TREATMENT OF HEPATOCELLULAR-CARCINOMA ASSOCIATED WITH CIRRHOSIS IN THE ERA OF LIVER-TRANSPLANTATION

Purpose: To review the treatment of cirrhotic patients with hepatocell ular carcinoma in the era of liver transplantation and to determine th e most appropriate approach to the treatment of patients at different stages of disease. Data Sources: A MEDLINE search of English-language articles published between 1981 and 1997 and the clinical experience o f the Mount Sinai Liver Transplant Program. Study Selection: Selected studies were 1) original articles reporting results of resection and t ransplantation in the treatment of hepatocellular carcinoma in cirrhot ic patients and 2) initial reports from major transplantation centers of multimethod therapies combining chemotherapy with transplantation. Data Extraction: Study designs were assessed with careful attention to methods and aims. Relevant data on patient population, tumor stage di stribution, treatment, survival, and rate of recurrent disease were ex tracted and analyzed. Data Synthesis: Options for the treatment of hep atocellular carcinoma in cirrhotic patients vary according to tumor st age and severity of underlying liver disease. Resection remains an imp ortant method primarily in eastern countries, where the screening of h igh-risk populations has been associated with early detection of small asymptomatic lesions. Long-term survival after resection, how ever, i s low. In western countries, liver transplantation is becoming the tre atment of choice in patients with advanced cirrhosis and small, unrese ctable lesions; resection is reserved for cirrhotic patients with smal l, peripheral lesions and preserved hepatic function. Minimally invasi ve procedures (such as percutaneous ethanol injection and transarteria l chemoembolization) have been developed to treat unresectable tumors. Transarterial chemoembolitation may also be effective in patients wit h advanced cirrhosis and unresectable lesions who are awaiting transpl antation. Conclusions: The efficacy of liver transplantation for hepat ocellular carcinoma has been proven mainly in patients with advanced c irrhosis and small lesions. Future studies may clarify the role of app roaches combining neoadjuvant chemotherapy with transplantation for la rge (stage III) tumors.