Salvage Transplantation for Recurrent Hepatocellular Carcinoma within Milan Criteria: Is It Worthwhile?

Abstract

Background: The approach of primary hepatic resection and salvage liver transplant (SLT) for intrahepatic recurrent hepatocellular carcinoma (HCC) is increasingly adopted. However, the survival benefi t of this approach as compared with that of primary transplantation (PLT) for HCC is still controversial. Aim of study: To compare the long-term survival outcome between SLT and PLT for HCC within Milan criteria Patients and methods: From July 1995 to December 2008, a total of 85 patients who underwent liver transplant for HCC within Milan criteria were retrospectively analyzed. There were 13 patients receiving SLT for recurrence after primary hepatic resection and 72 patients receiving PLT. Clinicopathologic characteristics, perioperative outcome and long-term survival were compared between the two groups. Results: Patients in SLT group had better liver function in terms of lower Child-Pugh score and MELD score than those in PLT group. All patients in SLT group received living donor liver transplant (LDLT), whereas 53 of 72 patients (73.6%) in PLT underwent LDLT. Waiting time was shorter and graft weight to standard liver weight ratio was lower in SLT group than PLT group. More patients in SLT group developed tumor recurrence than those in PLT group (46.1% vs. 6.9%, P = 0.001) Recurrence in SLT group tended to occur earlier than PLT group (median time: 8.5 months vs. 25.6 months) With median follow-up period of 36 months (range 4 – 120 months), the overall recurrence-free survival was signifi cantly worse in SLT group than PLT group (1-year: 60% vs. 92.5%; 3-year: 60% vs. 86.1%; 5-year: 36.4% vs. 84.5%; P = 0.0001). Univariate analysis identifi ed tumor number, TNM staging and the approach of SLT as the prognostic factors that affected recurrence-free survival. Conclusion: Despite strict selection criteria based on tumor size and number, patients who underwent salvage transplant had signifi cantly worse survival outcome than those receiving primary transplant for hepatocellular carcinoma.