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Surgical Resection in Hepatocellular Carcinoma Patients with Minimal Background Fibrosis
A Strategy in the Era of Organ Shortage
Ryan T Groeschl, MD;; Kiran Turaga, MD, MPH
Division of Surgical Oncology, Department of Surgery
Medical College of Wisconsin, Milwaukee, WI
The optimal treatment of primary liver cancer also known as hepatocellular carcinoma (HCC) is a subject of frequent debate. When these tumors arise in the setting of advanced cirrhosis, partial liver resection may be prohibitively difficult due to background liver fibrosis. As a result, total hepatectomy with transplantation is well-established as the preferred curative-intent treatment for patients with severe cirrhosis. The Milan criteria (solitary tumor <5cm, or up to three nodules <3cm) are currently considered the benchmark for selecting patients with HCC for transplantation, although several criteria do exist.
In patients without extensive background liver fibrosis, however, liver resection can be accomplished with greater safety and efficacy. For the patient with minimal background liver fibrosis and HCC tumor(s) within Milan criteria, neither liver resection nor transplantation has been clearly established as the preferred treatment. In 2010, Lee and colleagues published an institutional experience of transplantation and resection for HCC. Although overall survival (OS) was similar with either approach, transplanted patients had a superior recurrence-free survival (RFS). They concluded that liver transplantation should be considered the primary treatment for such patients. The following year, Koniaris and colleagues published a similar series which showed no survival advantage for transplanted patients. Figure 1 summarizes the overall 5-year survival for transplantation vs resection in several recent publications.[1-6]
Our objective was to address this debate with a population-based approach using the Surveillance, Epidemiology, and End-Results (SEER) database, especially in the current era of organ shortage. We hypothesized that OS after surgical resection was non-inferior to transplantation in patients with minimal background fibrosis.
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