Survival advantage of primary liver transplantation for resectable hepatocellular carcinoma with vascular invasion

Abstract

BACKGROUND: Vascular invasion is a poor prognostic factor of surgical resection (LR) and liver transplantation (LT) for hepatocellular carcinoma (HCC). Microvascular invasion in the LR specimen is paradoxically considered an indication for LT in some centers. METHODS: From July 2000 to June 2009, adult patients underwent primary LT and LR for HCC were included. Those who received neoadjuvant systemic chemotherapy, targeted therapy, with positive resection margins, with direct or metastatic spread of HCC were also excluded. RESULTS: This study included 95 LT recipients and 620 LR patients. Among the LT recipients 81% were within up-to 7 criteria, 77% within UCSF criteria. Slightly over one quarter (26.3%) had HCC with either macro- or micro-vascular invasion. About three-quarter (73.7%) were of LDLT. 5-year overall survival was 82%. When within up-to-7 criteria (n = 75), the 5-year survival improved to 85.3%. The presence or absence of either macro- or micro-vascular invasion was did not affect survival (5-year overall survival, 88.2 vs. 84.7%, respectively). LT recipients with HCC with vascular invasion had survival comparable to LR patients with HCC without vascular invasion (88.2 vs. 78.9%, p = 0.828) LR patients had 5-year survivals much better than those with vascular invasion who under LR (47.3%). Thus, the significant survival advantage of LT over LR for treatment of HCC with vascular invasion. For the entire cohort of 95 LT recipients and 620 LR patients, the overall 5-year survivals were compromised by: multiple tumors (OR = 1.592, CI = 1.196–2.119, p = 0.001), presence of vascular invasion (OR = 2.332, CI = 1.782–3.052, p < 0.0001) and beyond up-to-7 criteria (OR = 1.526, CI = 1.152–2.023, p = 0.003). Liver transplantation was a favorable factor for survival (OR = 0.410, CI = 0.246–0.684, p = 0.001). CONCLUSIONS: Primary LT for HCC within up-to-7 criteria irrespective of vascular invasion has 5-year survival over 80%. Those with microvascular invasion has the survival advantage of twice as likely a cure.