Primary liver transplantation vs liver resection followed by transplantation for transplantable hepatocellular carcinoma: Liver functional quality and tumor characteristics matter.

Liver resection (LR) and primary liver transplantation (LT) are two potentially curative treatment modalities for patients with hepatocellular carcinoma (HCC). If an underlying chronic liver disease exists, however, making a decision on which method should be selected is difficult. If a patient has no chronic liver disease, LR may be the preferable option with salvage transplantation (ST) in mind in case of recurrence. Presence of a moderate-to-severe liver failure accompanying HCC usually warrants primary LT. The treatment of patients with HCC and early-stage chronic liver disease remains controversial. The advantages of "LR-followed-by-ST-if-needed" strategy include less complicated index operation, no need for immunosuppression, use of donor livers for other patients in today's organ shortage setting and comparable survival rates. However, primary LT has its own advantages as it also treats underlying chronic liver disease with carcinogenic potential, removes undetected tumor nodules and potentially eliminates need for a ST. An article recently published by Fuks et al in Hepatology offers an approach by which selecting between LR-followed-by-ST and immediate LT might be easier. Here we discuss the results of the aforementioned report in the light of currently available knowledge.