Recurrence of hepatocellular carcinoma after liver transplantation: Is there a place for resection?

Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) is widely considered as a terminal condition. Therefore, the role of surgery is uncertain in this case. The purpose of this study was to identify the prognostic factors of survival after post-LT HCC recurrence and to evaluate the impact of surgery in this setting. All patients transplanted for HCC between 1991 and 2013 in a single institution and who further developed a post-LT recurrence were included in this study. Univariate and multivariate analyses were performed to identify factors affecting postrecurrence survival. Of the 493 patients transplanted for HCC, a total of 70 (14.2%) consecutive patients developed a recurrence after a median disease-free interval of 17 months. Median survival (MS) from the time of recurrence was 19 months, with a 3-year postrecurrence survival of 26%. Most recurrences were extrahepatic (lung, lymph node, and bone; n=51; 72.9%), whereas only intrahepatic recurrences were observed in 2 (2.8%) patients. Both intrahepatic and extrahepatic locations were found in 17 (24.3%) patients. A total of 22 (31.4%) patients underwent macroscopically complete resection of the recurrence (intrahepatic [n=2] and extrahepatic [n=20]). The MS for resected patients after transplantation was 35 months compared with 15 months for nonresected patients (P<0.001). In multivariate analysis, the independent unfavorable factors of postrecurrence survival were alpha-fetoprotein level >100ng/mL at relapse (hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.1-4.1; P=0.03), intrahepatic location (HR, 1.8; 95% CI, 1.0-3.2; P=0.05), and multifocal recurrence (HR, 1.8; 95% CI, 1.1-3.1; P=0.04). The management including surgery (HR, 0.4; 95% CI, 0.2-0.7; P=0.004) was identified as an independent favorable factor. In conclusion, recurrence of HCC after LT is associated with a poor prognosis. However, resection is associated with improved survival and should therefore be considered when feasible. Liver Transplantation 23 440-447 2017 AASLD.