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HCC: Liver Transplant Vs Resection

Insights From: Richard S. Finn, MD, Geffen School of Medicine;Arndt Vogel, MD, Hannover Medical School
Published: Wednesday, Nov 09, 2016


Transcript:

Arndt Vogel, MD:
In general, patients who are candidates for surgery, which means liver resection or liver transplantations, are patients who do not have a very advanced tumor disease. In Germany, and in most countries, I think the Milan criteria are well established for liver transplantation. The patients are not allowed to have more than three tumor nodules or one tumor nodule that is smaller than 5 cm. If the patients are within these Milan criteria, they are candidates for liver transplantation. And here, it’s really important that with a liver transplantation, we will exchange the complete liver. We can also include here patients who have poor liver function in contrast to all other treatments we use in HCC. So, liver transplantation is independent of the underlying liver cirrhosis because the liver will be replaced. The only point we really have to acknowledge is here, the tumor burden is within Milan criteria so that they can be transplanted.

On the other hand, for liver resection, it’s also recommended for early HCC. I personally think, and this is our experience, it does not really depend so much on the size of the tumor. If possible, there should be no vascular invasion in the tumor. And what is most important is that the patients do not have too advanced liver cirrhosis, because otherwise they will not recover after liver transplantation. If you think about the numbers for liver transplantation in our center, we have treated around 2000 patients in the last 15 years. And, out of these 2000 patients, 200 were transplanted. So, it’s around 10% of the patients that were, in the end, really candidates for liver transplantation and that made it to the transplantation.

Richard Finn, MD: Patients with liver cancer often have some degree of liver dysfunction. So, regardless of the size and location of the tumor, a patient’s physiology is often the limiting factor for a curative resection. Often, things we consider are the Child-Pugh status. What’s their liver reserve looking at: their bilirubin, their INR (international normalized ratio)? Do they have evidence of decompensation, such as encephalopathy or ascites? The latter few things being contraindications to surgery. Another very important assessment, in regards to their physiology, is the absence of portal hypertension. Patients who have had GI bleeding or large varices are not going to do well with a surgical resection, and often we look at a platelet count as a surrogate for portal hypertension. I know at my center, patients who have a platelet count less than 100,000 in the setting of cirrhosis are not going to be candidates for surgery. And that’s not because they’re at a bleeding risk because of thrombocytopenia, but it’s because that low platelet count represents portal hypertension. That is someone who won’t do well with a resection.

For patients who have good liver physiology, then it becomes a matter of tumor characteristics. There is a fair amount of debate about size of tumors for resection. I think most surgeons will feel that if you have invasion into the portal vein that you’re not a candidate. If there’s bilobar disease, often they’re not candidates. So, you really need to have someone who has a lot of experience in managing these patients surgically to assess them for resection.

The recurrence rate with resection is very high. It can be as high as 80%. Really, what goes into outcomes is patient selection. We can only do our best based on preoperative imaging, but we know that patients who have macrovascular invasion or patients who have a larger tumor, the more likely there will be a recurrence. The other thing that surgery has limitations for in curing patients with hepatocellular carcinoma is the field defect. The cirrhotic liver, or the liver that has given rise to liver cancer, is at risk for developing other tumors. It’s often a multifocal disease. So, even though a patient might surgically do very well with resection of a small tumor that’s 3 cm, they’re at very high risk of recurrence just of developing a new tumor. Often, across the board, we say the recurrence rate is about 50% at 2 years, and that can often be higher if the patient who is felt to be high risk is taken to surgery.

Transcript Edited for Clarity
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Transcript:

Arndt Vogel, MD:
In general, patients who are candidates for surgery, which means liver resection or liver transplantations, are patients who do not have a very advanced tumor disease. In Germany, and in most countries, I think the Milan criteria are well established for liver transplantation. The patients are not allowed to have more than three tumor nodules or one tumor nodule that is smaller than 5 cm. If the patients are within these Milan criteria, they are candidates for liver transplantation. And here, it’s really important that with a liver transplantation, we will exchange the complete liver. We can also include here patients who have poor liver function in contrast to all other treatments we use in HCC. So, liver transplantation is independent of the underlying liver cirrhosis because the liver will be replaced. The only point we really have to acknowledge is here, the tumor burden is within Milan criteria so that they can be transplanted.

On the other hand, for liver resection, it’s also recommended for early HCC. I personally think, and this is our experience, it does not really depend so much on the size of the tumor. If possible, there should be no vascular invasion in the tumor. And what is most important is that the patients do not have too advanced liver cirrhosis, because otherwise they will not recover after liver transplantation. If you think about the numbers for liver transplantation in our center, we have treated around 2000 patients in the last 15 years. And, out of these 2000 patients, 200 were transplanted. So, it’s around 10% of the patients that were, in the end, really candidates for liver transplantation and that made it to the transplantation.

Richard Finn, MD: Patients with liver cancer often have some degree of liver dysfunction. So, regardless of the size and location of the tumor, a patient’s physiology is often the limiting factor for a curative resection. Often, things we consider are the Child-Pugh status. What’s their liver reserve looking at: their bilirubin, their INR (international normalized ratio)? Do they have evidence of decompensation, such as encephalopathy or ascites? The latter few things being contraindications to surgery. Another very important assessment, in regards to their physiology, is the absence of portal hypertension. Patients who have had GI bleeding or large varices are not going to do well with a surgical resection, and often we look at a platelet count as a surrogate for portal hypertension. I know at my center, patients who have a platelet count less than 100,000 in the setting of cirrhosis are not going to be candidates for surgery. And that’s not because they’re at a bleeding risk because of thrombocytopenia, but it’s because that low platelet count represents portal hypertension. That is someone who won’t do well with a resection.

For patients who have good liver physiology, then it becomes a matter of tumor characteristics. There is a fair amount of debate about size of tumors for resection. I think most surgeons will feel that if you have invasion into the portal vein that you’re not a candidate. If there’s bilobar disease, often they’re not candidates. So, you really need to have someone who has a lot of experience in managing these patients surgically to assess them for resection.

The recurrence rate with resection is very high. It can be as high as 80%. Really, what goes into outcomes is patient selection. We can only do our best based on preoperative imaging, but we know that patients who have macrovascular invasion or patients who have a larger tumor, the more likely there will be a recurrence. The other thing that surgery has limitations for in curing patients with hepatocellular carcinoma is the field defect. The cirrhotic liver, or the liver that has given rise to liver cancer, is at risk for developing other tumors. It’s often a multifocal disease. So, even though a patient might surgically do very well with resection of a small tumor that’s 3 cm, they’re at very high risk of recurrence just of developing a new tumor. Often, across the board, we say the recurrence rate is about 50% at 2 years, and that can often be higher if the patient who is felt to be high risk is taken to surgery.

Transcript Edited for Clarity
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