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Page 4 of 9 Pasini et al. Hepatoma Res 2020;6:26 I http://dx.doi.org/10.20517/2394-5079.2019.47

Table 1. Review of the literature on the surgical treatment of recurrent hepatocellular carcinoma
Ref. Year No of pts Mortality (%) 5-year OS (%)
Zou et al. [35] 2016 635 7 47
Huang et al. [37] 2012 85 1 22
Faber et al. [38] 2011 27 0 42
Roayaie et al. [34] 2011 35 0 67
Kubo et al. [39] 2008 51 0 48
Itamoto et al. [40] 2007 84 0 50
Tralhão et al. [41] 2007 16 1 31
Kobayashi et al. [42] 2006 80 0 53
Sun et al. [31] 2005 57 0 31
Minagawa et al. [33] 2003 67 0 56
Sugimachi et al. [43] 2001 78 0 48
Shimada et al. [30] 1998 41 NR 45 (3-y)
Hu et al. [44] 1996 59 0 44 (3-y)
OS: overall survival

Nevertheless, we acknowledge that this important aspect surely requires further dedicated study and every
effort should be made to minimize blood loss and the associated transfusion requirements to improve
outcomes in both liver surgery and LT.

Liver transplantation (salvage)
Many transplant centres recommend LT as salvage for rHCC. Salvage LT (SLT) was proposed as an ideal
treatment for patients fulfilling the Milan criteria, treating both the cancer and the underlying cirrhosis
[47]
at the same time . However, many authors have questioned whether RH could be performed instead of
[48]
LT. A recent meta-analysis comparing SLT with RH showed that SLT was inferior to RH with regard
to operative and postoperative short-term results, but had better results in terms of overall- and disease-
free survival. In fact, in SLT, a more complex operation has to be accounted for, especially in patients who
[49]
are thought to have more advanced liver cirrhosis. A recent study by Lim et al. showed, in particular,
that 90-day mortality was significantly higher in the SLT group compared to the RH group. The negative
impact of resection on subsequent LT was also demonstrated in other studies comparing SLT and primary
liver transplantation (PLT). Adam et al. first showed that LT after prior liver resection was associated
[50]
with higher operative mortality and risk of intraoperative bleeding than PLT. Similarly, a recent meta-
analysis has demonstrated a significantly higher rate of postoperative bleeding and operative mortality
in the SLT group. However, despite the higher perioperative risk, SLT may still achieve better disease-
free survival (DFS) rates compared to RH. This has to be expected, given that resection of existing distant
micrometastases and removal of the underlying liver disease may prevent de novo HCC development in
the remnant liver. A recent meta-analysis comparing SLT to curative locoregional treatments among
[51]
seven retrospective studies showed better outcomes with SLT. In particular, SLT was associated with higher
5-year OS and DFS; when compared to RH alone, subgroup analysis still indicated a significantly higher 3-
and 5-year DFS for the SLT group. Nevertheless, the authors stated that the feasibility of SLT is impaired
due to donor organ shortage.

The decision to proceed with either strategy is clearly biased by institutional practices and for this reason,
any comparison between SLT and RH may not be completely reliable. However, it is our opinion that
patients should be listed for LT in case of worsening liver function, or any other case such that a second
liver resection will not be tolerated. When feasible, any attempt to rescue these patients without affecting
[52]
the donor pool should be made .
Locoregional treatments
Radiofrequency ablation (RFA), applicable both via the percutaneous or open approach, is considered a
[53]
safe procedure and as effective in achieving long-term survival as surgical resection, in selected patients .