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Invited Critique
January 19, 2009

Indication of the Extent of Hepatectomy for Hepatocellular Carcinoma on Cirrhosis by a Simple Algorithm Based on Preoperative Variables—Invited Critique

Arch Surg. 2009;144(1):63. doi:10.1001/archsurg.2008.523

Paramount to the treatment of patients with low MELD scores with HCC is the question of resection vs listing for liver transplantation with or without bridging therapy. Two previous articles (one from this group) have demonstrated that carefully selected patients with a MELD score of less than 9 can undergo limited liver resection safely.1,2 Cescon and colleagues present data from a 2-center retrospective review of liver resections for HCC in patients with compensated cirrhosis. Their data support using serum sodium levels and MELD scores in combination to make resection decisions for patients with MELD scores of 9 and 10. Algorithms such as this are important aids for therapeutic planning and illustrate that liver resection in patients with MELD scores greater than 9 should be undertaken cautiously. The reader should note that the authors censored all causes of death except liver failure. A similar cohort of cirrhotic patients (MELD scores, 7 to 11) would have an estimated 30-day operative mortality rate between 5% and 10% (1-year mortality rate, 19%-29%).3 The decision to resect any HCC with background cirrhosis is complicated because completely resected patients lose United Network for Organ Sharing exception points for liver transplantation, which remains the standard of care for United Network for Organ Sharing stage II HCC. Furthermore, the decision to list a patient for transplant can be complicated by the scarcity of organs and prolonged wait times with significant regional variation. When examined on an intention-to-treat basis, patients undergoing liver transplantation following HCC resection have increased operative mortality, lower disease-free survival rates, and lower 5-year survival rates.4 Further complicating this scenario is the debate surrounding the optimal “bridge to transplant” therapy for HCC.5 However, one must remember that when deciding on resection in cirrhotic patients with HCC, other factors are equally important to the risk of liver failure. The optimal therapeutic strategy for an individual patient is best decided via a multidisciplinary approach of hepatobiliary and liver transplant surgeons and hepatologists. The patient's suitability for transplantation, current institutional expertise and strategies, and current regional organ allocation schemes are all important considerations. An incorrect initial decision can dramatically damage future therapeutic options and inadvertently worsen the patient's prognosis. The study by Cescon and colleagues adds further to our ability to assess risk with easily available clinical variables. This may be useful in determining the safest and most effective treatment strategies for these challenging patients.

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