Liver transplantation for primary hepatocellular carcinoma: tumor size and number determine outcome

Liver transplantation for primary hepatocellular carcinoma (HCC) has in general been complicated by high recurrence rates. In the present study results from experience of 87 patients were analyzed [56 cirrhotic, 31 non-cirrhotic, 6 with the fibrolamellar (FL) variant] in relation to curative potential. Sixty-two survived > 90 days and form the study cohort. Fifty-six had non-fibrolamellar HCC and, of these, 39 had discrete lesions, measuring 0.8–21 cm (median 5.0 cm) including 4 in whom the diagnosis was made after examination of the explanted liver; 23 had multifocal lesions (> 2 tumor masses). There was no tumor recurrence in the group of 14 cases with single dominant lesions measuring < 4 cm, whereas in the 15 cases with lesions of 4–8 cm the recurrence rate was 40%, and 78% in those > 8 cm and the multifocal lesions ( n = 27, P = 0.0001). Five-year actuarial survival figures were 57.1%, 44.4% and 11.1% ( P < 0.003) respectively. The mean survival times in patients who died of recurrence were: 4–8 cm, 3.3 years (range 10 months to 6.3 years); > 8 cm or multifocal, 13 months (3–25 months). Reduction of serum α-fetoprotein (AFP) to normal levels does not exclude a later recurrence (7 of 17 cases) and this was documented after maintenance of normal AFP levels for up to 29 months. Five of the 6 fibrolamellar tumors were multifocal and recurred leading to death in 4 after prolonged periods of palliation (mean survival 4.4 years, range 1.8–7.9 years); the one solitary lesion measuring 9 cm did not recur, death being due to a lymphoma after 4.2 years.