Should Resection Be the Preferred Therapeutic Option for Patients Within the Milan Criteria and Compensated Cirrhosis Without Portal Hypertension?

Optimal results of hepatic resection for hepatocellular carcinoma are achieved when the tumor is solitary, liver function is normal, and there is no portal hypertension. Patients with single tumors between 2 and 5 cm are eligible for priority on the transplant waiting list, but for those with normal liver function and no portal hypertension overall survival after resection or transplant is similar. While tumor-specific death is less after transplant, there is effective treatment for tumor recurrence, and transplant is associated with an array of complications that can lead to nontumor-related death. Donor organ availability varies regionally but in most locales patients must wait, raising the possibility of drop-out due to tumor progression. The benefit of transplant over resection in appropriate resection candidates is minimal compared to the benefit transplant provided to patients with end-stage liver disease; recognizing this, the US allocation system has progressively lowered the priority accorded to tumor patients. For patients with solitary tumor >2 cm, normal liver function, and no portal hypertension, resection is the treatment of choice whether or not the tumor is within Milan criteria.