Liver Transplantation for Recurrent HCC After Liver Resection
Liver resection (LR) for patients with small hepatocellular carcinoma (HCC) with preserved liver function, employing liver transplantation (LT) as a salvage procedure (SLT) in the event of HCC recurrence, is a debated strategy.
From 1996 to 2005, we treated 227 cirrhotic patients with HCC transplantable: 80 LRs and 147 LTs of 293 listed for transplantation. Among 80 patients eligible for transplantation who underwent LR, 39 (49%) developed HCC recurrence and 12/39 (31%) of these patients presented HCC recurrence outside Milan criteria. Only 10 of the 39 patients underwent LT, a transplantation rate of 26% of patients with HCC recurrence.
According to intention-to-treat analysis of transplantable HCC patients who underwent LR (n = 80), compared to all those listed for transplantation (n = 293), 5-year overall survival was 66% in the LR group versus 58% in patients listed for LT, respectively (p = NS); 5-year disease-free survival was 41% in the LR group versus 54% in patients listed for LT (p = NS).
Comparable 5-year overall (62% vs. 73%, p = NS) and disease-free (48% vs. 71%, p = NS) survival rates were obtained for SLT and primary LT for HCC, respectively.
LR is a valid treatment for small HCC and in the event of recurrence, SLT is a safe and effective procedure.

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and its incidence will increase in the next two decades both in Europe and the United States. HCC now constitutes the most frequent cause of death in cirrhotic patients. Strict follow-up programs in cirrhotic patients allow identification of HCC at an early stage when curative nontransplant treatments are possible.

Liver resection (LR) is the first-line treatment in patients with HCC and preserved liver function (Child class A) with acceptable results in terms of perioperative risk and overall survival; it is, however, linked to a high incidence of HCC recurrence, up to 50-70% of cases at 5 years of follow-up. Liver transplantation (LT) is advisable in patients with HCC and decompensated cirrhosis (Child class B-C) with excellent results in term of overall and disease-free survival in selected patients. Recently, promising results after LT have been reported also with extension of the Milan criteria. The main problem affecting the applicability of the LT option is the high dropout rate from the waiting list related to HCC progression, despite the systematic use of nonsurgical bridging techniques such as trans-arterial chemoembolization (TACE) and/or radio-frequency ablation (RFA) or percutaneous alcohol injection (PEI), caused by organ shortage in relation to the continuously increasing number of patients awaiting LT. Supported by good results in terms of overall survival from LR for HCC in selected transplantable patients with preserved liver function and working with the assumption that at the time of HCC recurrence LT can be performed secondarily, a third surgical strategy named 'salvage transplantation' was first proposed by Majno et al. with encouraging results.