What are the criteria for choosing between liver resection and transplantation in the treatment of hepatic (liver) malignancy?

Liver Resection vs Transplantation for Hepatic Malignancy

For hepatocellular carcinoma (HCC), liver transplantation is the superior first-line treatment for patients meeting Milan criteria (single tumor ≤5 cm or ≤3 tumors each ≤3 cm) with cirrhosis, while resection is preferred for non-cirrhotic patients or those with Child-Pugh A cirrhosis without portal hypertension. 1

Decision Algorithm Based on Liver Function and Tumor Burden

For Patients WITHOUT Cirrhosis or Minimal Liver Disease

• Liver resection is the primary treatment for patients with localized resectable tumors and well-preserved liver function 1
• Post-resection 5-year survival reaches 54-74% with R0 resections 1
• Transplantation should only be considered if diffuse intrahepatic recurrence occurs after resection in highly selected cases 1

For Patients WITH Compensated Cirrhosis (Child-Pugh A)

Critical decision point: Assess portal hypertension and bilirubin

• Resection is appropriate if ALL of the following are met: 1

  • Child-Pugh A cirrhosis
  • No portal hypertension (HVPG ≤10 mmHg)
  • Normal bilirubin (≤1 mg/dL)
  • Single tumor or ≤3 tumors

• Transplantation is preferred if ANY of the following exist: 1

  • Portal hypertension present (HVPG >10 mmHg)
  • Elevated bilirubin (>1 mg/dL)
  • Tumor meets Milan criteria (single ≤5 cm or ≤3 tumors ≤3 cm each)
  • Patient age ≤65 years

The combination of bilirubin >1 mg/dL and HVPG >10 mmHg is a critical predictor of early postoperative mortality from decompensation after resection. 1

For Patients WITH Decompensated Cirrhosis (Child-Pugh B or C)

• Transplantation is the ONLY curative option for patients within Milan criteria 1
• Child-Pugh C patients should receive only supportive care if tumors exceed Milan criteria 1
• Resection carries prohibitive risk of hepatic decompensation and poor 5-year survival in Child-Pugh B/C patients 1

Tumor-Specific Considerations

Within Milan Criteria (Single ≤5 cm or ≤3 tumors ≤3 cm)

• Transplantation achieves 70-88% 5-year survival and addresses both tumor and underlying cirrhosis 1
• Transplant recipients have recurrence rates <15% compared to 50% at 3 years and 70% at 5 years after resection 1
• For tumors ≤2 cm with compensated cirrhosis, percutaneous ablation achieves equivalent survival (>70% at 5 years) with lower mortality risk (very low vs 1-3% for resection vs 10% for transplant) 1

Beyond Milan Criteria

• Resection may be considered for patients with: 1

  • ≤3 intrahepatic tumors with well-preserved liver function
  • Portal/hepatic vein invasion WITHOUT main portal trunk involvement
  • Child-Pugh A cirrhosis without portal hypertension

• Downstaging to within Milan criteria followed by transplantation shows superior outcomes compared to other treatments 1, 2

• Successful downstaging requires: 2, 3

  • Tumor reduction to within Milan criteria
  • AFP <1,000 ng/mL maintained for ≥3 months
  • Waiting period of ≥3 months after locoregional therapy to assess tumor biology

Critical Biomarker: Alpha-Fetoprotein (AFP)

AFP >1,000 ng/mL is an absolute contraindication to transplantation regardless of tumor burden. 2

• AFP provides prognostic information and should guide transplant decisions in combination with imaging criteria 2
• Elevated AFP (>400 ng/mL) predicts poor post-transplant outcomes 1

Special Circumstances

Vascular Invasion

• Macrovascular invasion is a contraindication to transplantation 1
• Resection may still be considered if main portal trunk is not invaded and liver function is preserved 1
• TACE or hepatic arterial infusion chemotherapy can be considered for HCC with vascular invasion 1

Waiting List Management

• Bridge therapy with locoregional treatments is recommended if waiting time exceeds 6 months 1
• Monitoring should include dynamic CT/MRI and AFP measurements 2
• Response to bridge therapy serves as a surrogate marker of tumor biology 4

Common Pitfalls to Avoid

1. Do not perform resection in patients with both portal hypertension (HVPG >10 mmHg) AND hyperbilirubinemia (>1 mg/dL) - this combination predicts early mortality from decompensation 1

2. Do not transplant patients with AFP >1,000 ng/mL - outcomes are uniformly poor regardless of tumor size 2

3. Do not immediately transplant downstaged patients - wait at least 3 months after locoregional therapy to assess tumor biology and ensure AFP remains <1,000 ng/mL 2, 3

4. Do not use Milan criteria alone - incorporate AFP levels, response to therapy, and liver function parameters for optimal patient selection 2, 5