Liver transplantation for hepatocellular carcinoma.

Liver transplantation has become the best option in patients with decompensated cirrhosis and a small hepatocellular carcinoma. Indeed, because of the severity of cirrhosis, resection is usually impossible and in addition, transplantation provides survival rates close to those obtained in cirrhotic patients without malignancy (70 to 80% 3-year survival rate). In patients with a small hepatocellular carcinoma and compensated cirrhosis, both resection and transplantation can be performed. Because of the scarcity of donors, there have been reservations concerning transplantation in patients who otherwise could have undergone resection. However, there is increasing evidence that long-term results of transplantation are significantly superior to those of resection. Therefore, patients with a small hepatocellular carcinoma and compensated cirrhosis are increasingly considered as suitable candidates for transplantation. In contrast to cirrhotic patients with a small hepatocellular carcinoma, patients with large and/or multifocal tumors should no longer be transplanted because of a high rate of early recurrence and the accelerated course of tumor progression due to immunosuppression, both factors being the source of poor results. On rare occasions, hepatocellular carcinoma develops in patients without underlying liver disease. In such cases the tumor is usually recognized when it is large and symptomatic. The absence of underlying liver lesions offers the possibility of extended resection. However, in case of nonresectable (bilobar) tumors or limited recurrence after resection, transplantation may be considered due to the slow progression this subtype of hepatocellular carcinoma. Whatever the underlying liver parenchymal status, efforts should be made to reduce the risk of recurrence.