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Resection or Transplantation for Early Hepatocellular Carcinoma in a Cirrhotic Liver: Does Size Define the Best Oncological Strategy?

Adam, Rene MD, PhD*,†,‡; Bhangui, Prashant MS*; Vibert, Eric MD*,†,‡; Azoulay, Daniel MD, PhD*,†,§; Pelletier, Gilles MD, PhD*; Duclos-Vallée, Jean-Charles MD, PhD*,†,‡; Samuel, Didier MD, PhD*,†,‡; Guettier, Catherine MD*; Castaing, Denis MD*,†,‡

Annals of Surgery:
doi: 10.1097/SLA.0b013e318273bad0

Background: Resection and liver transplantation (LT) are the only curative options for hepatocellular carcinoma in cirrhotic patients (HCC-cirr).

Objective: We tried to define the best primary intention-to-treat strategy in patients undergoing either resection or LT for early single HCC-cirr (≤5 cm).

Methods: From 1990 to 2010, 198 patients with early HCC-cirr underwent either resection (group R, n = 97) or LT (group T, n = 101) as the primary procedure. Our policy was to prioritize Childs A patients with peripheral lesions for resection rather than LT. Patient and tumor characteristics, and outcomes (recurrence-free survival [RFS] and overall survival [OS]), were studied.

Results: A longer diagnosis-to-surgery interval, more Child Pugh B/C patients, and more tumor nodules (on histopathological examination) were found in group T patients. The postoperative mortality (4.1% vs 3.0%, P = 0.72) and rate of major complications (19.1% vs 24.7%, P = 0.35) were similar in groups R and T, respectively, whereas tumor recurrence was higher in group R (62% vs 10% in group T, P < 0.0001). The 5-year OS (75% vs 52%, P = 0.0008) and RFS (72% vs 20%, P < 0.0001) were better in group T; similarly, more patients were disease free at last follow-up (27% vs 62%, P < 0.0001). Resection as the surgical procedure, tumor diameter 3 cm or more on histology, and microvascular tumor invasion were poor prognostic factors for OS and RFS. Including dropout patients from LT list in the analysis, the outcomes in group T were still better (70% and 61% vs 51% and 36% at 5 and 10 years, P = 0.01).

Conclusions: On an intention-to-treat basis, LT is associated with the best survival outcomes in patients with early HCC-cirr. Resection may achieve comparable OS in patients with single HCC-cirr of size smaller than 3 cm; however, the RFS still remains lower than that in patients of group T. This study could serve as a guide for HCC-cirr patients who are candidates for either resection or LT.

In Brief

Our study in 198 cirrhotic patients with single hepatocellular carcinoma (HCC) of 5 cm or smaller size showed that among curative options, liver transplantation is associated with the best survival outcomes on an intention-to-treat basis. Resection may achieve comparable overall survival in patients with single HCC of 3 cm or smaller size with, however, a lower recurrence-free survival.

Author Information

*AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire

Université Paris-Sud

Inserm, Unité 785

§Inserm, Unité 1004, Villejuif, France.

Reprints: Rene Adam, MD, PhD, Centre Hépato-Biliaire, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris(AP-HP), 12 Avenue Paul Vaillant Couturier, 94804 Villejuif, France. E-mail:

Disclosure: The authors declare no conflicts of interest.

© 2012 Lippincott Williams & Wilkins, Inc.