1. Treatment Strategy for Recurrent Hepatocellular Carcinoma: Salvage Transplantation, Repeated Resection, or Radiofrequency Ablation? Albert C. Y. Chan, 1 * See Ching Chan, 1,2 Kenneth S. H. Chok, 1 Tan To Cheung, 1 Dai Wing Chiu, 1 Ronnie T. P. Poon, 1,2 Sheung Tat Fan, 1,2 and Chung Mau Lo 1,2 1 Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery, and 2 State Key Laboratory for Liver Research, University of Hong Kong, Hong Kong, China LIVER TRANSPLANTATION, April 2013

2. BCLC Staging System for HCC Very early stage (0) Early stage (A) Intermediate stage (B) Advanced stage (C) Terminal stage (D) HCC PEI/RFALiver transplantationResectionChemoembolizationSorafenib RCTs (50-60%) Median survival untr eated: 6-16 months Symptomatic Tx (10%) Survival <3 months Curative treatments (30%) 5-year survival: 50–70% 3 nodules ≤3cm Normal Single HCC Portal pressure bilirubin Yes Associated diseases No Increased Llovet JM, et al, Lancet 2003

3. Early HCC (Within criteria) Poor LFTGood LFT Prevention of tumor progress 1 o LDLT DDLT Surgical resection RFA 2 o LT (Salvage or Rescue) ResectionRFA

4. PLT SLT Belghiti et al, Annals of Surgery. 2003 In selected patients, liver resection prior to LT does not significantly increase the technical difficulty of the transplantation procedure or impair the survival after LT.

5. Fucks et al. Hepatology 2012

6. Purpose To review our experience with the survival outcomes of different operative treatments for recurrent HCC so that we could define a logical management algorithm for patients with postoperative tumor recurrences.

7. Patients & Methods Jan. 1993 to Sep. 2009 in Queen Mary Hospital A total of 532 HCC patients, underwent hepatic resection or RFA as primary treatment; 183 intrahepatic recurrence 87 patients received Salvage LT, Repeat Resection and rRFA

8. Treatment Algorithm for HCC LR –Child A cirrhosis, ICG <15% at 15 minutes –Platelet count >100 X 10 9 /L, remnant liver volume > 30% RFA –Unresectable tumors 5 cm in diameter or fewer than 3 tumor nodules (each <3 cm in diameter) –Child A cirrhosis or select patients with Child B –Percutaneous, laparoscopic or open approach LT –Tumor location or poor liver function

9. Patient Demographics

10. Tumor Characteristics

11. RFS1-year3 years5 years SLT68.4 %57.9 % RR69.7 %49.3 % RFA40.0 %19.8 %10.6 % RFS1-year3 years5 years SLT60.0 % RR70.2 %48.0 % RFA41.0 %20.3 %10.9 %

12. Pattern of Recurrence

13. Risk Factors for HCC Recurrence RFS1-year3 years5 years ≤1 year23.3 %10.0 %6.7 % > 1 year76.1 %53.5 %47.5 %

14. SLT is an efficacious treatment for patients with recurrent HCC and should be considered when RR is not feasible. –Overall survival (SLT vs RR : P = 0.81 ) –late recurrence –lower serum AFP levels Conclusion