J. P. Silva1, N. G. Berger1, T. C. Gamblin1 1Medical College Of Wisconsin,Surgical Oncology,Milwaukee, WI, USA
Introduction: Shortage of available organs has led to the method of salvage liver transplantation (SLT). Primary hepatic resection is carried out, and then transplantation may occur in the setting of hepatocellular carcinoma (HCC) recurrence or liver function deterioration. The survival outcomes of SLT compared with primary liver transplantation (PLT) have not been described in a nationally representative population. The present study sought to evaluate the differences in overall survival (OS) between SLT and PLT in hepatocellular carcinoma patients, using prior upper abdominal surgery (UAS) as a proxy for prior hepatic resection or ablation.
Methods: HCC patients undergoing liver transplantation were identified using the Organ Procurement and Transplantation Network (OPTN) database (1987-2015). The patients were separated by presence of prior UAS into two cohorts, PLT and UAS. In order to focus on patients with prior surgery related to HCC, prior UAS without a corresponding record of prior HCC treatment were excluded. OS was analyzed by log-rank test and graphed using Kaplan-Meier method. Recipient and donor demographic and clinical characteristics were also studied using Cox univariate and multivariate analysis.
Results: A total of 15,070 patients were identified, with a median age of 58 years. 78.5% of all patients were male. 6,220 patients (41.3%) composed the UAS group, and 8,850 (58.7%) composed the PLT group. Compared to the UAS cohort, PLT patients were more likely to be older (p<0.001), female (p<0.001), and diabetic (p<0.001). OS was improved in the PLT compared to UAS , with median OS of 131.4 months and 122.4 months, respectively (p<0.001). UAS was associated with an increased hazard ratio (HR) on univariate analysis (HR 1.14, 95% CI 1.07-1.22; p<0.001). However, upon multivariate analysis, UAS was not associated with significantly increased HR (HR 1.15, 95% CI 0.92-1.42; p=0.21). Independent factors associated with increased HR include increased recipient age (HR 1.02, 95% CI 1.01-1.04; p=0.005), African American race (HR 1.43, 95% CI 1.03-2.00; p=0.034), and number of tumors (HR 1.09, 95% CI 1.04-1.15; p<0.001).
Conclusion: Primary liver transplant for hepatocellular carcinoma patients is associated with an improved overall survival when compared to patients with prior UAS. However, on multivariate analysis, no significant increased hazard ratio exists, likely due to differences in patient demographics and disease characteristics. With thoughtful patient selection, SLT is a feasible alternative to PLT and a deserving focus for further investigation.
