Resection and liver transplantation for HCC

About 10 years ago, several studies made it clear that liver transplantation (LT) for patients with chronic liver disease and limited hepatocellular carcinoma (HCC) without vascular invasion offers better long-term survival than resection alone. However, during the past 10 years, the persistent imbalance between the increasing numbers of candidates for LT and a limited organ supply has made it necessary to temper the enthusiasm for LT. Organ shortage necessarily results in prolonged waiting time. In turn, prolonged waiting time results in tumor growth with an increasing risk of vascular invasion, a source of post-LT recurrence. In parallel, advances in liver surgery have significantly improved the safety of resection. It has been shown that, in contrast to what could be expected, prior resection neither increases operative morbidity nor impairs survival following deceased donor transplantation. Resection can be used as a treatment for HCC before LT in three different settings. First, resection can be used as a primary therapy, with LT reserved as a “salvage” therapy for patients who develop recurrence or liver failure. Second, resection can be used as an initial therapy to select patients who might obtain benefit from LT according to detailed pathological examination of the tumor and the surrounding liver parenchyma. Third, resection can be used as a “bridge” therapy for patients who have been already enlisted for LT. Resection and transplantation should be associated rather than opposed. The use of different strategies depends not only on the availability of graft and waiting time in different centers, but also the expertise of individual centers. This strategy opens a completely new field of investigation with multiple indications of resection in patients eligible for LT.