Liver Transplantation in the Treatment of Liver Cancer

The treatment of choice for hepatic malignancy has been total surgical removal of tumor(s). Extensive liver resect..ion such as right and left trisegmentectomies can now be performed with an operative mortality ofless than 5% [I). Five-year survival of primary liver malignancy after suhtotal liver resection has heen as high as 46% [I]. On the other hand, the prognosis of liver cancer which cannot be treated with the conventional technique of subtotal liver resection because of extensive hepatic involvement of tumors or coexisting nonneoplastic liver disorders has been quite poor. Total hepatectomy with hepatic replacement (orthotopic liver transplantation) is, at least in concept, an ideal approach for the "unresectable" liver cancer. The world's first attempt to treat "unresectable" liver cancer by total hepatectomy with hepatic replacement was made in Denver on May 5,1963. The patient was a 48-year-old man with hepatocellular carcinoma in a cirrhotic liver. He died 22 days after transplant from pulmonary emboli and sepsis. The postmortem examination did not reveal any residual tumors. The first patient to live more than I year after liver transplantation also had hepatocellular carcinoma. This I-year 7-month-old girl was the eighth recipient in Denver and lived 400 days after transplantation on July 23, 1967. Her tumor first recurred in the lungs 3 months after transplant and then disseminated into the liver homograft. other abdominal organs, and the brain. Despite ..--efforts to control the tumor by chemotherapy, radiation therapy, and surgical debulking procedure, she died from carcinomatosis on August 26, 1968. These early two cases clearly illustrated the issues involved in liver transplantation for hepatic malignancies. By-the time the early Denver experience in liver transplantation was reported in the monograph in ) 969 [2], the enthusiasm for treating so-called unresectable liver cancer with orthotopic liver transplantation had been dampened because of the high incidence of aggressive tumor recurrence after pOlentially curative total hepatectomy with liver replacement. Nevertheless, the treatment of malignant tumors by liver transplantation has continued because of: () the lack of other effective therapy; (2) rare examples of cure of malignancy by total hepatectomy with hepatic replacement; and (3) the improved overall survival after liver trans-