330Crossref PubMed Scopus (688) Google Scholar) and overall survival (7Grazi GL Ercolani G Pierangeli F et al.Improved results of liver resections for hepatocellular carcinoma on cirrhosis give the procedure added value.Ann Surg. 2001; 234: 71-78Crossref PubMed Scopus (309) Google Scholar); it is, however, linked to a high incidence of HCC recurrence, up to 50–70% of cases at 5 years of follow-up (8Fong Y Sun RL Jarnagin W Blumgart LH An analysis of 412 cases of hepatocellular carcinoma at a Western center.Ann Surg. 1999; 229: 790-799Crossref PubMed Scopus (746) Google Scholar, 9Poon RT Fan ST Lo CM et al.Improving survival results after resection of hepatocellular carcinoma: A prospective study of 377 patients over 10 years.Ann Surg. 2001; 234: 63-70Crossref PubMed Scopus (535) Google Scholar, 10Ercolani G Grazi GL Ravaioli M et al.Liver resections for hepatocellular carcinoma on cirrhosis: Univariate and multivariate analysis of risk factors for intrahepatic recurrence.Ann Surg. 2003; 237: 536-543Crossref PubMed Scopus (0) Google Scholar). Liver transplantation (LT) is advisable in patients with HCC and decompensated cirrhosis (Child class B-C) (5Pugh RN Murray-Lyon IM Dawson JL Pietroni MC Williams R Transection of the oesophagus for bleeding oesophageal varices.Br J Surg. 1973; 60: 646-649Crossref PubMed Scopus (6863) Google Scholar) with excellent results in term of overall and disease-free survival in selected patients (11Mazzaferro V Regalia E Doci R et al.Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis.N Engl J Med. 1996; 334: 693-699Crossref PubMed Scopus (5781) Google Scholar). Recently, promising results after LT have been reported also with extension of the Milan criteria (12Yao FY Ferrell L Bass NM et al.Liver transplantation for hepatocellular carcinoma: Expansion of tumor size limits does not adversely impact survival.Hepatology. 2001; 33: 1080-1086Crossref PubMed Scopus (1803) Google Scholar). The main problem affecting the applicability of the LT option is the high dropout rate from the waiting list related to HCC progression (13Llovet JM Fuster J Bruix J Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: Resection versus transplantation.Hepatology. 1999; 30: 1434-1440Crossref PubMed Scopus (1497) Google Scholar,14Yao FY Bass NM Nikolai B et al.Liver transplantation for hepatocellular carcinoma: Analysis of survival according to the intention-to-treat principle and drop-out from the waiting list.Liver Transpl. 2002; 8: 873-883Crossref PubMed Scopus (364) Google Scholar), despite the systematic use of nonsurgical bridging techniques such as trans-arterial chemoembolization (TACE) (15Majno PE Adam R Bismuth H et al.Influence of pre-operative transarterial lipiodol chemoembolisation on resection and transplantation for hepatocellular carcinoma in patients with cirrhosis.Ann Surg. 1997; 226: 688-703Crossref PubMed Scopus (472) Google Scholar) and/or radio-frequency ablation (RFA) (16Mazzaferro V Battiston C Perrone S et al.Radiofrequency ablation of small hepatocellular carcinoma in cirrhotic patients awaiting liver transplantation: A prospective study.Ann Surg. 2004; 240: 900-909Crossref PubMed Scopus (458) Google Scholar) or percutaneous alcohol injection (PEI) (17Lencioni RA Allgaier HP Cioni D et al.Small hepatocellular carcinoma in cirrhosis: Randomized comparison of radiofrequency thermalablation versus percutaneos ethanol injection.Radiology. 2003; 228: 235-240Crossref PubMed Scopus (876) Google Scholar), caused by organ shortage in relation to the continuously increasing number of patients awaiting LT (18Trotter JF Wachs M Everson GT Kam I Adult-to-adult transplantation of the right hepatic lobe from a living donor.N Engl J Med. 2002; 346: 1074-1082Crossref PubMed Scopus (413) Google Scholar). Supported by good results in terms of overall survival from LR for HCC in selected transplantable patients with preserved liver function and working with the assumption that at the time of HCC recurrence LT can be performed secondarily, a third surgical strategy named ‘salvage transplantation’ was first proposed by Majno et al. (19Majno PE Sarasin FP Mentha G Hadengue A Primary liver resection and salvage transplantation or primari liver transplantation in patients with single, small hepatocellular carcinoma and preserved liver function: An outcome-oriented decision analysis.Hepatology. 2000; 31: 899-906Crossref PubMed Scopus (288) Google Scholar) with encouraging results. From January 1996 to November 2005, 317 consecutive patients with documented HCC, by two imaging studies, were treated by hepatic resection (n = 170) or LT (n = 147) at our institution. Thirty-six patients (5 LR patients and 31 LT patients) included in the analysis had two imaging studies documenting HCC; they were treated with preoperative ablative therapies and complete tumor necrosis was found on the operative specimen, preventing pathological confirmation of HCC. The 170 cirrhotic patients treated by liver resection during the study period were selected mainly when they had one or two nodules, preserved hepatic function (Child-Pugh A) and pre- and intra-operative absence of macroscopic portal invasion and of an extrahepatic tumor. All resections were potentially curative. Among this group, 90 patients (53%) were considered as nontransplantable because of age >65 years (n = 70), maximum tumor size exceeding 5 cm (n = 11) or large and multinodular (up to three nodules and >3 cm; n = 9) according to the selection criteria used for transplantation in the same period. The remaining 80 patients (47%) were potentially transplantable but were treated by liver resection since this was the primary preference to LT, because of organ shortage. Postoperative follow-up included liver function tests, dosage of serum alpha-feto protein (AFP) and abdominal ultrasonography on a 3-month basis in the first 6 months after surgery and on a 6-month basis in the subsequent period, and chest-abdominal CT scan once a year. The policy was to consider LT for patients who would have developed hepatic HCC recurrence, documented by liver ultrasonography and confirmed by CT scan of the abdomen, or deterioration of liver function after resection. Accordingly, among the 80 transplantable patients, 16 (20%) were subsequently transplanted: 10 (12.5%) for tumor recurrence and 6 (7.5%) for hepatic decompensation. The 147 patients transplanted for HCC in the study period were selected according to the following pretransplant criteria: age <65 years, absence of metastatic lymph nodes or extrahepatic spread at the preoperative evaluation, absence of macroscopic vascular invasion, no history of other malignant tumors within the last 5 years, HCC meeting Milan criteria. As a result, the study population consisted of 80 LR transplantable patients and 147 LTs out of 293 listed patients in the study period. The indication for LT depended mainly on the technical un-resectability of the HCC or on decompensated liver function (Child-Pugh class B or C). Preoperative staging routinely included hepatic ultrasound, chest and abdominal CT, and bone scintigraphy to look for any extrahepatic tumor spread. Patients with HCC were given no priority on the waiting list as compared with other patients from 1996 to 2003 when recipients were selected for LT according to their Child score and HCC patients were eligible for marginal donors (20Ravaioli M Grazi GL Ercolani G et al.Liver allocation for hepatocellular carcinoma: A European center policy in the pre-MELD era.Transplantation. 2006; 81: 525-530Crossref PubMed Scopus (23) Google Scholar); after April 2003 our local policy led to adopting the model for end-stage disease (MELD) score (21Kamath PS Wiesner RH Malinchoc M et al.A model to predict survival in patients with end-stage liver disease.Hepatology. 2001; 33: 464-470Crossref PubMed Scopus (3832) Google Scholar) for LT candidates. Patients with HCC listed in our institution did not receive a MELD score upgrade, similar to US policy, but the score was calculated by considering their real MELD score, the waiting time with tumor and the tumor stage. In particular, in the first period of MELD experience, the MELD score for HCC patients was calculated in the following way: real MELD score + 5 points for T1, 8 points for T2 + 1 point for every month on the waiting list with a diagnosis of HCC. As a result, we observed a high rate of LT for HCC (22Ravaioli M Grazi GL Ballardini G et al.Liver transplantation with the MELD system: A prospective study from a single European center.Am J Transplant. 2006; 6: 1572-1577Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar); on the basis of these data, the points added to the HCC patients scores were reduced as following: real MELD score + 3 points for T1 or 6 for T2 + 0.5 for T1 or 1 for T2 every month on the waiting list with a diagnosis of HCC. Tumor-stage T1 was a single HCC with a diameter ≤3 cm, while T2 was a single HCC with a diameter between 3 and 5 cm or multiple HCCs no more than three with a diameter ≤3 cm. This ranking for HCC patients led to a rate of removals from the list similar to the non-HCC patients (22Ravaioli M Grazi GL Ballardini G et al.Liver transplantation with the MELD system: A prospective study from a single European center.Am J Transplant. 2006; 6: 1572-1577Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar). The survival data were not affected by changes in allocation policy: 3-year overall survival was 83% in patients transplanted before 2002, 74% in patients transplanted adopting MELD score and 70% in patients transplanted adopting the MELD-modified score. The minimum criteria for placing adults on the liver transplant waiting list were those reported by the American Society of Transplant Physicians and the American Association for Study of Liver Disease (23Lucey MR Brown KA Everson GT et al.Minimal criteria for placement of adults on the liver transplant waiting list: A report of a national conference organized by the American Society of Transplant Physicians and the American Association for the Study of Liver Diseases.Liver Transpl Surg. 1997; 3: 628-637Crossref PubMed Scopus (320) Google Scholar) in both eras. To avoid patient dropout from the waiting list in the LT group and tumor growth in the LR group, and to achieve a good degree of necrosis of the tumor, TACE is performed whenever possible. RFA or PEI are applied if the HCC is <3 cm in size and not more than three nodules are present, not in contiguity with vascular or biliary structures and easy to reach by the transabdominal approach with abdominal ultrasonography guide and not deep in the liver parenchyma. In particular, a complete degree of tumor necrosis was achieved in 31 cases out of 68 (45%) in the LT group (22 with TACE, 3 with a combination TACE and RFA, 5 with RFA and 1 with PEI) and in 5 cases out of 31 (16%) in the LR transplantable group (all with TACE). Liver resection in patients potentially eligible for transplantation (n = 80) was compared with primary LT patients (n = 147), to assess the outcome of each treatment strategy. Survival in each group was calculated from the time of the primary procedure (LR or LT). Patients with salvage LT were included in the resection group, and their survival was calculated from the time of the resection. Disease-free survival was computed considering patients that developed HCC recurrence and patients who died as censored. An intention-to-treat analysis was performed of all transplantable HCC patients who underwent resection (n = 80) compared to all those listed for transplantation in the study period, including only those that were within Milan criteria (n = 293), as well as considering the patients aged below 65 years in each group (Table 1). As a consequence, intention-to-treat analysis started at the time of listing for liver transplantation for those who were considered for transplantation and at the time of resection for those who underwent resection; assuming the time between the decision to resect and actually resecting was short (<21 days). Disease-free survival was computed considering patients that developed HCC recurrence after LT or LR and patients who died as censored and in the group of patients listed for LT also patients who died on the waiting list or patients who were excluded from the waiting list for any reasons.Table 1Indications for patients listed for LT and LR potentially transplantable patientsIndicationsPatients listed for LT (n = 293)LR potentially transplantable (n = 80)Age<= 65 years<= 65 yearsChild AYesYesChild BYesYesChild CYesNoGastroesophageal varicesYesNoAscitesYesNoEncephalopathyYesNoMELD score>= 13<= 11HCC features:- Number of nodules< = 3<= 3- Maximum size of the lesions (cm)- Solitary HCC<= 5 cm<= 5 cm- Multinodular HCCs<= 3 cm each<= 3 cm eachLT = liver transplantation; LR = liver resection; MELD = model for end-stage disease; HCC = hepatocellular carcinoma. Open table in a new tab LT = liver transplantation; LR = liver resection; MELD = model for end-stage disease; HCC = hepatocellular carcinoma. Salvage LT after LR for HCC (n = 16) was compared to primary LT for HCC (n = 147) to assess the operative risk and the postoperative complications of this surgical procedure. Survival in each group was calculated from the time of transplantation. Statistical analysis was performed using the Statistical Package for Social Sciences software (SPSS 10.0., Inc., Chicago, IL). Parametric analyses were performed using one-way analysis of variance (ANOVA); nonparametric analyses were performed using the chi-square test or Fisher exact test as appropriate. Survival curves were generated using the Kaplan-Meier method, with differences between curves assessed using the log-rank test. Possible risk factors for HCC recurrence were analyzed by univariate and multivariate analysis. Stepwise logistic analysis was used to test for independent significance of variables that were statistically significant by univariate tests. Results were reported as the mean ± standard error of the mean, and significance levels were set at p < 0.05. In the resection group, patients were older (59 ± 6 vs. 55 ± 7, p < 0.0001), with a greater prevalence of virus C-related cirrhosis (76% vs. 54%, p = 0.003) and Child A status (82% vs. 4%, p < 0.0001), compared with the LT group. Preoperative tumor characteristics showed that maximum size >30 mm was more frequent in the LR group (32% vs. 9%, p < 0.0001) and serum levels of AFP were higher in the LR group compared to the primary LT group (220 ± 808 vs. 42 ± 97 ng/mL, p = 0.01). Preoperative nonsurgical treatments (TACE, RFA, PEI) were more prevalent in the primary LT group (46% vs.39%, p = NS) (Table 2).Table 2Patient and tumor characteristics in primary LT and LR potentially transplantable groupVariablesPrimary LT (n = 147)LR potentially transplantable (n = 80)pGender M/F126 (86%)/63 (79%)/21 (14%)17 (21%)NSRecipient age55 ± 759 ± 6<0.001Cirrhosis etiology:Alcohol21 (14%)8 (10%)HCV+79 (54%)61 (76%)0.003HBV+43 (29%)9 (11%)HCV+/HBV+4 (3%)2 (3%)Child A6 (4%)66 (82%)< 0.001Child B53 (36%)14 (18%)Child C88 (60%)−MELD17.8 ± 10.78.56 ± 1.31<0.001Tumor characteristics before LTMax size (mm.)12.7 ± 13.431.3 ± 10.3<0.001>30 mm13 (9%)26 (32%)<0.001Mean no of nodules1.7 ± 1.21.11 ± 0.39<0.001AFP (ng/mL)42 ± 97220 ± 8080.01Pre-LT treatments:TACE55 (37%)28 (35%)Alcohol injection3 (2%)3 (4%)RFA10 (7%)−All treatments68 (46%)31 (39%)NSLT = liver transplantation; LR = liver resection; MELD = model for end-stage disease; HCC = hepatocellular carcinoma; AFP = alpha-feto protein; RFA = radio-frequency ablation; TACE = trans-arterial chemoembolisation. Open table in a new tab LT = liver transplantation; LR = liver resection; MELD = model for end-stage disease; HCC = hepatocellular carcinoma; AFP = alpha-feto protein; RFA = radio-frequency ablation; TACE = trans-arterial chemoembolisation. The hospital readmissions rates were: 23 (15.5%) in the LT group versus 6 (7.5%) in the LR group, p = NS. The initial transplantability of the resected population in relation to preoperative tumor characteristics was 47% (80 of 170). As 16 patients were subsequently transplanted for tumor recurrence or hepatic decompensation, the transplantation rate was 20% (16 of 80). Among 80 patients eligible for transplantation that underwent liver resection, 39/80 (49%) developed hepatocellular carcinoma (HCC) recurrence and 12/39 (31%) of this subgroup of patients presented an HCC recurrence outside Milan criteria and only 4/12 (33%) of these are alive. Among 39 (49%) patients that developed HCC recurrence after liver resection, 27 (69%) patients presented HCC recurrence within Milan criteria and for this reason were theoretically eligible for transplantation. Only 10 of these (37%) were submitted to liver transplantation determining a real transplantability rate of 26% of patients with HCC recurrence and 7 (70%) of these are alive. The remaining 17 patients with HCC recurrence within Milan criteria were not transplanted for the following reasons: in 6 cases (35%) because they were over 65 years at the time of HCC recurrence and 3 (50%) of these are alive, in 3 cases (17%) due to death on the waiting list, in 4 cases (23%) they were still on the waiting list for transplantation, in 1 case (5.8%) for de novo uro-genital cancer after liver resection with subsequent death, in 2 case (12%) a re-resection was performed without HCC recurrence at the time of writing and in 1 case (5.8%) due to patient refusal with subsequent death. The site of recurrence was always intrahepatic with only one case of right adrenal gland with HCC recurrence. The mean time to recurrence was 21.8 months ± 20.6 months and in particular the time to recurrence of 90% of the LR patients was 57 months. In particular, we noted no difference in term of time to recurrence, on the remnant liver after LR, in patients with HCC recurrence outside Milan criteria (18.5 months ± 24 months) versus patients with recurrence within Milan criteria (23.4 months ± 19 months, p = NS). We considered the following variables and their relationship with development of HCC recurrence in the analysis: age of patients >60 years was associated with incidence of HCC recurrence (43% vs. 45% in patients aged <60 yrs), sex of patients (65% vs. 45%, p = 0.04 in females and males, respectively), single versus multiple nodules (45% vs. 50%), nodule size >3 cm (54% vs. 46% in patients with nodules <3 cm), AFP serum levels >20 ng/mL (44% vs. 42% in patients with AFP <20 ng/mL), presence of microvascular invasion on the pathological specimen (54% vs. 46% in patients without microvascular invasion), satellite nodules (54% vs. 46%, in patients with satellite nodules and without satellite nodules, respectively) and tumor grading (56% vs. 48%, in G3-G4 and G1-G2, respectively). The only variable that proved to be predictive of tumor recurrence at the univariate analysis was female gender against male gender. At the multivariate analysis, the relative risk of HCC recurrence related to female gender was 1.9 (0.9–3.6) with 95% CI: 0.92–3.65, (p = 0.02). Among the 147 patients that underwent transplantation, 30 (20%) died: 7 due to HCC recurrence, 5 due to liver decompensation secondary to HCV recurrence, 5 due to multiorgan failure, 4 due to sepsis, 3 due to other causes, 2 due to liver failure, 1 due to cardiovascular disease, 1 due to intraoperative complication caused by massive bleeding, 1 due to de novo tumor and 1 due to HBV recurrence. Among the 80 patients submitted to resection, 34 (42%) died: 18 due to HCC recurrence, 11 due to liver failure, 3 due to HCV recurrence, 1 due to cardiovascular disease and 1 due to de novo tumor. Time of death was 37 months ± 32 months in the resection group versus 18 months ± 23 months in the transplantation group, p = 0.007. Transplantable resected patients (n = 80) had a similar 5-year overall survival comparable with primarily transplanted patients (n = 147) (66% vs. 73%, p = NS) (Figure 1A). However, transplantable resected patients had a lower 5-year disease-free survival than in primarily transplanted patients (41% vs. 71%, p = 0.001) (Figure 1B). No difference was observed in terms of mean time to recurrence considering both groups of patients: 23 months ± 21 months in the LR group versus 15 months ± 15 months in the LT group, p = NS. According to the intention-to-treat analysis of all transplantable HCC patients who underwent resection (n = 80) compared to all those listed for transplantation that met Milan criteria (n = 293), the 5-year overall survival was 66% in the LR group versus 58% in patients listed for transplantation, respectively, p = NS (Figure 2A). In particular, considering the 293 patients listed for transplantation, 147 (50%) patients were actually treated with LT and the outcomes of the remaining patients are shown in Table 3.Table 3Intention-to-treat analysis of all patients listed for LT and LR potentially transplantable patientsVariablesListed patients for LT (n = 293)LR potentially transplantable (n = 80)pGender M/F245 (84%)/48 (16%)63 (79%)/17 (21%)NSAge54 ± 759 ± 6<0.001Cirrhosis etiologyAlcohol21 (7%)8 (10%)HCV+172 (59%)61 (76%)0.04HBV+82 (28%)9 (11%)HCV+/HBV+12 (4%)2 (3%)Others6 (2%)−Child A23 (8%)66 (82%)<0.001Child B139 (47%)14 (18%)Child C131 (45%)−MELD16.8 ± 9.18.56 ± 1.31<0.001Patients awaiting LT74 (25%)−Patients who died on waiting list:43 (15%)−- For tumor progression14 (5%)−- For others reasons29 (10%)−Patients excluded from waiting list:29 (10%)−- For tumor progression20 (7%)−- For de novo tumor6 (2%)−- For other reasons3 (1%)−Patients treated147 (50%)80 (100%)<0.001Patients alive:- Without HCC recurrence after LT or LR105 (36%)27 (34%)- Awaiting LT74 (25%)−- With HCC recurrence after LT or LR2 (0.6%)20 (25%)- With de novo tumor that excluded LT1 (0.3%)- With tumor progression that excluded LT7 (2.1%)Total patients alive189 (64%)47 (59%)NSLT = liver transplantation; LR = liver resection; MELD = model for end-stage disease; HCC = hepatocellular carcinoma. Open table in a new tab LT = liver transplantation; LR = liver resection; MELD = model for end-stage disease; HCC = hepatocellular carcinoma. Following the intention-to-treat analysis principle, the 5-year disease-free survival was 41% in the LR group versus 54% in patients listed for transplantation, respectively, p = NS (Figure 2B). Operative mortality was 0% versus 5% in the salvage and primary LT groups, respectively (p = NS). Among the 8 patients who died in the primary LT group: 1 died of intraoperative bleeding, 1 from primary dysfunction complicated by multiorgan failure, 4 from multiorgan failure, 1 from sepsis and 1 from liver failure. The intra-operative number of transfused units of packed red blood cells did not differ (2774 ± 2838 vs. 3953 ± 3544 cc in primary vs. salvage LT, respectively) (p = NS). The mean cold ischemia time (439 ± 106 vs. 425 ± 135 min., p = NS) and the incidence of postoperative complications were similar in the primary and salvage LT groups, respectively (Table 4).Table 4Postoperative complications in the primary and salvage LT groupsVariablesPrimary LT (n = 147)Salvage LT (n = 16)pBiliary complications38 (26%)5 (31%)NSVascular complications13 (9%)1 (6%)NSImmunological complications20 (14%)3 (19%)NSInfections31 (21%)3 (19%)NSNeurological complications12 (8%)1 (6%)NSPrimary graft nonfunction5 (3%)−NSRetransplantation12 (8%)−NSTotal complications131/14713/16NSTotal complicated patients116/147 (79%)10/16 (62%)NSLT = liver transplantation. Open table in a new tab LT = liver transplantation. Twelve patients (75%) who underwent salvage LT had underlying hepatitis C virus-related cirrhosis or coinfection with hepatitis B virus in 3 cases (19%) and only 1 (6%) patient with SLT had HBV-related cirrhosis. Three patients received treatment for HCC before liver resection: 2 had previous TACE and 1 had previous alcohol injection. All liver resections were done by a transabdominal approach in all 16 patients resected for HCC and subsequently transplanted by salvage procedure either for HCC recurrence (n = 10/16) or for liver decompensation after LR (n = 6/16). Hepatectomy was limited to fewer than three segments in 4/16 patients (25%) and 1/16 patient (6%) underwent a right hepatectomy and in the remaining 11/16 patients (69%) a nonanatomical liver resection was performed. There were no differences between the primary and salvage transplantation groups in age, gender or severity of the underlying cirrhosis. As regards the etiology of cirrhosis, HCV-related cirrhosis was more frequent in the salvage LT group, while HBV-related cirrhosis and alcohol cirrhosis were prevalent in the primary LT group (Table 5).Table 5Patients and tumor characteristics in the primary and salvage LT groupsVariablesPrimary LT (n = 147)Salvage LT (n = 16)pGender M/F126 (86%)/13 (81%)/NS21(14%)3 (19%)Recipient age55 ± 754 ± 8NSCirrhosis etiologyAlcohol21 (14%)−HCV+79 (54%)12 (75%)HBV+43 (29%)1 (6%)HCV+/HBV+4 (3%)3 (19%)0.007Child A6 (4%)6 (37%)Child B53 (36%)3 (19%)NSChild C88 (60%)7 (44%)MELD17.8 ± 10.717.6 ± 6.0NSTumor characteristics before LTMax size (mm.)12.7 ± 13.424.3 ± 7.1NS>30 mm13 (9%)1 (6%)NSMean no of nodules1.7 ± 1.22.8 ± 1.5NSAFP (ng/mL)42 ± 9723 ± 42NSPre-LT treatmentsTACE55 (37%)7 (44%)Alcohol injection3 (2%)1 (6%)RFA10 (7%)2 (12%)All treatments68 (46%)10 (62%)NSAFP = alpha-feto pro" @default.
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• W2068355080 date "2008-06-01" @default.
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• W2068355080 title "Liver Transplantation for Recurrent Hepatocellular Carcinoma on Cirrhosis After Liver Resection: University of Bologna Experience" @default.
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